COVID-19 driven decline in emergency visits: Has it continued, is it permanent, and what does it mean for emergency physicians?

INTRODUCTION: Hospital-based emergency departments have been a sustained source of overall hospital utilization in the United States. In 2019, an estimated 150 million hospital-based emergency department (ED) visits occurred in the United States, up from 90 million in 1993, 108 million in 2000 and 137 million in 2015. This study analyzes hospital ED visit registration data pre and post to the COVID-19 pandemic describe the impact of on hospital ED utilization and to assess long-term implications of COVID and other factors on the utilization of hospital-based emergency services. METHODS: We analyze real-time hospital ED visit registration data from a large sample of US hospitals to document changes in ED visits from January 2020 through March 2022 relative to 2019 (pre-COVID baseline) to describe the impact of the COVID-19 pandemic on EDs and assess long-term implications. RESULTS: Our data show an initial steep reduction in ED visits during the first half of 2020 (compared to 2019 levels) with rebounding occurring in 2021, but never reaching pre-pandemic levels. Overall, ED visit volumes across the study states declined in each year since 2019: 2020 declined by -18%, 2021 by -10% and the first quarter of 2022 is -12% below 2019 levels. CONCLUSIONS: There is a wide range of potential long-term implications of the observed reduction in the demand for hospital-based emergency services not only for emergency physicians, but for hospitals, health plans and consumers.

Spending and mortality in US acute care hospitals.

BACKGROUND: Despite evidence that greater US Medicare spending is not associated with better quality of care at a regional level, recent studies suggest that greater hospital spending is associated with lower risk-adjusted mortality. Studies have been limited to older data, specific US states and conditions, and the Medicare population. OBJECTIVES: To analyze the association between hospital spending and risk-adjusted inpatient mortality for 6 major medical conditions in US acute care hospitals. STUDY DESIGN: Retrospective cohort study of risk adjusted inpatient mortality, with hospital spending taken from the Dartmouth Atlas of Health Care. The study population included 2,635,510 patients admitted to 1201 US hospitals between 2003 and 2007. METHODS: Patient-level logistic regression models were used to estimate the effect of hospital spending on inpatient mortality, controlling for mortality risk, comorbidities, community characteristics (eg, median household income in a patient's zip code), hospital volume and ownership, and admission year. RESULTS: Patients treated at hospitals in the highest spending quintile (relative to the lowest) had lower risk-adjusted inpatient mortality for acute myocardial infarction (odds ratio [OR] 0.751, 95% confidence interval [CI] 0.656-0.859), congestive heart failure (OR 0.652, 95% CI 0.560-0.759), stroke (OR 0.852, 95% CI, 0.739-0.983), and hip fracture (OR 0.691, 95% CI 0.545-0.876). Greater spending was associated with lower mortality primarily in nonteaching hospitals, hospitals with fewer than the median number of beds, and nonprofit/public hospitals. CONCLUSIONS: Greater hospital spending is associated with lower risk-adjusted inpatient mortality for major medical conditions in the United States.

Medicare HMO impact on utilization at the end of life.

OBJECTIVE: To estimate the effect of independent practice association (IPA) model HMOs and the Kaiser Foundation Health Plan's group model on inpatient utilization of Medicare beneficiaries in the last 2 years of life, compared with traditional fee-for-service (FFS) coverage. STUDY DESIGN: Data from the Centers for Medicare & Medicaid Services were linked to inpatient discharge data from the California Office of Statewide Health Planning and Development for 1991-2001. A sample of aged Medicare beneficiaries who died between January 1998 and June 2001 and were continuously enrolled during the 2 years before death in (1) FFS (n = 234,498), (2) an IPA (n = 109,577), or (3) Kaiser (n = 29,434) were selected. METHODS: The probability of at least 1 hospitalization, number of inpatient days given at least 1 hospitalization, and total inpatient days per year in the last 2 years of life were estimated for each subgroup. A 2-part regression model, which adjusted for age, sex, Medicaid status, race, ethnicity, and chronic condition associated with the last hospitalization, was applied to determine the HMO-FFS difference in inpatient utilization during the last 2 years of life. RESULTS: During their last 2 years of life, decedents in IPAs and Kaiser used approximately 34% and 51% fewer inpatient days, respectively, than decedents in FFS. CONCLUSIONS: Medicare beneficiaries who died while enrolled in an HMO, particularly Kaiser, had many fewer hospital days during the 2 years before death than beneficiaries who died with FFS coverage.

Effect of disease management on prescription drug treatment: what is the right quality measure?

Measures of medication adherence have become common parameters with which disease management (DM) programs are being evaluated, leading to the question of how this concept should be measured in the particular context of a DM intervention. We hypothesize that DM improves adherence to prescriptions more than the rate with which prescriptions are being filled. We used health plan claims data to construct 13 common measures of medication adherence for five chronic conditions. The measures were operationalized in three different ways: the Prescription Fill Rate (PFR), which requires only one prescription; the Medication Possession Ratio (MPR), which requires a supply that covers at least 80% of the year; and the Length of Gap (LOG), which requires no gap greater than 30 days between prescriptions. We compared results from a baseline year to results during the first year of a DM program. Changes in adherence were quite small in the first year of the intervention, with no changes greater than six percentage points. In the intervention year, three measures showed a significant increase based on all three operational definitions, but two measures paradoxically decreased based on the PFR. For both, the MPR and the LOG suggested either no change or significant improvement. None of the MPR and LOG measures pointed toward significantly lower compliance in the intervention year. Different ways to operationalize the concept of medication adherence can lead to fundamentally different conclusions. While more complex, MPR- and LOG-based measures could be more appropriate for DM evaluation. Our initial results, however, need to be confirmed by data covering longer term follow-up.

