Patterns of Emergency Department Utilization in New York City, 2008

Prepared by: United Hospital Fund David Gould, Senior Vice President Ewa Wojas, Senior Programmer/Analyst Consultant: Maria Raven, MD

Contact: David A. Gould United Hospital Fund 1411 Broadway, 12Floor New York, New York 10018 212-494-0740 dgould@uhfnyc.org

I.

Introduction In the past two decades, emergency department (ED) use has increased while the number

of EDs has declined.1 Evidence shows that EDs are increasingly being used by patients for nonemergent care.2 Nationally, it is clear that ED use is on the rise, but exactly what is driving this increase remains unclear. Frequent ED use may be a marker for unsuccessfully treated health and social issues, as well as a consequence of fragmented care.3-5 It is highly likely that the rising rates of ED use nationwide result from a convergence of multiple issues, including declining availability of primary care, especially among specific populations including Medicaid beneficiaries, and rising rates of chronic disease. Use of EDs to manage problems suited for an ambulatory care environment may be suboptimal, as ED care is episodic and administered by varying providers which promotes lack of care continuity. On the other hand, it is available 24-7 and offers the opportunity to immediately address what could be a severe health issue, with a waiting time limited normally by minutes to hours rather than days, weeks, or months as can be the case for outpatient care. Until we can better understand patterns and causes of ED use, including whether ED use varies by geographic area, it will be difficult to optimize care delivery within and outside of EDs and improve access to needed health and social services. Recent work by Wennberg et.al., published in the Dartmouth Atlas6 and elsewhere, has highlighted the importance of evaluating small area variation, or large differences in the rates of use of medical services between geographic regions when conducting health services research. Variation in practice and outcomes exists even among locations that are geographically juxtaposed. New York City is a unique environment and often, its inhabitants define themselves by their neighborhood: East Harlem, Upper West Side, Soho, Greenwich Village, Astoria, the people make the neighborhoods. Does the neighborhood, with its unique population mix and distribution of resources (or lack thereof) influence health services use? This report is the result of a HEAL-9 grant to allow the United Hospital Fund (UHF) to examine a critical issue for policy makers, providers, and planners: the use of hospital EDs in New York City.7 This issue is especially timely given the current state and federal focus on health care and Medicaid reform, much of which is centered on improving care and reducing costs for heavy users of health care services. We looked at ED utilization in UHF neighborhoods to capture potential small area variations in care seeking and delivery that would be important for
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stakeholders, from hospital administrators to policy makers at New York State invested in this issue. In building this report, we took advantage of our ability to examine variations in ED utilization based on UHF neighborhood, enabling readers to view differences in ED utilization patterns among the population of ED users at a local level. We also are able to distinguish patterns of use by individuals who had more than one ED visit in the year a first look at frequent users. By conducting the analyses herein, we hope to create a tool that can be used by individual communities and hospitals to better understand how consumers access the emergency care system and the role EDs play in the health of the communities they serve.

II.

Data Sources and Methodology A. Data Sources This report uses four sources of data: 1) the SPARCS ED visit dataset, 2) hospital cost

reports, 3) Community Health Profiles prepared by the New York City Department of Health and Mental Hygiene (NYCDOHMH), and 4) the SPARCS hospital inpatient dataset.

