Alcohol-Related Illness: St. Patrick's Day Edition

St. Patrick’s Day marks the veneration of the island’s patron saint. In the dioceses of Ireland, it is both a solemnity and a holy day of obligation, and throughout Ireland it has become a day of parades, family feasts, and celebrations of Irish cultural heritage.
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Asthma and EpiCenter

Now that we’ve sprung forward, health care professionals are readying themselves for the yearly increase in seasonal asthma visits. While spring allergens related to pollen do lead to increased ED visits for exacerbation of asthma symptoms, the highest spikes in asthma-related ED visits usually occur each year in the fall, beginning in September.
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ICD-9 to ICD-10: An Upgrade

The year 2014 is bringing a lot of changes for the health care industry, including the ICD-10 compliance date. ICD is the classification used to code and classify diseases. The ICD has been revised periodically to incorporate changes in the medical field. To date, there have been 10 revisions of the ICD. On October 1st, 2014 all of the ICD-9 code sets that were previously used will be replaced by ICD-10 code sets. This transition is required for everyone covered by HIPAA.
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Dr. Andrew Walsh to Present at 2014 CSTE Conference

It has just been announced that Dr. Andrew Walsh of HMS will be giving a poster presentation on his abstract, Visualizing Spatio-Temporal Patterns of Emergency Department Utilization during a Polar Vortex at the 2014 CSTE Annual Conference in Nashville, TN.
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The HIE: Part 1

One of the great mysteries of the recent healthcare reform movement is why “HIE” has been used as the acronym for both Health Insurance Exchanges and Health Information Exchanges. As the Affordable Care Act health insurance exchanges continue to garner media coverage, the original HIEs—health information exchanges—continue to struggle.
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Urgent Care and Mini Clinics – the Donut Hole in Syndromic Surveillance

doughnut-1023028-mIn recent years the range and availability of ambulatory care service providers has continued to grow. These include urgent care centers, mini clinics, and so-called “Doc in a box” providers. While the emergence of these services benefits consumers on many levels, it also creates a potentially serious “donut hole” in regional syndromic surveillance. A proliferation of these facilities can lead to diminished accuracy and efficacy of the population health data that’s made available, which can result in potentially serious negative consequences…for both public health officials and the communities they serve.
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In Development: Hospital Readmissions Tracking Tool

In light of the recent Medicaid changes regarding hospital readmissions within a 30 large_readmitday time period, HMS is working to create a tool which will allow facilities to track readmissions.

Beginning on October 1, 2012, section 3025 of the Affordable Care Act added section 1886(q) to the Social Security Act establishing the Hospital Readmissions Reduction Program (HRRP). The HRRP has imposed a financial penalty on hospitals with many readmissions during a certain timeframe. The HRRP defines readmission as a patient who is readmitted to the same or another hospital within a 30-day time period. It excludes certain readmissions, such as transfers to another hospital. The goal of this penalty is to encourage improvements to patient care and reduce Medicare costs.
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Population Health and the Polar Vortex

This winter’s “polar vortex” has led to discussions about everything from the devastating effects sub-zero temperatures can have on homeless populations, to the difficulties it’s caused marathon runners in training, and the dangers extreme cold can pose to pets.

Here at HMS, we saw several state public health departments use EpiCenter to implement a cold weather classifier that would enable them to track the number of injuries related to the extreme cold. This tool allowed for the tracking and analysis of emergency department registrations with chief complaints containing phrases like “out in the cold,” “no heat,” “hypothermia,” “frostbite,” and “exposure.” Observing event-specific data in situations like these allows public health to track the overall health of the population, and also to monitor the effectiveness of public outreach efforts and public health warnings.

New Jersey used EpiCenter to create a cold-related injury classifier with input from HMS, which they utilized in conjunction with their Super Bowl surveillance. Ohio created their own, separate cold-related injury classifier in EpiCenter and then shared the SAS code for that classifier with the International Society for Disease Surveillance (ISDS). Several other regions, including Indiana, New Hampshire, Washington, and Boston, then implemented the same code in their own cold weather surveillance.

During the first round of severely cold temperatures on January 6th, 7th, and 8th, temperatures in Ohio dropped well below zero degrees Fahrenheit. As could be expected, they observed a surge in ED visits due to cold-related injuries, with visit numbers peaking on the 8th. After that initial cold snap, Ohio initiated public health messages warning the population about taking precautions to seek shelter and stay out of the cold. The second cold snap on January 28th and 29th, during which temperatures dropped even lower, yielded dramatically fewer emergency department visits, a trend that Ohio’s public health officials believe can be attributed in part to the warnings they issued following the initial burst of below-freezing temperatures.

