Clinical differences between freestanding and hospital-based emergency departments 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 significantly increasing2

FED vs. HBED Patients Research on differences in patient populations limited Acuity level3 Insurance type4 Communities they serve2 Objective: describe demographic and clinical differences between FED and HBED patients.

Methods Retrospective study of adult visits 7/1/2014 – 6/30/2015 Electronic health records, registration, and claims data One HBED and 3 FEDs within same health system Service area is urban-rural mix Major metropolitan area population of 700,0005

Results: Visit Demographics Percent of HBED Visits (N=55,909) Percent of FED Visits (N=44,108) P-value Gender <0.0001 Male 43.5% 39.5% Female 56.5% 60.5% Race/Ethnicity White, non-Hispanic 59.7% 85.9% Black, non-Hispanic 38.2% 11.8% Other 2.1% 2.3% Marital Status Single 49.0% 33.6% Now married 27.5% 41.0% Divorced 12.1% 8.7% Widowed 8.9% 6.1% Separated 0.8% Life partner 0.1% Unemployed 50.9% 33.2% Mean Age 48 46

Results: Visit Characteristics Percent of HBED Visits (N=55,909) Percent of FED Visits (N=44,108) P-value Emergency Severity Index Level <0.0001 Level 1 1.6% 0.1% Level 2 26.4% 5.0% Level 3 44.8% 54.6% Level 4 24.1% 39.7% Level 5 3.1% 0.5% Arrival Method Car/Motorcycle 60.1% 88.0% Emergency services 25.7% 5.9% Ambulatory 11.1% 4.8% Other 3.0% 1.3% Insurance Type Commercial 19.6% 42.9% Medicaid 41.5% 24.8% Medicare 29.7% 22.5% Uninsured 6.0% 5.5% 4.4%

Cont’d: Visit Characteristics Percent of HBED Visits (N=55,909) Percent of FED Visits (N=44,108) P-value Condition on Arrival <0.0001 Good 34.5% 31.1% Stable 56.8% 64.0% Fair 6.1% 4.1% Serious 1.0% 0.4% Critical 1.3% 0.3% Expired 0.1% Patient Admitted 29.5% 8.3%

Results: Presenting Problems Percent of HBED Visits FED Visits P-value Gastrointestinal 19.0% 18.1% 0.0004 Cardiorespiratory 18.4% 16.1% <0.0001 Extremity injury-pain-swelling 14.2% 16.9% Non-specific musculoskeletal trauma 13.1% 17.6% General medical 12.8% 9.3% EENT and Dental 10.1% 6.3% Skin 4.5% 6.8% Genitourinary 4.9% .9992 Neurology 4.6% 1.0% Psychiatry 2.0% .6448 Laceration 1.9% .8463 Infection 1.8% 1.7% .0464 Obstetrics/gynecology 1.1% Mouth and teeth 0.4% Head injury (minor) 0.6%

Results: Primary ICD-9 Code Clinical Classification Software Category6 Percent of HBED Visits FED Visits P-value Injury and poisoning 17.7% 25.4% <0.0001 Diseases of the respiratory system 9.4% 12.1% Symptoms; signs; and ill-defined conditions and factors influencing health status 10.1% 9.7% .0113 Diseases of the musculoskeletal system and connective tissue 9.3% .0218 Diseases of the circulatory system 11.0% 7.0% Diseases of the digestive system 8.6% 8.1% .0016 Diseases of the nervous system and sense organs 7.3% 7.8% .0070 Diseases of the genitourinary system 7.2% 7.9% Mental illness 5.9% 1.5% Diseases of the skin and subcutaneous tissue 3.3% 4.2% Infectious and parasitic diseases 3.4% 2.4% Endocrine; nutritional; and metabolic diseases/immunity disorders 1.8% Complications of pregnancy; childbirth; and the puerperium 1.4% .7299 Residual codes; unclassified; all E codes 0.7% Diseases of the blood and blood-forming organs 0.8% 0.2% Neoplasms 0.5% Congenital anomalies <0.1% .1492

Conclusions Patients triaging themselves HBED visits higher acuity FED lower admittance rate Little variation in presenting problem and ICD9 code

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. Simon EL, Kovacs M, Jia Z, Hayslip D, Orlik K, Jouriles N. A comparison of acuity levels between 3 freestanding and a tertiary care ED. Am J Emerg Med. 2015;33(4):539-541. doi:10.1016/j.ajem.2015.01.021. Simon EL, Griffin G, Orlik K, et al. Patient Insurance Profiles: A Tertiary Care Compared to Three Freestanding Emergency Departments. J Emerg Med. 2016;51(4):466-470. doi:10.1016/j.jemermed.2016.05.058. 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. Elixhauser A, Steiner C, Palmer L. Clinical Classifications Software (CCS), 2015. U.S. Agency for Healthcare Research and Quality. Available: http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp

Co-Authors Erin L. Simon, DO1,3 Brian Keaton, MD1 Laura Kukral, MBA4 Nicholas J. Jouriles, MD1,3

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