houston hospitals emergency department use study · 2. primary care-sensitive visits per month,...
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HOUSTON HOSPITALS
EMERGENCY DEPARTMENT USE STUDY
January 1, 2004 through December 31, 2004
FINAL REPORT
Prepared By
School of Public Health University of Texas Health Science Center at Houston
Charles Begley, Manish Aggarwal, Keith Burau, Hyvan Dang
For
Gateway to Care
January 2006
1
TABLE OF CONTENTS
I. Executive Summary ........................................................................................2 II. Purpose .............................................................................................................9 III. Methods ..........................................................................................................10 IV. Results ............................................................................................................14
ED Visits by Type……………………………………………………………….15
Summary Tables and Figures
ED Visits by Month, Day of Week, and Time of Day…………………………18 Summary Tables and Figures
ED Visits by Characteristics of Patients……………………………………….21
Summary Tables and Figures
ED Visits by Primary Diagnoses……………………………………………….32
Summary Tables and Figures
ED Visits by Patient Residence………………………………………………...34
Summary Maps
V. 2002-2004 Comparison……………………………………………………..41
Summary Tables and Figures
2
I. EXECUTIVE SUMMARY
Houston/Harris County hospitals’ emergency departments have become major providers
of primary care, particularly for low-income uninsured people unable or unwilling to access
basic medical services at private or public clinics or doctor’s offices. Under the sponsorship of
Gateway to Care, the University Of Texas School Of Public Health has been collecting and
analyzing emergency department visit data in major Harris County hospitals to monitor primary
care-related use of the emergency room. This report provides an analysis of 2004 ED visit data
and describes trends over the last three years.
Data and Analysis
Sixteen hospitals which have large emergency departments (EDs) and provide a
substantial amount of discounted and free care to the uninsured of Harris County have provided
ED visit data in 2004. They include: two hospitals of the Harris County Hospital District, Ben
Taub General, and LBJ General; eight hospitals of the Memorial Hermann Health Care System,
Memorial Hermann, Memorial Hermann Southwest, Memorial Hermann Southeast, Memorial
Hermann Northwest, Memorial Hermann The Woodlands, Memorial Hermann Memorial City,
Memorial Hermann Katy, and Memorial Hermann Fort Bend; three hospitals of the Hospital
Corporation of America, Bayshore Medical Center, Spring Branch Medical Center and East
Houston Regional Medical Center; CHRISTUS St. Joseph Hospital; Texas Children’s Hospital;
and St. Luke’s Episcopal Hospital. Together, these hospitals reported $1.1 billion in
uncompensated care in 2003, representing 61% of total uncompensated care reported by all
hospitals in the county.1
1 Center for Health Statistics, Texas Department of State Health Services, December 2004.
3
Each hospital supplied the following data elements on all ED visits not requiring
admission that were made during the period January 1, 2004 through December 31, 2004:
1. Date and time of admission to ED 2. Primary and secondary discharge diagnosis 3. Discharge date and time 4. Payment source 5. Patient age 6. Patient gender 7. Patient race/ethnicity 8. Patient zip code 9. Employment status 10. Where discharged to (e.g. home, nursing home, etc.)
The probability that each visit was one or more of the following types of visits was
assigned based on applying the New York University ED Algorithm to the discharge diagnosis.
1. Non-emergent: Immediate treatment was not required within 12 hours. 2. Emergent-Primary Care Treatable: Treatment was required within 12 hours, but
could have been provided effectively and safely in a primary care setting. Continuous observation was not required, no procedures were performed or resources used that are not typically available in a primary care setting.
3. Emergent-ED Care Needed-Preventable/Avoidable: ED care was required within
12 hours, but the emergent nature of the condition was potentially preventable/ avoidable if timely/continuous primary care had been received for the underlying illness.
4. Emergent-ED Care Needed-Not Preventable/Avoidable: ED care was required
within 12 hours and primary care could not have prevented the condition.
The frequencies of visits for each diagnosis were multiplied by their respective
probabilities of visit type and then the number of visit types was aggregated for all diagnoses to
produce estimates of the total number of ED visits by type. ED visits in the first three categories
are considered primary care-sensitive use of the ED. Those in the fourth category reflect non-
primary care-sensitive use of the ED. The time and geographic pattern of primary care and non-
4
primary care-sensitive ED visits are summarized in the report. In addition, the demographic,
coverage, and health conditions of patients with primary care and non-primary care-sensitive
visits are shown. The Executive Summary and main body of the report presents 2004
information for fifteen of hospitals. The comparison of 2002, 2003 and 2004 data is for eleven
hospitals for which three years of data are available.
2004 Results
1. Total ED Visits by Type
♦ During 2004, 585,328 ED visits were made to the hospitals in Houston by Harris
County residents, (Table IV.1). This represents about half of the 1.05 million non-
admission ED visits made to all hospitals in the county.
♦ 54.5% of all ED visits by Harris County residents were primary care-sensitive. This
represents 83.1% of categorizable ED visits (Table IV.1).
♦ Over one quarter of ED visits (23.3%) were non-emergent (Table IV.1). About the
same percentage (23.4%) were primary care treatable. This represents 35.6% and
35.7% respectively, of categorizable visits (Table IV.1).
♦ 21, 459 ED visits had either a primary or secondary diagnosis that was behavioral
health-related, representing 3.8%.