1. SPARCS ED Visit Dataset This report examines all-payer ED utilization in 2008 for treat and release visits (ED visits that did not result in hospitalization) within the Statewide Planning and Research Cooperative System (SPARCS) dataset. SPARCS is a comprehensive data reporting system mandatory for all hospitals within New York State. SPARCS collects patient level data on specific characteristics related to each hospital discharge, ambulatory surgery, and most recently, starting in 2003, emergency department (ED) visits in New York State. The dataset includes only ED visits that did not result in hospital admission. ED visits that resulted in admission can be identified in SPARCS hospital discharge datasets, but we did not analyze these visits in our study because they are unlikely to be preventable. For the same reason we decided to leave out ED visits that took place in specialty hospitals (Manhattan Eye, Ear, & Throat Hospital; Memorial Hospital for Cancer and Allied Diseases; and New York Eye and Ear Infirmary). Our study explores only ED visits by New York City residents to New York State hospitals, not all ED visits occurring at hospitals located in NYC. We deleted the overflow records (records with sequence number greater than one). They have been used in SPARCS since 1994 if
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more than five UB-92 Accommodation Codes or more than 20 Ancillary Services Codes were reported for a patient stay. According to a SPARCS representative, if there are multiple records for a particular patient the only difference between the records is in the Accommodation and/or Ancillary Services codes. All other data elements for the same patient are repeated, that is all diagnosis, procedures codes, etc. are the same for each record. Overflow records account for about 1% of all records and were deleted. In addition, we excluded patients with Emergency Department Indicator "A" for Ambulatory Surgery from Emergency Department or blank for Ambulatory Surgery only. We also decided to delete patients transferred to a Short-Term General Hospital for Inpatient Care, Designated Cancer Center or Children's Hospital. Most importantly, the dataset we received includes patient identifiers, permitting the analysis of not only visits, but also individual patients.

2. Hospital Cost Reports Prior to the release of SPARCS ED data, the only available data on ED visits in New York City were reported in hospitals Institutional Cost Reports (ICRs) that are filed annually with the New York State Department of Health (NYSDOH). ED visit data in ICRs include only total counts of ED visits and counts of ED visits not resulting in admission by hospital or hospital system, by payer. Because patient origin data are not available in ICRs, ED visits can be identified only by hospital location and not by patient residence. For each category of ED visit (admit and treat and release), payer class information is also available in ICRs. We used ICR data in this report to assess the completeness and reliability of SPARCS ED visit data by comparing visit counts and payer mix by hospital from both sources.

3. Community Health Profiles The Community Health Profiles prepared by the NYCDOHMH provide a comprehensive set of population demographic/SES and health status indicators for each of the 42 UHF neighborhoods. Indicators of health status in the profiles are obtained from a community survey that was most recently conducted in 2009. We also used 2008 New York City Department of Health Population Estimates for UHF neighborhoods.

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4. SPARCS inpatient dataset Patient-level SPARCS dataset for 2008 describes all inpatient services provided within New York State. This dataset includes patient characteristics, diagnoses, treatments, services, and payer classes. Most importantly, UHF had access to patient identifiers that linked inpatient data with SPARCS ED which gave us a unique opportunity to compare inpatient and ED utilization of individual patients.

B. Methodology 1. Upweighting Process We first evaluated the SPARCS ED visit dataset to determine if it was sufficiently complete and reliable to conduct the study. To assess the completeness of the data, we compared counts of ED visits without admission by hospital in SPARCS to those reported in hospitals ICRs. Citywide, visits were underreported in SPARCS by 13%. 70% of hospitals had variances under 20%. Many researchers who work with SPARCS discharge data correct for underreporting by grossing up discharges by hospital to counts reported in ICRs. This method assumes that unreported discharges have the same characteristics (demographics, diagnoses, procedures) as reported discharges. If reported data are not representative, grossing up may magnify the misrepresentation of hospitals that have atypical patient populations (e.g., safety net hospitals with large concentrations of low income, HIV, mentally ill, and substance abuse patients have more underreporting than other types of hospitals). A second consideration, especially relevant to study, was that ED visits in some key low income neighborhoods would be significantly underreported if we did not gross up visits. To evaluate this possibility, we examined the patient characteristics (age, sex, clinical mix) in 2007 for hospitals with underreporting in 2008 of 20% or more. We found that patient characteristics in both years were similar for all of these hospitals. Thus, we decided to gross up or upweight ED visits for all hospitals to ICR counts. For two hospitals (Parkway and Caritas) that had much better reporting in other years, we substituted their earlier data (2005 in the case of Parkway and 2006 data in the case of Caritas) in our 2008 dataset. Since 2008 ICR numbers were not available for Our Lady of Mercy and Peninsula we used 2007 figures for the
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upweights. We also decided to delete specialty hospitals (Manhattan Eye, Ear, & Throat Hospital; Memorial Hospital for Cancer and Allied Diseases; and New York Eye and Ear Infirmary) and that minimum weight will be 1 (ignoring cases where ICR < SPARCS). We evaluated the reliability of data elements to be used in our study (patient zip code, patient demographics, payer class, and clinical diagnoses) through comparison with alternative data sources where they were available (e.g., payer class data in ICRs) or through tests of reasonableness where alternative data sources were not available. Our findings from this evaluation are summarized below: 2. Duplicate Records When discovered, 9.6% of the records (294,094) were deleted based on: unique personal identifier (UPIDE), encrypted date of birth (DOBE), sex, date of admission, time of admission and primary diagnosis code.

