Differences in patient-reported reasons for presenting to a freestanding ED compared to a hospital-based ED May 18, 2017 Ryan C. Burke, MPH

Freestanding Emergency Departments (FEDs) “A facility that is structurally separate and distinct from a hospital and provides emergency care”1 Open 24/7 and staffed by qualified emergency care providers Popularity and number of FEDs substantially increasing2

Why do people come to the emergency department? Severity of condition (65%)3 Barriers to accessing primary care or outpatient services (79%)3 Referred from doctor (35%)4 Objective: examine if reasons for coming to an ED differ for FED and HBED patients.

Methods Questionnaire to eligible patients after triage Exclusion criteria: Ambulance arrival Age<18 Physical or mental inability to understand consent or complete survey June – August 2016

Setting One HBED and 3 FEDs within same health system Service area is urban-rural mix Major metropolitan area population of 700,0005

Results: Participants Demographic Percent of HBED Respondents (N=267) Percent of FED Respondents (N=318) P-value Race/ethnicity   <0.001 White, non-Hispanic 54.2% 86.8% Black, non-Hispanic 34.5% 7.5% Other 11.3% 5.8% Educational attainment 0.001 Less than high school 13.1% 5.1% High school graduate or GED 37.1% 35.6% Some college or 2-year degree 35.1% 33.6% 4-year college graduate 10.2% 14.2% More than 4-year college degree 4.5% 11.5% Insurance type Commercial/Private 20.6% 45.9% Medicaid 48.3% 24.5% Medicare 19.1% 19.5% Uninsured 5.3% 4.7% Unemployed 35.4%  14.0%

Results: Participants Survey Response Percent of HBED Respondents Percent of FED Respondents P-value ESI Level   <0.001 Level 1 or level 2 15.7% 2.2% Level 3 36.3% 38.1% Level 4 or level 5 47.9% 59.7% Self-reported severity of condition 0.002 Possibly life-threatening if not treated within 1 hour 4.7% 3.5% Requiring treatment in the next 1-2 hours to prevent it from becoming more serious or life-threatening 19.2% 10.0% Very uncomfortable or worrisome, in need of treatment in the next 3-6 hours 34.5% 29.7% Uncomfortable, in need of treatment today 36.9% 49.7% In need of treatment within a couple of days 7.1% Usual place of care 75.6%  82.7% 0.053 No other ED visits in last 12 months 30.6% 46.6% Delayed getting medical care in last 12 months 45.0% 33.2% 0.006

Percent of HBED Respondents Percent of FED Respondents Reason for ED Visit Reason Percent of HBED Respondents Percent of FED Respondents P-value Believed problem was serious 45.5% 30.0% <0.001 Could not get appointment with a doctor 15.8% 20.2% 0.196 ED is convenient 10.9% 24.3% After hours (usual place/doctor closed) 12.4% 19.9% 0.018 Doctor told me to come 20.3% 11.0% 0.003 Don't have a regular doctor 12.8% 9.8% 0.291 Access to labs/other medical tests 4.5% 14.2% Doctor would have sent me here anyway 6.8% 9.5% 0.290 ED does better job diagnosing and treating 10.1% 0.012 Did not know where else to go 9.0% 5.4% 0.104 Can see a doctor without having to pay first 1.5% 1.6% 1.000

Reason for ED Visit: Regression Results Reason for Coming to the ED Adjusted Odds Ratio (95% Confidence Interval) Confounders Included in the Model Believed problem was serious 2.08 (1.36 - 3.18) Patient's doctor made decision to come to ED; usual place of care; race/ethnicity; employment; insurance type Doctor told me to come 1.91 (1.06 - 3.45) Self-reported severity; ESI level; usual place of care; ED visits in last 12 months; education; insurance type ED is convenient 0.44 (0.28 - 0.71) ESI level; Patient's doctor made decision to come to the ED

Conclusions Differences in why FED patients seek emergency care compared to HBED patients. Patients choose location based on perceived acuity Convenience more of a factor in FED patients seeking ED care

References American College of Emergency Physicians. Freestanding emergency departments: Policy statement. Ann Emerg Med. 2014;64:562. Schuur JD, Baker O, Freshman J, Wilson M, Cutler DM. Where do freestanding emergency departments choose to locate? A national inventory and geographic analysis in three states. Ann Emerg Med. 2016 [epub ahead of print]. doi: 10.1016/j.annemergmed.2016.05.019. Capp R, Rooks SP, Wiler JL, Zane RD, Ginde AA. National study of health insurance type and reasons for emergency department use. J Gen Intern Med. 29(4);621-7. Lobachova L, Brown DFM, Sinclair J, Chang Y, Thielker KZ, Nagurney JT. Patient and provider perceptions of why patients seek care in emergency departments. J Emerg Med. 46(1): 104-12. Annual Estimates of the Resident Population: April 1, 2010 to July 1, 2015. U.S. Census Bureau, Population Division. https://factfinder.census.gov/faces/nav/jsf/pages/index.xhtml. Updated March 2016. Accessed February 2017.

Co-Authors Erin L. Simon, DO, Natasha Kesav Brian Keaton, MD Laura Kukral, MBA Timothy J. Kiss Jonathan Sanchez, MBA Nicholas J. Jouriles, MD

Questions? Ryan Burke, MPH burker@ccf.org rburke11@kent.edu 330-344-5121