2. Primary Care-Sensitive Visits Per Month, Day, and Time
• Harris County residents make 30,000-34,000 visits each month to these hospitals
(Figure IV.2). Primary care-sensitive ED visits range from 25,000 to 28,500 a month.
• The largest number of primary care-sensitive visits per day occurs on Mondays,
declining each day thereafter (Figure IV.3).
5
• Most ED visits occurred during the hours of 8 am to 11 pm (Figure IV.4).
3. Primary Care-Sensitive Visits by Patient Characteristics
• 37.8% of primary care-sensitive visits were by patients who were uninsured, 30.9%
had Medicaid, and 28.8% had private insurance or Medicare (Figure IV.5).
• 34.7% of primary care-sensitive visits were by Blacks, 38.8% Hispanics, and 21.4%
Whites, 2.8% Other, and 1.2% Asian (Figure IV.6).
• 56.2% of primary care-sensitive visits were by adults age 18-64, 38.1% were children
and youth age 0-17, and 5.8% were older adults age >65 (Figure IV.7).
• 57.0% of primary care-sensitive visits were by females, 42.9% were by males and
0.1% by unknown (Figure IV.8)
• Patients with Medicaid had the highest proportion of ED visits that were primary
care-sensitive (86.6%), followed by other private (85.4%) and then followed by the
uninsured (84.2%) (Table IV.3, Figure IV.9).
• Race/ethnicity groups with the highest proportion of visits primary care-sensitive
were Blacks 85.0 % and Hispanics 83.7% (Table IV.3, Figure IV.10).
• The proportion of visits that were primary care-sensitive was 87.5% for children and
81.2% for adults between the ages of 18-64, and 75.6% for ages 65 and older (Table
IV.3, Figure IV.11).
• Males had slightly higher rates of primary care-sensitive visits than females (83.7%
vs. 83.1%) (Table IV.3, Figure IV.12).
4. Health Conditions of Patients with Primary Care-Sensitive Visits
6
The five most frequent diagnoses of patients with primary care-sensitive visits were: acute upper
respiratory infection (unspecified site), otitis media (unspecified), fever, gastroenteritis, and
urinary tract infection (Table IV.4).
• The five most frequent diagnoses of patients with non-primary care-sensitive visits
were: chest pain (unspecified), fever, abdominal pain, chest pain (other), and syncope
& collapse (Table IV.5).
5. Geographic Distribution of Patients with Primary Care-Sensitive Visits
• Residents in zip codes nearest the hospitals have the highest frequency of ED visits
(Map IV.1).
• Residents in inner-city and suburban zip codes in the east, northeast, and south have
the highest rates of ED visits (Map IV.2).
• Residents in zip codes nearest the hospitals have the highest frequency of primary
care sensitive ED visits (Map IV.3)
• Residents in inner-city and suburban zip codes in the east, northeast, and south have
the highest rates of primary care sensitive ED visits (Map IV.4).
• Residents in zip codes that are relatively near the hospitals and have large numbers of
uninsured have the highest frequency of primary care sensitive ED visits (Map IV.5).
• Among the uninsured, the highest rates of primary care sensitive ED visits to Houston
hospitals are patients from inner city zip codes, particularly in the northeast and south
(Map IV.6).
2002-2004 Comparison
7
♦ ED visits in eleven hospitals (includes two hospitals of the Harris County Hospital
District, Ben Taub General, and LBJ General; eight hospitals of the Memorial
Hermann Health Care System, Memorial Hermann, Memorial Hermann Southwest,
Memorial Hermann Southeast, Memorial Hermann Northwest, Memorial Hermann
The Woodlands, Memorial Hermann Memorial City, Memorial Hermann Katy, and
Memorial Hermann Fort Bend; CHRISTUS St. Joseph Hospital; Texas Children’s
Hospital; and St. Luke’s Episcopal Hospital) increased from 465,909 in 2002 to
485,882 in 2003, a 4.3% increase and decreased to 408,199 in 2004, a 16% decline
(Table V.1). The percentage of visits that were primary care-sensitive rose from
52.1% to 53.3% to 54.8% of total visits and from 81.5% to 81.9% to 83.5% of
categorized visits in consecutive years. Most of the increase in primary care-sensitive
visits occurred in the non-emergent category.
♦ There was a change in payer mix away from commercial insurance (declined from
about 25% to 20%) and toward the Medicaid (increase from 20% to 25%) and
uninsured (increased from 40% to 45%) (Figure V.1).
♦ Patients making primary care-sensitive visits continue to be predominantly Black and
Hispanic adults age 18-64 (Figure V.2, V.3). The proportion Black has remained
about the same. The proportion of Hispanics grew from about 27% to over 35%
(Figure V.2, V.3).
♦ The use of safety net hospital emergency rooms for primary care-related services
continues to vary by zip code, with the majority of uninsured residents in the central,
southern, and northeastern zip codes in 2004 having the highest rates (Map IV.6).
8
Conclusions
There was a decline in total ED visits in Houston hospitals in 2004.
A growing majority of ED visits are for primary care-sensitive conditions.
About half of all primary care-sensitive visits are made by the uninsured and more than
75% by the combined uninsured and Medicaid populations.
The frequency of primary care-sensitive visits to hospital EDs is relatively constant on a
monthly and daily basis.
Most primary care-sensitive visits to the ED occur during the day when other physicians
and clinics are available.
The uninsured, Medicaid, children, Blacks and Hispanics have higher rates of primary
care-sensitive visits.