3. Linking Patients The dataset we received includes patient identifiers. We were able to identify individual patients using the ED by linking patients using UPIDE, DOBE and sex.

4. Race/Ethnicity Some values were missing or coded as other. Health and Hospitals Center (HHC) data was less complete than nonprofit hospitals. We obtained improved data from HHC, which we used to adjust for the race/ethnicity analysis.

5. UHF Neighborhoods The 42 UHF neighborhoods consist of adjoining zip code areas with similar characteristics, designated to approximate New York City Community Planning Districts, and based on the demographic, economic, and social diversity found there. The assignment of zip code areas to neighborhoods, the decisions about which community planning districts were most appropriate to combine, and the delineation of neighborhoods were made by UHF staff in consultation with staff of the New York City Planning Commission and the New York City Health Systems Agency. Originally developed in 1982, this neighborhood listing was updated in 2002 to reflect socio-demographic changes.
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6. UHF Neighborhood 999 A small subset of records within the SPARCS dataset contain a NYC county code but do not link to a specific UHF neighborhood because they have an incomplete or missing 5-digit zip code. These data were pooled into a single category 999, and account for 0.3% of people and 0.2% of all ED visits in the 2008 SPARCS dataset.

7. ED Use Definitions As no uniform definition of frequent ED users exists, for the purposes of this analysis, we categorized use in multiple ways. An ED user was any person with at least one ED visit in 2008. We also examined those with 2, 3, 4, and 5 or more visits in 2008. Super users were those with serial use, who had 5 or more visits in each of three consecutive years (2006, 7, 8).

8. Movers To assign ED users with at least two visits residing in more than one UHF neighborhood to one neighborhood we used the following decision rules: Patients with two visits who resided in two neighborhoods: one of the two neighborhoods was randomly selected. Patients with 3 or more visits: the most frequent neighborhood was used (mode). Where there was no mode, one of the neighborhoods was chosen at random.

9. Clinical Data We used H-CUP Clinical Classifications Software (CCS) level two (about 140 categories) to analyze data on diagnoses and procedures.

10. Payer Mix To determine the accuracy of the payer reported in the SPARCS ED dataset, we compared each hospitals payer mix as reported in SPARCS to its ICR for years 2005 through 2008. We believe the ICR is more accurate because it is submitted at the end of the year reviewed by an independent auditor.
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The SPARCS ED dataset has two data fields that identify payer: Source of Payment and Expected Principal Reimbursement. We compared hospitals payer mix using both SPARCS data fields to the ICR and determined that the Expected Principal Reimbursement field is more accurate (Figure i). The percent of total admissions reported as Medicaid in the SPARCS ED Source of Payment field varied from the ICR by more than 50% at 28 of 44 hospitals. The Expected Principal Payment field for Medicaid varied from ICR data by more than 50% at only one hospital. The Expected Source of Payment field also proved more accurate with other payer classes.

Figure i: Hospital payer mix reported in SPARCS and ICR, 2008. Medicare Number of hospitals 25% over/under Source of Payment 28 34 9 13 18 36 14 Medicaid Self-Pay All Other

Expected Principal 6 Payment Number of hospitals 50% over/under Source of Payment Expected Principal Payment Total number of hospitals = 44 5 2

28 1

6 4

34 10

We found that in SPARCS data, hospitals tend to over-count Medicaid visits and undercount self-pay visits (Figure ii). Data accuracy improved by combining these two payer classes into one category which we labeled, Safety Net, though this action came at the expense of losing some detail of the data.

