1. 2012 Update on U.S. emergency care and longitudinal trends (1995-2010) Jesse M. Pines, MD, MBA, MSCE and Mark Zocchi, MPH AHRQ National MeetingSeptember 10, 2012

2. Disclosures  Funding and support  Centers for Medicare and Medicaid Services  National Quality Forum  Agency for Healthcare Research and Quality  Robert Wood Johnson Foundation  Saudi Arabian Cultural Mission  University of Cincinnati

3. Project co-authors / collaborators  Ryan Mutter, PhD, AHRQ  Lan Zhao, PhD, Social and Scientific Systems

4. Objectives  Provide a update on emergency care for 2012  Where are we since the IOM report?  Describe emergency care policy issues and longitudinal trends in emergency care in the U.S.

5. Introduction  Why does emergency care matter? Asplin Ann Emerg Med 2003

6. Institute of Medicine  Future of Emergency Care Series (2006)  Hospital-Based Emergency Care: At the Breaking Point  ED crowding, ambulance diversion, ED boarding very common  Call to end boarding, except under “extreme” circumstances  Emergency departments not prepared for mass- casualty events  Call for greater health information technology, information-sharing  Emergency Medical Services: At the Crossroads  Emergency Care for Children: Growing Pains

7. Where are we in 2012?  ED crowding, diversion, ED boarding very common Pitts Pines Ann Emerg Med 2012

8. Where are we in 2012?  ED crowding, diversion, ED boarding very common Pitts Pines Ann Emerg Med 2012

9. What is causing crowding?  Visits are going up  The total time spent in the ED is rising faster

10. What is causing crowding? Pitts Pines Ann Emerg Med 2012

11. What is causing crowding? Pitts Pines Ann Emerg Med 2012

12. Expanded literature on ED crowding  ED crowding is associated with:  Poorer quality pain care  Delays in medications  Delays in critical tests  Higher medication errors  Higher rates of complications  Lower quality care in pediatric asthma  ED boarding is associated with:  Higher medical errors  Higher mortality rates

13. Where are we in 2012?  What has happened from a policy perspective?  2008 ED National Quality Forum ED crowding measures  ED LOS discharged, admitted, overall  Left without being seen rate  2009 Diversion ban in Massachusetts  2011 – ED LOS measures released on Hospital Compare

14. Where are we in 2012?  What may happen in the future?  2012 – ASPR-funded ED crowding/preparedness measurement concepts  2012 & beyond – ED LOS measures part of Value-Based Purchasing?

15. Where are we in 2012?  2012 – Joint Commission Flow Standard (82% of hospitals)  EP1: Hospital has a process that supports the flow of patients throughout the hospital.  EP2: Hospital must plan and care for the patients who are admitted and whose bed is not ready or a bed is unavailable.  EP3: Hospital must plan for the care for patients who are placed in an overflow location. (Appropriate care regardless of location)  EP4: Hospital should have a policy and procedure on diversion.

16. Where are we in 2012?  EP5: Hospitals must measure and set goals for the components of the patient flow process.  EP 6: (2014): Hospital must measure and set goals for mitigating and managing the boarding of emergency department patients.  EP 7 (2014): Hospital staffs or individuals who manage the patient flow processes must review the measurement results.  EP8 (2014): Hospital leaders must act to improve patient flow when the goals were not achieved. Leaders who must take action involve the board, medical staff, along with the CEO and senior leadership staff.  EP9 (2014): Hospital must determine if the population at risk for boarding due to behavioral health emergencies. Hospital leaders must communicate with the behavioral health providers to improve coordination.

17. Where are we in 2012?  EP5: Hospitals must measure and set goals for the components of the patient flow process.  EP 6: (2014): Hospital must measure and set goals for mitigating and managing the boarding of emergency department patients.  EP 7 (2014): Hospital staffs or individuals who manage the patient flow processes must review the measurement results.  EP8 (2014): Hospital leaders must act to improve patient flow when the goals were not achieved. Leaders who must take action involve the board, medical staff, along with the CEO and senior leadership staff.  EP9 (2014): Hospital must determine if the population at risk for boarding due to behavioral health emergencies. Hospital leaders must communicate with the behavioral health providers to improve coordination.

18. Next policy questions  Why do people come to the ED?  Beyond the critically ill  What are alternatives?  How will new policy changes impact these trends?  What care are people receiving?  Higher intensity care  Advanced radiography, laboratory tests, IVs  Sicker patients  Admissions  How is the ED changing over time, compared to other parts of the system  At what cost?

19. Why do so many people come to the ED? Ragin Acad Emerg Med 2005

20. How does the ED compare to alternatives? Morgan Pines Am J Manag Care 2012

21. Policy changes and the ED  Payment bundling, accountable care organizations  Will this impact the ED  How? Depends…..  Medical home model  Early results that becoming a medical home is associated with lower ED visits  Diversion of low-acuity patients to alternative settings  Wellpoint; others  Has been somewhat effective, but may not reduce overall costs

22. Why do people come to the ED? 2009 NHAMCS data, CDC

23. Why do people come to the ED  The reasons people come to the ED (and get admitted to the hospital are not changing)  There are just more and more people, and the growth is outpacing population expansion

24. How is the intensity of care changing?  More intense care, higher complexity care SEDD 2004-2010: GA, HI, MA, MD, MO, NE, VT, WI Emergency Department Visits: Percentage of Services (denominator = all ED records) CPT Code2004200520062007200820092010 9928116%15%10%16% 9928215%14%10%14%16%15%14% 9928319% 14%24%32%34% 992848%9%7%14%19%21%22% 992852%3%2%5%6%7%8%

25. How about hospital admissions? HCUP data, AHRQ

26. How about admission rates?  Is the likelihood of admission increasing?

27. ED admission rates over time HCUP data, AHRQ

28. How about specific populations?  ED admission rates are increasing for older adults  CDC data  36.2% in 2001; 38.7% in 2009  Numbers of ICU admissions are increasing dramatically  CDC data  2.76 million in 2002-2003  4.14 million in 2008-2009 Pines J Am Geriatric Soc 2012 (in press) ; Mullins Pines Crit Care Med (under review)

29. Policy questions  ED visits increasing  Patients are sicker, more ICU-bounds  Staying for more prolonged work-ups  Admission rates are unchanged on average  Perhaps preventing some hospital admissions in younger patients?  Next questions:  Where are ED visits increasing more?  What is happening to the supply of EDs?

30. Total U.S. ED volume v. # of EDs HCUP data, AHRQ

31. Profit v. non-profit v. public HCUP data, AHRQ

32. Urban v. rural location HCUP data, AHRQ

33. Hospital average ED volume v. # EDs HCUP data, AHRQ

34. Growing role of ED admissions Schuur Venkatesh New Engl J Med 2012

35. Average cost per admission HCUP data, AHRQ

36. ED admissions as a cost driver HCUP data, AHRQ

37. Recap  ED crowding and boarding  How far have we come since the 2006 IOM Report  Trends in demand for emergency care in the U.S.  Will this go unabated?  What does this mean for U.S. healthcare costs?

38. Questions?