The zip codes with the highest rates of primary care-sensitive ED visits are in the central,
northeast, and southern areas of the city.
9
II. PURPOSE
The increasing number of hospital emergency department visits, many of which are
primary care-related, is leading to a multitude of associated issues regarding equity and access to
care in the U.S. One of the most pressing issues in Houston is the capacity of hospitals to
provide emergency care when emergency rooms are crowded with patients seeking basic care.
The main purpose of this study is to provide information on the frequency, type, and distribution
of ED visits in Houston hospitals that are primary care-related. To achieve this purpose, the
study obtained ED data from fifteen major hospitals in Houston for 2004, classified the visits of
Harris County residents in terms of primary care-sensitive/non-primary care-sensitive use of the
ED, and examined the demographic, coverage, and geographic characteristics of patients making
the visits. The goal is to replicate the study over time in order to determine trends and evaluate
primary care enhancement activities.
10
III. METHODS
The study resulted from a partnership between Gateway to Care, the Harris County
Hospital District (HCHD), and The University of Texas School of Public Health (UTSPH). In
2002, UTSPH worked with Gateway to Care on a pilot study to develop a process for monitoring
ED use in Houston. The process developed in the pilot study was then applied to 11 hospitals in
2002 (two hospitals of the Harris County Hospital District, Ben Taub General, and LBJ General;
eight hospitals of the Memorial Hermann Health Care System, Memorial Hermann, Memorial
Hermann Southwest, Memorial Hermann Southeast, Memorial Hermann Northwest, Memorial
Hermann The Woodlands, Memorial Hermann Memorial City, Memorial Hermann Katy, and
Memorial Hermann Fort Bend; and CHRISTUS St. Joseph Hospital). Data were obtained from
these hospitals and Texas Children’s Hospital, and St. Luke’s Episcopal Hospital in 2003. In
2004, data was collected from an additional three hospitals from the Hospital Corporation of
America system, Bayshore Medical Center, Spring Branch Medical Center and East Houston
Regional Medical Center.
The first step in the study involves requesting the following information on ED visits that
did not result in hospitalization at safety net hospitals:
1. Date and time of admission to ED 2. Primary and secondary discharge diagnosis 3. Discharge date and time 4. Payment source (payer codes from the Patient Data Set of the Texas Hospital
Association and the Texas Health Care Information Council) 5. Patient age 6. Patient gender 7. Patient race/ethnicity (Black, Asian, American Indian, Hispanic, White, Other,
Unknown) 8. Patient zip code 9. Employment status (Employed, Unemployed, Other, Unknown) 10. Where discharged to (e.g. home, hospital, etc)
11
Working with the hospitals, a dataset was obtained, reviewed, and cleaned comprising a full set
of ED visit information for the period January 1, 2004 – December 31, 2004.
The second step involved the application of the New York University ED Classification
Algorithm to classify ED visits of Harris County residents into the following four categories:
1. Non-emergent: Immediate treatment was not required within 12 hours.
2. Emergent-Primary Care Treatable: Treatment was required within 12 hours, but could have been provided effectively and safely in a primary care setting. Continuous observation was not required, no procedures were performed or resources used that are not typically available in a primary care setting.
3. Emergent-ED Care Needed-Preventable/Avoidable: ED care was required within
12 hours, but the emergent nature of the condition was potentially preventable/avoidable if timely/continuous primary care had been received for the underlying illness.
4. Emergent-ED Care Needed-Not Preventable/Avoidable: ED care was required
within 12 hours and primary care could not have prevented the condition.
The NYU Center for Health and Public Service Research and the United Hospital Fund
of New York developed the ED Algorithm as a measure of primary care-related ED use. The ED
Algorithm is a set of probabilities that when applied to the primary diagnosis (ICD-9 code) of the
patient estimates the likelihood that the patient’s ED visit was one or more of the types described
above. The ED algorithm was developed with the advice of a panel of ED physicians and is
based on information abstracted from a sample of complete ED records – 3,500 cases in 1994
and 2,200 cases in 1999 – from six Bronx, New York hospitals. The decision tree followed by
the panel is summarized below.
12
The distribution of ED visits by type represents the weighted sum of all visits with a
certain probability of being that type. ED visits in the first three categories are considered
primary care-sensitive use of the ED, while those in the fourth category reflect non-primary care-
related use of the ED. A number of visits are not categorized using the Algorithm. These
include injury, mental health-related, and alcohol or drug-related visits, and visits with missing
data. The ED Algorithm for these visits has not yet been developed by the NYU researchers.
Various analyses were conducted of the classified visit data to determine patterns of
primary care-sensitive and non-primary care-sensitive visits. These included monthly, daily, and
time of day patterns of visits; the distribution of visits by the coverage and demographic
characteristics of patients (payment source, race/ethnicity, age, employment status, and sex); the
distribution of visits by primary diagnosis (ICD9 Codes); and the distribution of visits by patient
residence using geo-coded maps.