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Figure ii: Payer Data: SPARCS EXPECTED and ICR Medicaid Number of hospitals 25% over/under 25% over 25% under 6 3 8 10 2 0 Self-Pay Medicaid + Self-Pay

Number of hospitals 50% over/under 50% over 50% under Total number of hospitals =44 1 0 0 4 0 0

11. Hour of Discharge Six percent of our sample had negative average length of stay (LOS) in the ED. After closely examining those records we decided that the negatives reflect times that should have been recorded for the next day and we corrected those cases accordingly. We also decided to delete records with zero LOS (3% of our sample) since they were randomly distributed between age and hospitals. Twenty four hospitals (including HHC), which represent 35% of ED visits had the hour of discharge coded as 99 (unknown). Three hospitals: Lutheran, LI Jewish, and North General had extremely high average LOS (10 hours or more), and two: Cabrini and LIJ Schneiders Children reported inexplicably low visit volumes. We decided to exclude them from the analysis as these data are likely inaccurate. Our analysis of the average length of stay in the ER was limited to 36 voluntary hospitals in the city for which data was complete.

12. Neighborhood Quartile Analysis We divided UHF neighborhoods by quartiles based on adjusted ED rates per 100 population. There are 42 UHF neighborhoods so we assigned 11 neighborhoods in the quartiles with the highest and lowest ED rates and 10 neighborhoods to the middle quartiles.

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13. Analysis of Variance (ANOVA) Analysis Analysis of Variance (ANOVA) is a powerful statistical test used to determine whether the means between two or more groups are equal (the null hypothesis) or different. We performed one-way ANOVA analyses to determine the association of multiple population and health system factors with ED use in neighborhood groupings characterized by low, medium, and high ED use rates. Statistically significant results indicate more difference between groups of neighborhoods than within ED user groups.

III. Study Strengths and Limitations To our knowledge, this is one of few in-depth analysis of ED use employing mandated data reported to New York States SPARCS system. Specifically, ED data reporting was mandated starting in 2003 and, as a result, hospitals have had the opportunity to address inaccuracies or incompleteness of reporting. However, as mentioned, some of these data were not accurately reported in SPARCS and as a result, we used appropriate statistical techniques to account for these inaccuracies. Our ability to examine small area variations in health services use by UHF neighborhood provides a unique opportunity to draw attention to potential gaps in care. In addition, our ability to link UHF neighborhood ED use with income and education level provides additional valuable context for this analysis. We were able to link SPARCS ED data to inpatient data, providing unique insight into the relationship between ED use and hospitalizations. In addition, we present some novel findings that show a possible link between ED use and unstable housing, which to date has been difficult to demonstrate using large administrative datasets. ED visits and other person-level characteristics were assigned to a neighborhood based on the persons reported zip code of residence. However, we cannot be certain that the health services use of those within specific UHF neighborhoods actually occurred within those neighborhoods. While portions of the study examined data over multiple years, the majority was based on a single year of data, 2008.

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IV. Citywide ED Use and Neighborhood Variation In 2008, New York City residents made approximately three million visits to the ED at acute care general hospitals that did not result in an admission (treat and release, or T&R), which accounted for 79.6% of all ED visits. This translates into 36 T&R visits per 100 residents, similar to rates found in prior UHF work analyzing 2006 SPARCS data.* When accounting for multiple visits made by individuals in 2008, just over one in five (22%) New York City residents visited an ED. The following analyses deal only with T&R ED visits.

1. ED Use by UHF Neighborhood Table 1 (see Attachment I for all tables) shows the percent of the NYC population with at least one ED visit in 2008 divided into UHF neighborhoods, which are grouped by borough. Throughout this report, distinct borough patterns emerge. In the Bronx, six of seven UHF neighborhoods had use rates that were above the city average, with the exception being Kingsbridge/Riverdale. Of Brooklyns 11 neighborhoods, eight had lower than average use, but three (Central Brooklyn, East New York/New Lots, and Bushwick/Williamsburg) had use rates quite a bit above the citywide average of 22%. Manhattan showed a mixed picture among its 10 neighborhoods, with some of the most dramatic variation encompassing not only UHF neighborhoods with the highest use (Central Harlem and East Harlem) but also the lowest (Upper East Side). These neighborhoods are in close proximity, but are comprised of people from differing socio-economic backgrounds who have access to different health care resources, which may account for such stark contrasts. Queens (10 neighborhoods) and Staten Island (four neighborhoods) had mostly below-average ED use, with a few exceptions that did not depart too greatly from average. The percentage of the neighborhood population visiting an ED varied from a low of 8% in the Upper East Side to a high of 41% in East Harlem. There was an almost seven-fold difference in age/sex-adjusted use rates among neighborhoods in the city from a high of 83 ED visits per 100 residents in East Harlem to a low of 13 ED visits per resident in Greenwich Village/Soho, the Upper East Side, and Northeast Queens (Table 2). The 10 neighborhoods with the highest ED
*

