Relationship of Affordable Care Act Implementation to Emergency Department Utilization Among Young Adults.

STUDY OBJECTIVE: The 2010 provision of the Patient Protection and Affordable Care Act (ACA) extended eligibility for health insurance for young adults aged 19 to 25 years. It is unclear, however, how expanded coverage changes health care behavior and promotes efficient use of emergency department (ED) services. Our objective was to use population-level emergency department data to characterize any changes in diagnoses seen in ED among young adults since the implementation of the ACA dependent coverage expansion. METHODS: We performed a difference-in-differences analysis of 2009 to 2011 ED visits from California, Florida, and New York, using all-capture administrative data to determine how the use of ED services changed for clinical categories after the ACA provision among young adults aged 19 to 25 years compared with slightly older adults unaffected by the provision, aged 26 to 31 years. RESULTS: We analyzed a total of 10,158,254 ED visits made by 4,734,409 patients. After the implementation of the 2010 ACA provision, young adults had a relative decrease of 0.5% ED visits per 1,000 people compared with the older group. For the majority of diagnostic categories, young adults' rates and risk of visit did not change relative to that of slightly older adults after the implementation of the ACA. However, although young adults' ED visits significantly increased for mental illnesses (2.6%) and diseases of the circulatory system (eg, nonspecific chest pain) (4.8%), visits decreased for pregnancy-related diagnoses and diseases of the skin (eg, cellulitis, abscess) compared with that of the older group (3.7% and 3.1%, respectively). CONCLUSION: Our results indicate that increased coverage has kept young adults out of the ED for specific conditions that can be cared for through access to other channels. As EDs face capacity challenges, these results are encouraging and offer insight into what could be expected under further insurance expansions from health care reform.

Cranial neurosurgical 30-day readmissions by clinical indication.

OBJECT: Postsurgical readmissions are common and vary by procedure. They are significant drivers of increased expenditures in the health care system. Reducing readmissions is a national priority that has summoned significant effort and resources. Before the impact of quality improvement efforts can be measured, baseline procedure-related 30-day all-cause readmission rates are needed. The objects of this study were to determine population-level, 30-day, all-cause readmission rates for cranial neurosurgery and identify factors associated with readmission. METHODS: The authors identified patient discharge records for cranial neurosurgery and their 30-day all-cause readmissions using the Agency for Healthcare Research and Quality (AHRQ) State Inpatient Databases for California, Florida, and New York. Patients were categorized into 4 groups representing procedure indication based on ICD-9-CM diagnosis codes. Logistic regression models were developed to identify patient characteristics associated with readmissions. The main outcome measure was unplanned inpatient admission within 30 days of discharge. RESULTS: A total of 43,356 patients underwent cranial neurosurgery for neoplasm (44.23%), seizure (2.80%), vascular conditions (26.04%), and trauma (26.93%). Inpatient mortality was highest for vascular admissions (19.30%) and lowest for neoplasm admissions (1.87%; p < 0.001). Thirty-day readmissions were 17.27% for the neoplasm group, 13.89% for the seizure group, 23.89% for the vascular group, and 19.82% for the trauma group (p < 0.001). Significant predictors of 30-day readmission for neoplasm were Medicaid payer (OR 1.33, 95% CI 1.15-1.54) and fluid/electrolyte disorder (OR 1.44, 95% CI 1.29-1.62); for seizure, male sex (OR 1.74, 95% CI 1.17-2.60) and index admission through the emergency department (OR 2.22, 95% CI 1.45-3.43); for vascular, Medicare payer (OR 1.21, 95% CI 1.05-1.39) and renal failure (OR 1.52, 95% CI 1.29-1.80); and for trauma, congestive heart failure (OR 1.44, 95% CI 1.16-1.80) and coagulopathy (OR 1.51, 95% CI 1.25-1.84). Many readmissions had primary diagnoses identified by the AHRQ as potentially preventable. CONCLUSIONS: The frequency of 30-day readmission rates for patients undergoing cranial neurosurgery varied by diagnosis between 14% and 24%. Important patient characteristics and comorbidities that were associated with an increased readmission risk were identified. Some hospital-level characteristics appeared to be associated with a decreased readmission risk. These baseline readmission rates can be used to inform future efforts in quality improvement and readmission reduction.

Interfacility transfer and mortality for patients with ruptured abdominal aortic aneurysm.

OBJECTIVE: Patients receiving interfacility transfer to a higher level of medical care for ruptured abdominal aortic aneurysms (rAAAs) are an important minority that are not well characterized and are typically omitted from outcomes and quality indicator studies. Our objective was to compare patients transferred for treatment of rAAAs with those treated without transfer, with particular emphasis on mortality and resource utilization. METHODS: We linked longitudinal data from 2005 to 2010 Healthcare Cost and Utilization Project (HCUP) State Inpatient Databases and Emergency Department Databases from California, Florida, and New York. Patients were identified using International Classification of Diseases-Ninth Revision-Clinical Modification codes. Our main outcome variables were mortality, length of stay, and cost. Data included discharge information on the transfer-out and transfer-in hospital. We used univariate and multivariate analysis to identify variables independently associated with transfer and in-hospital mortality. RESULTS: Of 4439 rAAA patients identified with intent to treat, 847 (19.1%) were transferred before receiving operative repair. Of those transferred, 141 (17%) died without undergoing AAA repair. By multivariate analysis, increasing age in years (odds ratio [OR] 0.98; 95% confidence interval [CI], 0.97-0.99; P < .001), private insurance vs Medicare (OR, 0.62; 95% CI, 0.47-0.80; P < .001), and increasing comorbidities as measured by the Elixhauser Comorbidity Index (OR, 0.90; 95% CI, 0.86-0.95; P < .001) were negatively associated with transfer. Weekend presentation (OR, 1.23; 95% CI, 1.02-1.47; P = .03) was positively associated with transfer. Transfer was associated with a lower operative mortality (adjusted OR, 0.81; 95% CI, 0.68-0.97; P < .02) but an increased overall mortality when including transferred patients who died without surgery (OR, 1.30; 95% CI, 1.05-1.60; P = .01). Among the transferred patients, there was no significant difference in travel distance between those who survived and those who died (median, 28.7 vs 25.8 miles; P = .07). Length of stay (median, 10 vs 9 days; P = .008), and hospital costs ($161,000 vs $146,000; P = .02) were higher for those transferred. CONCLUSIONS: The survival advantage for patients transferred who received treatment was eclipsed by increased mortality of the transfer process. Including 17% of transferred patients who died without receiving definitive repair, mortality was increased for patients transferred for rAAA repair compared with those not transferred after adjusting for demographic, clinical, and hospital factors. Transferred patients used significantly more hospital resources. Improving systems and guidelines for interfacility transfer may further improve the outcomes for these patients and decrease associated hospital resource utilization.