The results of the analysis of ED visits should be treated cautiously and are best viewed
as indicators of utilization rather than a definitive assessment. This is because only a portion of
all visits that did not result in a hospitalization are collected and only a subset of those visits is
Emergent
Non-emergent
ED Care Needed
Primary Care Treatable
Primary Care Treatable
Not Preventable/Avoidable
Preventable/Avoidable
Step 1 Steps 2 and 3 Step 4
ED CLASSIFICATION PROCESS
13
categorized by the Algorithm. ED visits that result in a hospital admission usually encompass no
more than 10-20% of total visits.2 Presumably such visits would not fall into primary care-
sensitive categories nor would most injury visits that are not categorized. Given these limitations
in the methods, the percentage of visits that fall into the primary care-sensitive categories should
be interpreted as a conservative estimate and may underestimate the true value in the population.
2 Billings J, Using administrative data to monitor access, identify disparities, and assess performance of the safety net, U.S. Agency for Healthcare Research and Quality, 2003.
14
IV. RESULTS
ED Visits by Type
The fifteen hospitals in Houston reported 585,328 patients from Harris County with
usable ICD-9 diagnosis codes and zip codes (Table IV.1). 383,507 visits of Harris County
residents were categorized using the NYU algorithm (65.5%). Injury, behavioral health-related,
and unclassified visits due to incomplete data, which made up 34.5% of visits, were not
categorizable. Of the categorized ED visits, 83.1% (318,805) represented primary care-sensitive
use of the ED.
The most frequent type of primary care-sensitive visit was Non-Emergent (35.6%),
followed by Emergent-Primary Care Treatable (35.7%), and Emergent-ED Care Needed-
Preventable/Avoidable (11.8%) (Figure IV.1). Only 16.9% of ED visits to the safety set
hospitals were classified as Emergent-ED Care Needed-Not Preventable/Avoidable, reflecting
non-primary care-sensitive use of the ED.
15
Table IV.1: 2004 ED Visits at All Hospitals (16) by Harris County Residents
Type of Visit ALL
Number of Hospitals 16 CATEGORIZED VISITS
Non-Emergent 136,518 Emergent, Primary Care Treatable 136,936 Emergent, ED Care Needed – Preventable/Avoidable 45,351
Total Primary Care Sensitive Visits 318,805 Emergent, ED Care Needed – NOT Preventable/Avoidable 64,702
Total Categorized Visits 383,507 NON-CATEGORIZED ED VISITS
Injury 132,725 Mental Health Related 9,268 Alcohol or Drug Related 4,235 Unclassified 55,593
Total Non-categorized Visits 201,821 Total Visits 585,328
Percent
DETAIL - CATEGORIZED ED VISITS % Non-Emergent 35.6% % Emergent - Primary Care Treatable 35.7% % ED Care Needed - Preventable/Avoidable 11.8%
% Total Primary Care Sensitive 83.1% % ED Care Needed - NOT Preventable/Avoidable 16.9%
TOTAL % Non-Emergent 23.3% % Emergent - Primary Care Treatable 23.4% % ED Care Needed - Preventable/Avoidable 7.7%
% Total Primary Care Sensitive 54.5% % ED Care Needed - NOT Preventable/Avoidable 11.1%
% Categorized ED Visits 65.5% % Injury 22.7% % Mental Health Related 1.6% % Alcohol or Drug Related 0.7% % Unclassified 9.5%
% All Visits 100.0%
16
Figure IV.1: 2004 ED Visits at Houston Hospitals- Categorical Visits (N=16)
Emergent, Primary Care
Treatable36%
Non-Emergent35%
Emergent, ED Care Needed -
Preventable/Avoidable12%
Emergent, ED Care Needed -
NOT Preventable/Avoid
able17%
17
ED Visits by Month, Day of Week, and Time of Day
Harris County residents make 30,000-34,000 visits each month to Houston sixteen
hospitals (Figure IV.2). The largest volume of visits occurred during the month of January. The
lowest months were February and June. Primary care-sensitive ED visits range from 25,000 to
28,500 each month. The largest number of primary care-sensitive visits per day occurs on
Mondays, declining each day thereafter (Figure IV.3). Most ED visits occurred during the hours
of 8 am to midnight (Figure IV.4). Interestingly most primary care-sensitive visits to the ED
occur during the day when other physicians and clinics are available.
18
Figure IV.2
19
Figure IV.3
20
Figure IV.4
21
ED Visits by Characteristics of Patients
Of all primary care-sensitive visits, 37.8% resulted from patients who were uninsured,
68.7% were by patients who were either uninsured or on Medicaid, 73.5% were made by Blacks
and Hispanics, 56.2% occurred in adults age 18-64, 38% occurred in children age 0-17, 5.8%
occurred in adults age >65 (Figure IV.5-IV.7). Women accounted for 57.0% of primary care-
sensitive visits and men for 42.9% (Figure IV.8).
Patients with the highest percentage of primary care-sensitive ED visits were: Medicaid
(86.6%), patients with other private payment sources (85.4%), and uninsured patients (84.2%)
(Figure IV.9). Patients with Medicare, other government, and commercial insurance coverage
had proportions ranging from 77.3% to 77.8% to 79.4% respectively. The highest proportions
of primary care-sensitive visits were for Blacks (85.0%) and Hispanics (83.7%) (Figure IV.10).
The lowest proportion was for Whites (79.6%). The proportion of primary care-sensitive visits
was high for adults and children at 87.5% and 81.2% respectively (Figure IV.11). The
proportion of primary care sensitive visits were slightly higher in women (83.7%%) compared to
83.1% in men (Figure IV.12).