A previous UHF study calculated 37 visits per 100 residents using 2006 SPARCS data. The 2008 rates, which we believe to be more accurate, were calculated using 2008 population estimates from DOHMH. The previous UHF estimate relied on 2000 census data for the population denominator. In the current analysis, we also deleted duplicate records. Page | 11

visit rates (less than 25% of all neighborhoods and comprising 34% of the total population) accounted for nearly 46% of citywide ED visits. It should be noted that neighborhood use rates were calculated at the visit level rather than the person level. As a result, we cannot determine to what extent visit rates are attributable to multiple users, which is explored below. However, we did find, and show later, that patients with frequent ED visits in 2008 were more concentrated in neighborhoods with higher overall rates of ED use.

V.

Race/Ethnicity Without controlling for income, Black and Hispanic residents use a disproportionate

amount of ED services. Blacks constitute 23% of the NYC population, yet account for 34% of all ED visits. Hispanics constitute 28% of the total population, and account for 37% of all visits. In contrast, Whites are less likely to use the ED, constituting 35% of the population but only 16% of all ED users (Table 3). These differential use rates by race/ethnicity are consistent with the variation we see among communities in Table 2. Recent studies8 have shown disproportionate and growing ED use among non-Hispanic Blacks. Our analysis supports this finding.

VI. Gender Females made 55% of all ED visits in 2008, slightly greater than their 52% share of the NYC population (Table 4).

VII. Payer-Mix Citywide, 65% of ED visits are categorized as safety-net (combined Medicaid and self-pay) (Table 5). In fact, this proportion is a minimum estimate because SPARCS groups patients enrolled in Medicaid Managed Care plans with commercial insurance. Therefore, the safety-net category undercounts persons with Medicaid and overcounts the commercial/other category. The difference between neighborhoods with high and low proportion of safety-net is striking (80% in Hunts Point and Mott Haven as compared to 28% in the South Shore or 29% in Upper East Side). These rates closely reflect the variation of socio-economic characteristics between NYC neighborhoods.
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VIII. ANOVA Analysis We used ANOVA techniques to examine the association between neighborhood level ED use and the population and health system characteristics of neighborhoods where patients resided. We divided the 42 UHF neighborhoods into three groups according to ED use based on our finding that the citywide neighborhood average is 36 visits per 100 population. High use neighborhoods had over 40 visits per 100 population, middle use neighborhoods 26-39 visits per 100 population, and low use neighborhoods had less than 23 visits per 100 population. We then used one-way ANOVA to test the significance of the association between the factors below and our neighborhood groupings. Below is a listing of the factors examined and data sources, followed by a graph highlighting differences between high, middle, and low use neighborhoods.

Measures of Population & Health Systems Characteristics by UHF Neighborhood Selected for the Study

Demographics % Below poverty level % Black % Hispanic Health Status % Reporting poor/fair health status Hospitalization rates/100 Access to Care % Uninsured % Foreign born % Reporting no regular doctor % Reporting no doctor visit in the last 12 m % Reporting that did not get needed med care

Source U.S. Census (2000) DOHMH Population estimates (2008) DOHMH Population estimates (2008)

Community Health Survey (Avg. of 2007, 2008 and 2009) Internal analysis of 2008 SPARCS

Community Health Survey (Avg. of 2007, 2008 and 2009) U.S. Census (2000) Community Health Survey (2008) Community Health Survey (2008) Community Health Survey (2009)

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Percent of Neighborhood Residents with Selected Characteristics by ED use category

In this analysis, the level of ED use in 2008 was strongly associated with neighborhood poverty; proportion of uninsured residents, Blacks, and Hispanics; and residents reporting poor/fair health status, no regular doctor, and problems with getting medical care when needed. Significant differences between neighborhood groupings are indicated at the bottom of the graph.