Cold

Cold-Related Injury ED visits in Ohio

The availability of this sort of data is opening doors for research on the relationships between public policy measures and emergency department utilization. For example, January’s cold-related injury data could be leveraged in conjunction with information about the capacity of homeless shelters and auxiliary facilities to assess the effects of public policy on the numbers of emergency department visits. Several state public health departments have also created heat-related injury classifiers in preparation for summer; as this sort of data becomes more widely available via tools like EpiCenter, we look forward to seeing the new ways public health discovers to more effectively monitor and improve population health.

The ACA, Urban Legends, and Data

For years an urban legend has circulated that the poor and uninsured use emergency departments as a substitute for a doctor visit because hospitals are non-profits and won’t turn these sick and injured patients away.

You don’t have to be in healthcare or public health to “know” that hospitals won’t or can’t turn anyone away. The overcrowded, underfunded “county” hospital is a common trope in television and movies; County General Hospital of “ER” fame is probably the most prominent example. The fictional doctors there routinely treated the indigent and homeless, and their outrage at greedy private hospitals dumping uninsured patients on their doorstep was a recurring plot point.

This practice of transferring patients who don’t have insurance and can’t pay for treatment has occurred, and has been covered by news outlets. It was one of the reasons for the creation of the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA), which instituted penalties for hospitals that denied emergency care to patients that required it. That law, and the fact that most institutions already practiced a policy of treating all emergency patients, likely contributed to the urban legend.

Even Snopes, the Internet clearinghouse for all urban legends, has weighed in on the topic, albeit indirectly. It addresses the specific question of a high profile hospital delivering more babies to illegal immigrants than legal residents. The recent political focus on immigration has brought that particular consequence of EMTALA and related legislation into the national consciousness.

But does this popular understanding of how emergency departments and EMTALA work reflect reality? Do the un(der)insured use emergency departments as a substitute for primary care providers, and do they do it because they can’t be turned away?

To begin with, let’s consider the implications of the EMTALA more closely. While it does protect patients who require emergency treatment and does include provisions for women in labor (making it relevant to the immigration conversation), the law does not mandate that all patients be treated for every complaint. If a qualified medical professional determines that there is no emergency, the patient can be turned away. This limits the ability to use emergency departments for preventive care, treating minor injuries and illness, and other primary care functions.

A recent report in JAMA by Raven et al would seem to bear this out. In an examination of nearly 35,000 emergency department visits, only 6% were found to be “primary care treatable.” Furthermore, of those 6%, nearly 90% had chief complaints identical to visits that did qualify as emergencies. Therefore, it may very well be that most nonurgent emergency department visits are not actually preventable by providing insurance to all individuals so they can get primary care. Instead, those visits may result from legitimate ambiguity on the patient’s part about the nature of their condition.

This was also corroborated in Massachusetts, where recent reforms improved access to insurance. A study by Smulowitz et al in the Annals of Emergency Medicine found that while low-severity visits to emergency departments were reduced after the reform, and the reduction was highest among the uninsured and those with newly subsidized insurance plans, only a small percentage of all low-severity visits were eliminated. Presumably other factors besides insurance were leading to the choice of the emergency department for healthcare.

The ACA and Syndromic Surveillance

Now that the ACA (aka “Obamacare”) has gotten past the government shutdown, past the debt ceiling crisis, and is almost to grandmother’s house (once the website is up and working), it’s time to think about how it will affect surveillance. 

Syndromic surveillance relies upon emergency department chief complaints for early indications of population health events.  Emergency department chief complaints work well for population surveillance because they provide early data on potentially severe cases and are widely available from most facilities.

Since this type of surveillance is tied so closely to emergency department utilization, it is affected by changes in the healthcare seeking behavior of the sick and injured.   It is also an excellent method of measuring the impact of the ACA.

Will the ACA result in an overall decrease in emergency department usage?

For years an urban legend has circulated that the poor and uninsured use emergency departments as a substitute for a doctor visit because hospitals are non-profits and won’t turn these sick and injured patients away.  In theory, the ACA will provide health insurance coverage to this group and they can then go to the doctor of their choice.

This thinking is part of the motivation for expanding state Medicaid programs and providing insurance subsidies.  Hospitals will no longer be subsidizing indigent care, costs won’t be transferred to other, insured patients.  Hospitals, especially those in urban poor centers will be better able to serve their community and in turn the health of the community will improve.

Improved health through earlier access to care is expected to further reduce emergency department visits, along with costs.  An average emergency department visit costs nearly ten times a visit to the doctor’s office.

This all sounds good.  Unless, of course, the premise is unsound. If that is the case, the ACA could even raise emergency department visits.

The key to untangling this is understanding the health seeking behavior of the sick and injured.  It seems like a simple question, but why does someone seek healthcare and how do they pick their provider?

Bringing this home to Health Monitoring Systems, we are beginning to look at how EpiCenter could measure the impact of policy on healthcare utilization.  On the flip side, we are also considering whether and how EpiCenter’s analysis will be impacted by healthcare reform.