22
Table IV.2: ED Visits by Coverage and Demographic Characteristics of Patients
T ype o f VisitC o mmerc. M ' caid M 'care Ot her Go vOt her Pr iv U nins U nkno wn A ll C o mmerc. M 'caid M 'care Ot her Go vOt her Priv U nins nis&M caid
Non-Emergent 27956 39775 9011 1679 1380 55456 1261 136518 20.5% 29.1% 6.6% 1.2% 1.0% 40.6% 69.8%Emergent-Primary Care Treatable 29295 44644 9516 1817 551 49448 1665 136936 21.4% 32.6% 6.9% 1.3% 0.4% 36.1% 68.7%Emergent Care Needed-Prev/Avoid 9090 14222 4906 735 86 15735 577 45351 20.0% 31.4% 10.8% 1.6% 0.2% 34.7% 66.1%
T o tal P rimary C are Sensit ive 66341 98641 23433 4231 2017 120639 3503 318805 20.8% 30.9% 7.4% 1.3% 0.6% 37.8% 68.8%Emergent, ED Care Needed-NOT Prev/Avo 17257 15271 6864 1208 346 22604 1151 64701 26.7% 23.6% 10.6% 1.9% 0.5% 34.9% 58.5%
TOTAL Categorized Visits 83598 113912 30297 5439 2363 143243 4654 383506 21.8% 29.7% 7.9% 1.4% 0.6% 37.4% 67.1%TOTAL All Visits 136589 157133 47548 8237 13692 214449 7680 585328 23.3% 26.8% 8.1% 1.4% 2.3% 36.6% 63.5%
A sian B lack Hisp anicA m. Ind ian Ot her U nkno wn W hit e A ll A sian B lack Hisp anic A m.Ind ian Ot her U nkno wn W hit e
Non-Emergent 1779 47523 53235 94 3841 1446 28599 136517 1.3% 34.8% 39.0% 0.1% 2.8% 1.1% 20.9%Emergent-Primary Care Treatable 1663 45642 54893 78 3916 1460 29284 136936 1.2% 33.3% 40.1% 0.1% 2.9% 1.1% 21.4%Emergent Care Needed-Prev/Avoid 460 17452 15521 26 1247 422 10223 45351 1.0% 38.5% 34.2% 0.1% 2.7% 0.9% 22.5%
T o tal P rimary C are Sensit ive 3902 110617 123649 198 9004 3328 68106 318804 1.2% 34.7% 38.8% 0.1% 2.8% 1.0% 21.4%Emergent, ED Care Needed-NOT Prev/Avo 956 19509 24056 41 1946 738 17455 64701 1.5% 30.2% 37.2% 0.1% 3.0% 1.1% 27.0%
TOTAL Categorized Visits 4858 130126 147705 239 10950 4066 85561 383505 1.3% 33.9% 38.5% 0.1% 2.9% 1.1% 22.3%TOTAL All Visits 7924 185832 221290 326 17062 6172 146722 585328 1.4% 31.7% 37.8% 0.1% 2.9% 1.1% 25.1%
0 - 17 18 - 6 4 6 5+ A ll 0 - 17 18 - 6 4 6 5+
Non-Emergent 47229 82271 7018 136518 34.6% 60.3% 5.1%Emergent-Primary Care Treatable 55751 73622 7563 136936 40.7% 53.8% 5.5%Emergent Care Needed-Prev/Avoid 18369 23223 3759 45351 40.5% 51.2% 8.3%
T o tal P rimary C are Sensit ive 121349 179116 18340 318805 38.1% 56.2% 5.8%Emergent, ED Care Needed-NOT Prev/Avo 17392 41400 5909 64701 26.9% 64.0% 9.1%
TOTAL Categorized Visits 138741 220516 24249 383506 36.2% 57.5% 6.3%TOTAL All Visits 203477 343266 38585 585328 34.8% 58.6% 6.6%
F emale M ale U nkno wn B o t h Female M ale
Non-Emergent 80579 55927 12 136518 59.0% 41.0%Emergent-Primary Care Treatable 77522 59404 10 136936 56.6% 43.4%Emergent Care Needed-Prev/Avoid 23758 21591 2 45351 52.4% 47.6%
T o tal P rimary C are Sensit ive 181859 136922 24 318805 57.0% 42.9%Emergent, ED Care Needed-NOT Prev/Avo 38101 26593 8 64702 58.9% 41.1%
TOTAL Categorized Visits 219960 163515 32 383507 57.4% 42.6%TOTAL All Visits 318345 266936 47 585328 54.4% 45.6%
read horizontal
GEN D ER
P A YM EN T SOUR C E
R A C E/ ET H N IC IT Y
A GE
23
Figure IV.5: Primary Care-Sensitive Visits by Payment Source (N=16)
Medicaid, 30.9%
Medicare, 7.4%
Uninsured, 37.8%
Other Gov, 1.3%
Other Priv, 0.6%
Commerc., 20.8%
24
Figure IV.6: Primary Care-Sensitive Visits by Race/Ethnicity (N=16)
Asian, 1.2%
Black, 34.7%
Other, 2.8%
Unknown, 1.0%
White, 21.4%
Am.Indian, 0.1%
Hispanic, 38.8%
25
Figure IV.7: Primary Care-Sensitive Visits by Age (N=16)
0-17, 38.1%
18-64, 56.2%
65+, 5.8%
26
Figure IV.8: Primary Care-Sensitive Visits by Gender (N=16)
Female, 57.0%
Male, 42.9%