IX.

Age Young children age 0-4 use a disproportionate amount of ED services, accounting for 7%

of the population and 14% of all visits (Table 7). Looking at neighborhood variation, we find that the spread between high and low use rates decreases in the 18-39 and 40-64 age groups, which account for almost two-thirds (65%) of all ED visits. To examine differences in neighborhood ED use rates between children and adults, whose health needs vary, we examined sex adjusted ED use rates per 100 population in children ages 0-17 and adults aged 18 and above. Children had higher adjusted rates of ED visits (46 per 100) than adults (33 per 100) (Tables 6a and 6b). Given their smaller share of the population, however, children aged 0-17 accounted for just 29% of total ED visits (Table 7).
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When examining neighborhood use rates by age group, we find several consistent patterns. High use neighborhoods shown in Table 2 also show high rates of use among children aged 0-17. Notably, for every UHF neighborhood, with the exception of Greenwich Village/Soho and Greenpoint, ED use rates for the 0-17 population were higher than adult use rates. The average citywide ratio of ED visits in the 0-17 population to ED visits in the population 18 and older was 1.4, and only a few neighborhoods departed significantly from the norm (Tables 6a and 6b). To more closely examine ED use by children, we separated those aged 0-4 from those aged 5-17. 44% of 0-4 year olds had at least one ED visit, the highest visit rate of any age group under study. One neighborhood, West Queens, deserves further discussion. While West Queens had lower-than-average ED use in its over-18 population, its under-18 population saw higher than average ED use (Table 6a) driven largely by the 0-4 year old population, as seen in Table 7. At 23%, West Queens was the UHF neighborhood with the highest proportion of ED use among 0-4 year olds, suggesting the value of further study of its current pediatric ambulatory capacity. In contrast, 22% of 5-17 year olds had an ED visit. When examining the proportion of children with at least one ED visit by neighborhood, we found a concentration in the same 17 neighborhoods (see box in Table 8a and Table 8b). These neighborhoods were home to children in both age groups who experienced more than the citywide visit rate of 44%, with neighborhood rates ranging from 72% in Central Harlem to 45% in Inwood/Washington Heights for children 0-4 and from 72% in Central Harlem to 47% in the Rockaways for children 5-17.

X.

ED Diagnoses To examine the clinical reasons persons visited the ED, we grouped UHF neighborhoods

into four quartiles (as described in the Methodology section). Looking at patterns of use among these four quartiles we can observe whether variations existed among high and low ED use neighborhood groupings (Table 9). Neighborhoods in the highest use quartile had the lowest proportion of ED visits categorized as injury, and this proportion increased with decreasing neighborhood quartile ED use. If injury is not considered a preventable reason for an ED visit, it may be that in neighborhoods with lower overall ED use rates, larger proportions of visits are categorized as
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unpreventable visits, so that both overall use rates are lower as is ED use for preventable causes. Conversely, neighborhoods in the highest use quartile had the highest proportion of ED visits categorized as general medicine, and these numbers decreased with decreasing ED use. It is likely that at least some of these medicine-related ED visits serve as substitutes for ambulatory care. Proportions of ED visits categorized as psychiatric or alcohol/drug related did not vary notably by quartile of neighborhood ED use, and were relatively uncommon diagnoses compared to injury and general medicine categorizations. We shall observe later in this report that while diagnoses related to mental health and substance use were less common in the general population of ED users, they were highly prevalent among the heaviest users of NYC EDs. Diagnoses related to mental health and substance use may be under-reported in SPARCS. However, a NYCDOHMH report from November 2010 stated that alcohol-related ED visits have steadily increased since 2003: in 2009, 2.75% of ED visits had an alcohol-related chief complaint, which is within the range of our findings in this analysis.*

