ABSTRACT
BACKGROUND: Potentially avoidable hospitalizations expose patients to unnecessary iatrogenic harm, undue financial burden, and emotional stress.We previously have published that during the first 6 months of the COVID-19 pandemic, potentially avoidable hospitalizations fell by 50.3% among non- Hispanic White patients, compared to only 8.0% among African American patients at a large urban health system. Understanding the financial ramifications of this disparity is an important part of designing health policy to redress the downstream impacts of COVID-19-related healthcare inequities. METHODS: This pre-post study included 904 potentially avoidable hospitalizations (defined per the Agency for Healthcare Research and Quality guidelines) at a large urban health system between March 1 - August 31 of 2019 (pre- COVID period) and March 1 - August 31 of 2020 (COVID period). Excess healthcare expenditures were estimated from the difference in cost of potentially avoidable hospitalizations between non-Hispanic White and African American patients using hospital financial data. Lost productivity was calculated using the human capital approach by estimating the indirect cost of absenteeism from patient-specific length of stay and county wage data. County wage data was obtained from the 2020 Labor Force Statistics (U.S. Bureau of Labor Statistics) and the 2019 American Community Survey (U.S. Census Bureau). RESULTS: While African American patients experienced only a modest reduction in potentially avoidable hospitalizations (8.0%), if they had experienced the same reduction as non-Hispanic White patients (50.3%), expenditures would have been reduced by $6,587,669 during the first 6- months of the COVID-19 pandemic within this single health system. Expanding this calculation to include other minoritized groups (Asian and Latinx patients) yielded $10,465,551 in lost healthcare savings over 6 months. Non-Hispanic White patients experienced a 22.6% reduction ($111,930 to $86,601) in foregone wages, whereas African American patients experienced an increase in foregone wages of 39.5% ($24,460 to $34,113) despite having fewer hospitalizations over this time period. CONCLUSIONS: If racial/ethnic minority patients experienced comparable reductions in potentially avoidable hospitalizations as non-Hispanic White patients, expenditures at this large urban health system would have been reduced by $10.46 million during the first 6-months of the COVID-19 pandemic. Additionally, we found that the financial harms of forgone wages disproportionately burdened African American patients compared to non- Hispanic White patients. While financial cost is not the only outcome of interest when examining avoidable admissions, these findings further inform the need to develop interventions and policies to prevent avoidable admissions by improving outpatient and self- care in order to combat these disparities. Future research is needed to ascertain whether some of these reductions in avoidable admissions may have been harmful.
ABSTRACT
BACKGROUND: Ensuring appropriate outpatient follow-up is a mainstay of Emergency Medicine to avoid poor patient outcomes. During the COVID-19 pandemic, many post-ED discharge visits were rapidly transitioned from inperson to telehealth. Our study investigates the associations between ED recidivism or subsequent hospitalization after either telehealth or in-person visits follow-up visits. We hypothesize that telehealth visits are less successful than in-person visits at preventing either outcome. METHODS: This retrospective study used electronic health record data from an urban academic health system. All adult patients were included if they presented to either of two in-system EDs between 1/1/20 - 10/31/21 with a chief complaint of chest pain, syncope, abdominal pain, or altered mental status. If patients had multiple ED visits, only their first was included. The post-ED follow-up window was restricted to two weeks. We used multivariate logistic regressions, which controlled for patient age, sex, race, ethnicity, primary language, insurance type, and social vulnerability index, to estimate the association between the type of post-ED follow-up and two outcomes within 30 days after the follow-up appointment: 1) returning to the ED or 2) hospitalization. RESULTS: Of 23,856 ED visits that met criteria, 10,180 (42%) had follow-up telehealth visits, 3,925 (16%) had in-person follow-up, and 9,760 (40%) had no follow-up. A total of 2,119 (9%) patients returned to the ED after their follow-up: 12% of whom had telehealth visits, 7% had in-person visits, and 6% had no follow-up visit. 684 (3%) of patients were admitted: 6% of those with telehealth visits, 2% with in-person visits, and 0.2% with no follow-up visit. Compared to having no visit, telehealth visits were associated with an adjusted OR (aOR) of returning to the ED of 2.7 (95% CI, 2.4 -3.1), and in-person visits were associated with an aOR of 1.8 (95% CI, 1.5 -2.1). Compared to those with an in-person visit, telehealth follow-up was associated with an aOR of 1.5 (95% CI, 1.3 -1.8) of returning to the ED. Compared to having no visit, telehealth visits were associated with an aOR of 27.8 (95% CI, 17.4 -44.4), and in-person visits were associated with an aOR of 12.1 (95% CI, 7.2 -20.1) of hospitalization. Compared to those with an in-person visit, telehealth was associated with an aOR of 2.3 (95% CI, 1.8 -2.9) of hospitalization. All aORs were significant with p < 0.001. CONCLUSIONS: Telehealth follow-up visits were associated with higher odds of returning to the ED and hospitalization compared to in-person visits;though some of this association is likely due to patients who are sicker choosing telemedicine over in-person, this finding also suggests in-person follow-up may be more effective than telehealth at decreasing repeat ED visits and hospitalizations. Further analysis that adjusts for patient comorbidities and illness severity will help us to better understand the impact of post-ED followup on ED recidivism and hospitalization.