27
Type o f V isitC o mmerc. M 'caid M ' care Ot her Go vOt her Priv U nins. U nkno wn A ll C ommerc. M 'caid M 'care Ot her Go vOt her Priv U nins. A ll
Non-Emergent 27956 39775 9011 1679 1380 55456 1261 136518 33.4% 34.9% 29.7% 30.9% 58.4% 38.7% 35.6%Emergent-Primary Care Treatable 29295 44644 9516 1817 551 49448 1665 136936 35.0% 39.2% 31.4% 33.4% 23.3% 34.5% 35.7%Emergent Care Needed-Prev./Avo id. 9090 14222 4906 735 86 15735 577 45351 10.9% 12.5% 16.2% 13.5% 3.6% 11.0% 11.8%
Total Primary Care Sensitive 66341 98641 23433 4231 2017 120639 3503 318805 79.4% 86.6% 77.3% 77.8% 85.4% 84.2% 83.1%Emergent, ED Care Needed - NOT Prev./ 17257 15271 6864 1208 346 22604 1151 64701 20.6% 13.4% 22.7% 22.2% 14.6% 15.8% 16.9%
TOTAL Classified Visits 83598 113912 30297 5439 2363 143243 4654 383506 21.8% 29.7% 7.9% 1.4% 0.6% 37.4% 98.8%TOTAL All Visits 136589 157133 47548 8237 13692 214449 7680 585328 23.3% 26.8% 8.1% 1.4% 2.3% 36.6% 98.7%
A sian B lack HispanicA m.Ind ian Ot her U nkno wn W hit e A ll A sian B lack Hisp anicA m.Ind ian Ot her U nknown W hit e A llNon-Emergent 1779 47523 53235 94 3841 1446 28599 136517 36.6% 36.5% 36.0% 39.3% 35.1% 35.6% 33.4% 35.6%Emergent-Primary Care Treatable 1663 45642 54893 78 3916 1460 29284 136936 34.2% 35.1% 37.2% 32.6% 35.8% 35.9% 34.2% 35.7%Emergent Care Needed-Prev./Avo id. 460 17452 15521 26 1247 422 10223 45351 9.5% 13.4% 10.5% 10.9% 11.4% 10.4% 11.9% 11.8%
Total Primary Care Sensitive 3902 110617 123649 198 9004 3328 68106 318804 80.3% 85.0% 83.7% 82.8% 82.2% 81.8% 79.6% 83.1%Emergent, ED Care Needed - NOT Prev./ 956 19509 24056 41 1946 738 17455 64701 19.7% 15.0% 16.3% 17.2% 17.8% 18.2% 20.4% 16.9%
TOTAL Classified Visits 4858 130126 147705 239 10950 4066 85561 383505 1.3% 33.9% 38.5% 0.1% 2.9% 1.1% 22.3% 100.0%TOTAL All Visits 7924 185832 221290 326 17062 6172 146722 585328 1.4% 31.7% 37.8% 0.1% 2.9% 1.1% 25.1% 100.0%
0 - 17 18 - 6 4 6 5+ A ll 0 - 17 18 - 6 4 6 5+ A llNon-Emergent 47229 82271 7018 136518 34.0% 37.3% 28.9% 35.6%Emergent-Primary Care Treatable 55751 73622 7563 136936 40.2% 33.4% 31.2% 35.7%Emergent Care Needed-Prev./Avo id. 18369 23223 3759 45351 13.2% 10.5% 15.5% 11.8%
Total Primary Care Sensitive 121349 179116 18340 318805 87.5% 81.2% 75.6% 83.1%Emergent, ED Care Needed - NOT Prev./ 17392 41400 5909 64701 12.5% 18.8% 24.4% 16.9%
TOTAL Classified Visits 138741 220516 24249 383506 36.2% 57.5% 6.3% 100.0%TOTAL All Visits 203477 343266 38585 585328 34.8% 58.6% 6.6% 100.0%
F emale M ale U nkno wn B o t h F emale M ale A llNon-Emergent 80579 55927 12 136518 36.6% 34.2% 35.6%Emergent-Primary Care Treatable 77522 59404 10 136936 35.2% 36.3% 35.7%Emergent Care Needed-Prev./Avo id. 23758 21591 2 45351 10.8% 13.2% 11.8%
Total Primary Care Sensitive 181859 136922 24 318805 82.7% 83.7% 83.1%Emergent, ED Care Needed - NOT Prev./ 38101 26593 8 64702 17.3% 16.3% 16.9%
TOTAL Classified Visits 219960 163515 32 383507 57.4% 42.6% 100.0%TOTAL All Visits 318345 266936 47 585328 54.4% 45.6% 100.0%
GEN D ER
read verticallyP A YM EN T SOUR C E
R A C E/ ET H N IC IT Y
A GE
Table IV.3: Coverage and Demographic Characteristics by Primary and Non-Primary Care-Sensitive Visits
28
Figure IV.9. 2004 ED Visits at Houston Hospitals by Payment Source (N=16)
33.4% 34.9% 29.7% 30.9%
58.4%
38.7% 35.7%
35.0%39.2%
31.4% 33.4%
23.3%
34.5% 35.7%
10.9%12.5%
16.2% 13.5%
3.6%11.0% 11.8%
20.6%13.4%
22.7% 22.2%14.6% 15.8% 16.8%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Commerc.
M-caid
M-care
Other G
ov.Othe
r Priv
.