XI. Frequent ED Users As there is no commonly accepted and uniform definition of frequent ED users, for the purposes of this analysis we categorized frequency of use in multiple ways. We show use by one through five or more visits in 2008; we examine persons with three or more visits in 2008 and five or more visits in 2008; and we take a closer examination of persons who display what we call serial use or super-users those who had 5 or more visits in each of three consecutive years. The majority of ED users are not frequent users. Of all ED users in NYC in 2008, 74.3% had only one visit, and 16% had only two visits. However, those with more frequent use have a disproportionate impact on the emergency care system in NYC: persons with three visits accounted for 5.3% of all ED users and 10.7% of all ED visits; persons with four visits accounted for 2.1% of all ED users and 5.8% of all ED visits; persons with five or more visits accounted for 2.3% of all ED users and 11.4% of all ED visits (Tables 10a and 10b).

http://www.nyc.gov/html/doh/downloads/pdf/survey/survey-2010alcohol.pdf) NYC Vital Signs A data report from the NYC health Dept: consequences of alcohol use in NYC. Nov 2010 vol. 9 no. 5 Page | 16

2.1% of NYC residents (176,000) had three or more ED visits in 2008 (which accounted for 27.9% of all visits), ranging from a low of 0.4% of residents in Northeast Queens to a high of 6.4% in East Harlem (Table 10c). Here too we find a common pattern of higher use among a familiar set of neighborhoods including East Harlem, Central Harlem, and the cluster of central Brooklyn and Bronx neighborhoods. We also noted variation in the frequent user population when broken down by age group. On average, 5% of all 0-4 year olds had three or more ED visits in 2008, the highest percentage of frequent ED users among any age group. In addition, this 0-4 age group had the most neighborhood variation: in East Harlem, 14% of 0-4 year olds were frequent ED users, while 1% of 0-4 year olds were frequent users in Southwest Brooklyn, the Upper East Side, Gramercy Park/Murray Hill, Greenwich Village/Soho, Northeast Queens, and the South Shore. In contrast, there were lower rates of frequent ED use among all other age groups (1%-2% on average) and among neighborhoods. This may represent more variability of resources available to the pediatric population by neighborhood, and likely reflects a lower threshold among parents of young children to turn to the emergency department for evaluation. A lower than NYC average rate of frequent ED use amongst the older (65+) population likely reflects the fact that these data are restricted to ED visits that do not result in hospitalization. It may be that providers have lower thresholds for admission to the hospital among those who are aged 65 and older. The percentage of residents in each neighborhood who were frequent ED users was highly correlated with overall neighborhood use rates in Table 2 (correlation coefficient 0.98), demonstrating that frequent ED users are concentrated in areas with high overall ED use rates.

XII. ED Use Variation by Day and Time Understanding patterns of ED use by time may shed light on the interplay between resource availability and health seeking behaviors, and the following analyses, which examine patterns at the neighborhood level, are among the first efforts to explore this issue.

1. Day of Week Citywide, most ED visits were made on Monday, and visit volumes slowly declined steadily for the rest of the week. To determine if this pattern was sustained when evaluating all UHF neighborhoods, we divided the neighborhoods into quartiles based on level of ED use, as
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described in the Methodology section. The general pattern was sustained in three of the four quartiles: in all but the lowest use quartile, the majority of visits occurred on a Monday with much lower use through the week and the least use on weekends. In the lowest use quartile, we found a lower peak occurred on Monday with higher use levels on the weekend. (Figure A) When we isolated individual UHF neighborhoods, the variation was more striking. On the Upper East Side, a wealthier neighborhood with the lowest ED use rates, the majority of visits occurred on the weekend. In contrast, Central Harlem, a neighborhood affected by higher poverty and ED use rates, followed use patterns present throughout most of the city. (Figure B) People who reside in neighborhoods with higher weekday use and also higher poverty levels, such as Central Harlem, may have less access to ambulatory care, fewer linkages to primary care physicians, or may be unaware of community resources for acute care outside of the ED independent of day of the week. Alternatively, on the Upper East Side and in other higher income neighborhoods, weekday options for care outside of the ED may be more adequate, but deteriorate over the weekend (fewer primary care weekend hours, etc).