The effect of medicare health maintenance organizations on hospitalization rates for ambulatory care-sensitive conditions.

OBJECTIVE: The objective of this study was to estimate the effect of Medicare Health Maintenance Organization (HMO) enrollment on hospitalization rates and total inpatient days for ambulatory care-sensitive conditions (ACSCs) after controlling for selection. RESEARCH DESIGN: Simultaneous equations using a discrete factor selection model are used to estimate the probability of HMO enrollment, hospitalization rates, and total inpatient days for ACSCs. SUBJECTS: Enrollment data on Medicare beneficiaries in California were linked to hospital discharge data from the California Office of Statewide Health Planning and Development for January through December 1996. The following beneficiaries were excluded: 1) end-stage renal disease, 2) under 65 years of age, 3) not covered by both Medicare Part A and Part B, 4) switched between HMOs and fee-for-service (FFS), and 5) switched between HMOs. The sample was stratified by age, gender, race, county, disability, Medicaid eligibility, HMO status, and death. A 2% random sample from the 4 California counties with the largest Medicare enrollment yielded 10,448 HMO enrollees and 11,803 FFS beneficiaries. RESULTS: Using a discrete factor selection model, we estimated the rate of ACSC hospitalizations among FFS beneficiaries would decline from 51.2 to 44.2 per 1000 if all FFS beneficiaries joined an HMO. Similarly, the mean total inpatient days for ACSC hospitalizations would be reduced from 7.5 days to 5.1 days if all FFS beneficiaries joined an HMO. CONCLUSIONS: After controlling for selection, Medicare HMO enrollees have lower hospitalization rates and fewer total inpatient days for 15 ACSCs than Medicare FFS beneficiaries. These findings suggest selection of healthier beneficiaries into HMOs does not completely explain their lower rates of ACSC hospitalization.

The effect of HMOs on the inpatient utilization of medicare beneficiaries.

OBJECTIVE: To determine the effect of joining HMOs (health maintenance organizations) on the inpatient utilization of Medicare beneficiaries. DATA SOURCES: We linked enrollment data on Medicare beneficiaries to patient discharge data from the California Office of Statewide Health Planning and Development (OSHPD) for 1991-1995. DESIGN AND SAMPLE: A quasi-experimental design comparing inpatient utilization before and after switching from fee-for-service (FFS) to Medicare HMOs; with comparison groups of continuous FFS and HMO beneficiaries to adjust for aging and secular trends. The sample consisted of 124,111 Medicare beneficiaries who switched from FFS to HMOs in 1992 and 1993, and random samples of 108,966 continuous FFS beneficiaries and 18,276 continuous HMO enrollees yielding 1,227,105 person-year observations over five years. MAIN OUTCOMES MEASURE: Total inpatient days per thousand per year. PRINCIPAL FINDINGS: When beneficiaries joined a group/staff HMO, their total days per year were 18 percent lower (95 percent confidence interval, 15-22 percent) than if the beneficiaries had remained in FFS. Total days per year were reduced less for beneficiaries joining an IPA (independent practice association) HMO (11 percent; 95 percent confidence interval, 4-19 percent). Medicare group/staff and IPA-model HMO enrollees had roughly 60 percent of the inpatient days per thousand beneficiaries in 1995 as did FFS beneficiaries (976 and 928 versus 1,679 days per thousand, respectively). In the group/staff model HMOs, our analysis suggests that managed care practices accounted for 214 days of this difference, and the remaining 489 days (70 percent) were due to favorable selection. In IPA HMOs, managed care practices appear to account for only 115 days, with 636 days (85 percent) due to selection. CONCLUSIONS: Through the mid-nineties, Medicare HMOs in California were able to reduce inpatient utilization beyond that attributable to the high level of favorable selection, but the reduction varied by type of HMO.

Inpatient utilization by dual Medicare-Medicaid eligibles in Medicare risk HMOs and fee for service, California, 1991-1996.

Inpatient use among dual Medicare-Medicaid eligible beneficiaries in California Medicare HMOs and fee-for-service plans from 1991 to 1996 was compared, using a unique dataset that links Medicare enrollment data to inpatient discharge data. Dual eligibles in HMOs were found to have lower discharge rates, shorter lengths of stay, and fewer inpatient days than dual eligibles in the traditional fee-for-service system. Both, however, had higher discharge rates and inpatient days than non-dual-eligible beneficiaries. The results are consistent with previous findings documenting the high cost of dual eligibles, with the lower use in HMOs likely the result of differences in beneficiary characteristics and delivery of care between systems.