Unins All
Emergent Care Needed-NOT Prev./Avoid.Emergent Care Needed-Prev./Avoid.Emergent-Primary CareTreatableNon-Emergent
29
Figure IV.10 2004 ED Visits at Houston Hospitals by Race/Ethnicity (N=16)
36.6% 36.5% 36.0%
0.0%
35.1% 35.6% 33.4% 35.6%
34.2% 35.1% 37.2%
0.0%
35.8% 35.9%34.2%
35.7%
9.5%13.4% 10.5%
0.0%
11.4% 10.4%11.9%
11.8%
19.7% 15.0% 16.3%
0.0%
17.8% 18.2% 20.4% 16.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Asian
Black
Hispan
icAm.In
dian
Other
Unknown
White All
Emergent Care Needed-NOT Prev./Avoid.Emergent Care Needed-Prev./Avoid.Emergent-Primary CareTreatableNon-Emergent
30
Figure IV.11. 2004 ED Visits at Houston Hospitals by Age (N=16)
34.0% 37.3%28.9%
35.6%
40.2% 33.4%
31.2%
35.7%
13.2%10.5%
15.5%
11.8%
12.5%18.8%
24.4%16.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
0-17 18-64 65+ All
Emergent Care Needed-NOT Prev./Avoid.Emergent Care Needed-Prev./Avoid.Emergent-Primary CareTreatableNon-Emergent
31
Figure IV.12. 2004 ED Visits at Houston Hospitals by Gender (N=16)
36.6% 34.2% 35.6%
35.2% 36.3% 35.7%
10.8% 13.2% 11.8%
17.3% 16.3% 16.9%
0%
10%
20%
30%
40%
50%
60%
70%
80%
90%
100%
Female Male All
Emergent Care Needed-NOT Prev./Avoid.Emergent Care Needed-Prev./Avoid.Emergent-Primary CareTreatableNon-Emergent
32
ED Visits by Primary Diagnoses
The five most frequent diagnoses of patients with primary care-sensitive visits were: acute
upper respiratory infection (unspecified site), otitis media (unspecified), fever, gastroenteritis,
and urinary tract infection (Table IV.4). The five most frequent diagnoses of patients with non-
primary care-sensitive visits were: chest pain (unspecified), fever, abdominal pain, chest pain
(other), and syncope & collapse (Table IV.5).
Table IV.4.Top 25 Conditions of Patients with Primary Care-Sensitive Visits (N=16) Obs Icd COUNT Description 1 4659 15654 acute uri nos 2 3829 12945 otitis media nos 3 7806 12026 fever 4 5589 9709 noninf gastroenterit nec 5 5990 9463 urin tract infection nos 6 7840 8246 headache 7 462 7566 acute pharyngitis 8 78039 6778 convulsions nec 9 64893 6437 oth curr cond-antepartum 10 6826 5755 cellulitis of leg 11 4019 5584 hypertension nos 12 78900 5419 abdmnal pain unspcf site 13 7242 5405 lumbago 14 49392 5320 chronic obstructive asthma 15 07999 5270 viral infection nos 16 486 5261 pneumonia, organism nos 17 78703 4941 vomiting alone 18 7295 4792 pain in limb 19 490 4233 bronchitis nos 20 78909 3865 abdmnal pain oth spcf st 21 7231 3719 cervicalgia 22 78659 3581 chest pain nec 23 49390 3499 asthma w/o status asthm 24 7804 3438 dizziness and giddiness 25 7245 2836 backache nos
33
Table IV.5 Top 25 Conditions of Patients with Non-Primary Care-Sensitive Visits (N=16) Obs Icd COUNT Description 1 78650 5204 chest pain nos 2 7806 2933 fever 3 78900 2673 abdmnal pain unspcf site 4 78659 2279 chest pain nec 5 7802 2157 syncope and collapse 6 78909 1906 abdmnal pain oth spcf st 7 5920 1688 calculus of kidney 8 V715 1673 observ following rape 9 5921 1405 calculus of ureter 10 64003 1289 threaten abort-antepart 11 7840 1231 headache 12 53550 1099 gstr/ddnts nos w/o hmrhg 13 78703 1059 vomiting alone 14 64403 990 thrt prem labor-antepart 15 4275 941 cardiac arrest 16 46619 894 acu brnchlts d/t oth org 17 78906 890 abdmnal pain epigastric 18 7851 883 palpitations 19 57420 879 cholelithiasis nos 20 4644 839 croup 21 7880 792 renal colic 22 78605 754 shortness of breath 23 64413 727 threat labor nec-antepar 24 7295 685 pain in limb 25 7242 676 lumbago
34
ED Visits by Patient Residence
Residents in zip codes nearest the hospitals have the highest frequency of ED visits (Map
IV.1). Residents in inner-city and suburban zip codes in the east, northeast, and south have the
highest rates of ED visits (Map IV.2). Residents in zip codes nearest the hospitals have the
highest frequency of primary care sensitive ED visits (Map IV.3). Residents in inner-city and
suburban zip codes in the east, northeast, and south have the highest rates of primary care
sensitive ED visits (Map IV.4). Residents in zip codes that are relatively near the hospitals have
the highest frequency of primary care sensitive ED visits (Map IV.5). The zip codes with the
highest rates of primary care sensitive ED visits to Houston hospitals by the uninsured are in the
central, northeast, and southeast (Map IV.6).
