HOUSTON AREA HOSPITALS EMERGENCY DEPARTMENT USE STUDY January 1, 2006 through December 31, 2006

1. HOUSTON AREA HOSPITALS EMERGENCY DEPARTMENT USE STUDY January 1, 2006 through December 31, 2006 Final Report April 3, 2008 Prepared By University of Texas School of Public Health Houston Health Services Research Collaborative

2. Monitor trends in ER use in Houston hospitals • Determine primary care related use • Describe characteristics of patients with PCR use • Map the distribution of patients with PCR use Study Purpose

3. Surveyed 37 Houston area hospitals with “public” ERs (receive 911 ambulance transports from the Houston Fire Department and walk-ins from the general population) Requested 9 data elements on all 2006 ED visits Checked the data for consistency and completeness Applied the NYU Algorithm to identify primary care related visits Analyzed the characteristics of patients with PCR visits Methods

4. Two - Harris County Hospital District • Ben Taub General and Lyndon B. Johnson General • Nine - Memorial Hermann Health Care System • Hermann/Texas Medical Center, Southwest, Southeast, Northeast, Northwest, The Woodlands, Memorial City, Katy, Sugar Land • Four - Hospital Corporation of America • Bayshore Medical Center, Spring Branch, East Houston Regional, West Houston • St. Joseph Medical Center • River Oaks Hospital • Texas Children’s Hospital • Two - CHRISTUS Gulf Coast Hospitals • St. Catherine and St. John • Two - St. Luke’s Hospitals • Episcopal and Community Medical Center • Three - Methodist Hospital System • Texas Medical Center, San Jacinto, Willowbrook 25 Participating Hospitals

5. Houston Community Hospital • Methodist Hospital • Sugar Land • Doctors Hospitals • Tidwell • Parker • Four - HCA Hospitals • Clear Lake Regional Medical Center • Kingwood Medical Center • Conroe Medical Center • Mainland Hospital • Tenet Hospitals • Cypress Fairbanks Medical Center • Houston Northwest Medical Center • Park Plaza Hospital • Tomball Regional Hospital 12 Hospitals Not Included

6. Date and time of admission to ED • Primary and secondary discharge diagnosis • Discharge date and time • Payment source • Patient age • Patient gender • Patient race/ethnicity • Patient ZIP code • Where discharged to (e.g. hospital, home, nursing home, etc.) Data Collected on ED visits

7. NYU ALGORITHM Not preventable/avoidable ED Care Needed Preventable/avoidable Emergent Primary Care Treatable Non-Emergent

8. Non-emergent: Treatment not required within 12 hours. Emergent-Primary Care Treatable: Treatment required within 12 hours, but could have been provided effectively and safely in a primary care setting. Continuous observation was not required, no procedures were performed or resources used that are not typically available in a primary care setting. Emergent-ED Care Needed-Preventable/Avoidable: ER treatment required within 12 hours, but the condition was potentially preventable/avoidable if timely primary care had been received (flare-ups of asthma, diabetes, congestive heart disease, etc.) (early intervention prevention of ENT infections, cellulitis, pneumonia, immunization preventable illness, etc.) Emergent-ED Care Needed-Not Preventable/Avoidable: ED care was required within 12 hours and primary care could not have prevented the condition. NYU Algorithm Categories

9. 991,861 ED visits were made to these 25 hospitals in 2006. • Represents about 76.0% of the 1.3 million ED visits to Harris County hospitals • 780,076 ED visits (78.6%) were non hospitalized • 709,496 non hospitalized ED visits were made by Harris County residents • This represents 91.0% of total non hospitalized ED visits. Total ED Visits

10. PCR ED visits by Houston Residents

11. Percentage of Categorized ED Visits by Type

15. Primary Care Related Visits by Payment Source

16. The Medical Expenditure Panel Survey (MEPS), conducted by the federal Agency for Healthcare Research and Quality, found that in 2003 (the most recent year for national estimates) the mean cost of an ED visit was $560, whereas the mean cost of an office-based physician visit was $121. In 2006, 118,689 PCR ED visits by Harris County area residents were by persons who were uninsured. Using the MEPS estimates, the estimated cost of those visits was $66,465,840. If those same visits had taken place in an office based setting, the estimated cost would have been $14,361,369 – a savings of over $50,000,000 to the community. Estimated cost of PCR visits by the uninsured

17. Primary Care Related Visits by Race/Ethnicity

18. Primary Care Related Visits by Gender

19. Primary Care Related Visits by Age

20. Payment Source by ED Visit Type

21. Age by ED Visit Type

22. Frequent Conditions of Patients with PCR Visits

23. frequent Conditions of Patients with Non PCR Visits

30. Five-year Trends in non-hospitalized ED Visits at 11 Hospitals MHHS hospitals, HCHD Hospitals, CHRISTUS St. Joseph Hospital

31. 2002-2006 PCR Visits by Payer Source

32. What has not changed? 1) More than 5 out of 10 non-hospitalized ED visits and 8 out of 10 categorized ED visits are primary care related. 2) The peak time for total ED visits and primary care related ED visits is the middle of the day. This is a time at which outpatient clinics would normally be open. 3) Almost 60% of primary care related ED visits are by those who are uninsured or have Medicaid coverage. 4) Roughly two out of three primary care related ED visits are by persons who are Black or Hispanic. 5) Just under four out of ten primary care related ED visits are by children age 17 or younger, and almost 60% of primary care related ED visits are by females. 6) The geographical concentrations of patients with the highest rates primary care related ED visits is in low-income areas of the County. Conclusions

33. What has changed? 1) The total number of non-hospitalized visits has declined over the last three years. 2) The percentage that are primary care related has come down slightly in the last three years. 3) The four-year trend in payer mix of more primary care related ED visits by the uninsured and fewer privately insured has ended. Conclusions