35
Map IV.1
36
Map IV.2
37
Map IV.3
38
Map IV.4
39
Map IV.5
40
Map IV.6
41
V. 2002-2004 COMPARISON
ED visits in eleven Houston hospitals (includes two hospitals of the Harris County
Hospital District, Ben Taub General, and LBJ General; eight hospitals of the Memorial Hermann
Health Care System, Memorial Hermann, Memorial Hermann Southwest, Memorial Hermann
Southeast, Memorial Hermann Northwest, Memorial Hermann The Woodlands, Memorial
Hermann Memorial City, Memorial Hermann Katy, and Memorial Hermann Fort Bend;
CHRISTUS St. Joseph Hospital; Texas Children’s Hospital; and St. Luke’s Episcopal Hospital)
increased from 465,909 in 2002 to 485,882 in 2003, a 4.3% increase, and decreased to 408,199
in 2004, a 16% decline (Table V.1). The percentage of visits that were primary care-sensitive
rose from 52.1% to 53.3% to 54.8% of total visits and from 81.5% to 81.9% to 83.5% of
categorized visits in consecutive years. Most of the increase in primary care-sensitive visits
occurred in the non-emergent category.
There was a change in payer mix away from commercial insurance (declined from about
25% to 20%) and toward the Medicaid (increase from 20% to 25%) and uninsured (increased
from 40% to 45%) (Figure V.1).
Patients making primary care-sensitive visits continue to be predominantly Black and
Hispanic adults age 18-64. The proportion Black has remained about the same. The proportion
of Hispanics grew from about 27% to over 35% (Figure V.2, V.3).
Adults made up the highest percentage of primary care-sensitive visits and the percentage
increased slightly from 63.8% in 2002 to 66.8% in 2004 (Figure V.3).
There was little change in the gender characteristics of patients making primary care-
sensitive visits (Figure V.4).
42
Table V.1: 2002-2004 ED Visits at 11 Hospitals by Harris County Residents
Memorial Hermann Hospital, Memorial Hermann Southwest Hospital Memorial Hermann Southeast Hospital, Memorial Hermann Northwest Hospital, Memorial Hermann The Woodlands Hospital, Memorial
Hermann Memorial City Hospital, Memorial Hermann Katy Hospital, Memorial Hermann Fort Bend Hospital, Ben Taub General Hospital, LBJ General Hospital, CHRISTUS St. Joseph Hospital
Type of Visit 2002 2003 2004
Number 11 11 11 CATEGORIZED VISITS
Non-Emergent 103,205 110,722 101,965 Emergent, Primary Care Treatable 103,377 109,885 93,447 Emergent, ED Care Needed – Preventable/Avoidable 36,371 38,340 28,229
Total Primary Care Sensitive Visits 242,953 258,947 223,641 Emergent, ED Care Needed - NOT Preventable/Avoidable 55,293 57,130 44,108
Total Categorized Visits 298,246 316,077 267,749 NON-CATEGORIZED ED VISITS
Injury 107,025 109,032 92,884 Mental Health Related 7,660 7,901 7,762 Alcohol or Drug Related 4,107 3,854 3,446 Unclassified 48,871 49,018 36,358
Total Non-Primary Care Sensitive Visits 167,663 169,805 140,450 Total Visits 465,909 485,882 408,199
Percent
DETAIL – CATEGORIZED ED VISITS Non-Emergent 34.6% 35.0% 38.1% Emergent - Primary Care Treatable 34.7% 34.8% 34.9% ED Care Needed - Prev./Avoid. 12.2% 12.1% 10.5%
% Primary Care Sensitive Visits 81.5% 81.9% 83.5% ED Care Needed - NOT Prev./Avoid. 18.5% 18.1% 16.5%
TOTAL Non-Emergent 22.2% 22.8% 25.0% Emergent - Primary Care Treatable 22.2% 22.6% 22.9% ED Care Needed - Prev./Avoid. 7.8% 7.9% 6.9%
% Primary Care Sensitive Visits 52.1% 53.3% 54.8% ED Care Needed - NOT Prev./Avoid. 11.9% 11.8% 10.8%
% Categorized ED Visits 64.0% 65.1% 65.6% Injury 23.0% 22.4% 22.8% Mental Health Related 1.6% 1.6% 1.9% Alcohol or Drug Related 0.9% 0.8% 0.8% Unclassified 10.5% 10.1% 8.9%
% All Visits 100.0% 100.0% 100.0%
43
Figure V.1. 2002-2004 Comparison of Primary Care Sensitive ED Visits at Houston Hospitals by Payment Source (n=11)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
50.0%
Commerc. M'caid M'care Oth.Gov Oth.Priv Unins
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Figure V.2. 2002-2004 Comparison of Primary Care Sensitive ED Visits at Houston Hospitals by Race/Ethnicity (n=11)
0.0%
5.0%
10.0%
15.0%
20.0%
25.0%
30.0%
35.0%
40.0%
45.0%
Asian Black Hispanic Am.Indian Other Unknown White
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Figure V.3. 2002-2004 Comparison of Primary Care Sensitive ED Visits at Houston Hospitals by Age (n=11)
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
80.0%
0-17 18-64 65+
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Figure V.4. 2002-2004 Comparison of Primary Care Sensitive ED Visits at Houston Hospitals by Gender (n=11)
0.0%
10.0%
20.0%
30.0%
40.0%
50.0%
60.0%
70.0%
Female Male
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