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Figure A

Figure B

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2. Hour of Visit Citywide, the volume of admissions* varied quite a bit throughout the day, with the peak at 11 a.m. and the trough at approximately 5 a.m. (Tables 11 and 12). We distinguished weekend use from weekday use to determine if peak hours differed between the two. The general pattern of peak use at approximately 11 a.m. with a trough around 5 a.m. did not differ from weekdays (Figure C and Table 11) to weekend (Figure D and Table 12). Similar patterns also held across the four use quartiles. However, on weekdays and weekends (Figures C and D), there was notable variation when we examined the ratio of peak-to-trough use in each quartile. On weekdays, Group 1, the quartile of UHF neighborhoods with the highest ED use, follows a similar curve to the other 3 groups, but the peak hour volume jumps disproportionately when compared to Groups 2, 3, and 4. Indeed, the ratio of peak-to-trough visit volume jumps in a linear fashion from Group 4, the lowest use quartile, to Group 1 the highest use quartile: the ratio is 5.0 in Group 4; 5.2 in Group 3; 5.4 in Group 2; and 6.5in Group 1, indicating a disproportionate increase in peak hours ED use for neighborhoods with the highest population-level ED use (Table 11). When examining weekend patterns (Figure D), we find that the ratio of peak-to-trough is relatively flat for the three higher use quartiles (3.6 to 3.7) but increases to 4.0 for the lowest use quartile (Table 12). (Please note the scale of the Y-axis differs between Figures C and D: the hourly changes in ED volume are not as extreme on weekends.)

The SPARCS data dictionary defines hour of admission as the hour during which the patient was admitted for *ED+ services. Page | 20

Figure C

Figure D

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3. Off- vs. On-Hours ED Use A majority of visits (57%) occurred off-hours, which we defined as weekdays between 5 p.m. and 8 a.m. or anytime on the weekend (Table 13) and comprise 73% of the hours in a week. Most physician offices and clinics are not open during these times, though the Medicaid program now offers enhanced reimbursement for expanded hours. Frequent ED users had essentially the same share of off-hour visits as other ED users. Onetime users had 58% of their visits off-hours while those with three or more visits had 57% of their visits off-hours (Table 13). There was not a large variation in the share of off-hour visits by neighborhood (maximum 62%; minimum 54%). However, there was a strong negative correlation between off-hour ED use and overall neighborhood ED use (-0.83): the neighborhoods with the highest ED use rates had the lowest percentage of off-hour ED use, a pattern consistent with weekend use rates. (Figure E and Table 14)

Figure E

This makes intuitive sense. It may be that residents of areas with lower poverty rates, higher self-reported health status, and lower overall ED use rates are more likely to go to the ED off-hours when they have decreased access to other more regular sources of outpatient
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primary care. In contrast, if residents of lower income neighborhoods with higher ED use have less access to alternative ambulatory health services and primary care regardless of the time of day or day of week, the off- /on-hours distinction is not important. We found very little variation in off- /on-hour usage between visits categorized as general medicine ED visits, ED visits for injury or behavioral health issues, and ED visits that were unclassifiable due to vague diagnostic data (Table 15). However, the percentage of off-hour visits in all categories was highest for the youngest patients, ages 0-4. This relatively high offhours use amongst the youngest group of children may be due to factors such as working parents less able to take acutely ill children for medical attention during normal pediatric office business hours, or parents worried overnight about sick children who are not improving with supportive care at home. In addition, since many children in that age group are unable to fully verbalize what might be bothering them, it is more difficult for on-call pediatricians to diagnose issues off-hours or overnight via telephone. Many pediatrician offices do offer off-hours care including the ability to make sick visits on weekends to accommodate such needs, and the population served by such offices may not be aware of these services.

XIII. Length of Stay We examined reported length of stay (LOS) based on hour of admission and hour of discharge variables as reported to SPARCS by 36 voluntary hospitals, which had an average overall length of ED stay of 4 hours and 4 minutes. Table 16 shows the mean LOS for each of the 36 hospitals compared to the average for this analysis. The mean LOS was slightly higher for adults (4.27 hours) than for children aged 0-17 (3.10 hours) (Table 17). As expected, the ED stay for patients reported to have injuries was shorter on average than those who sought care for general medicine reasons (Table 18). Interestingly, LOS was not correlated with ED volume (correlation coefficient 0.01) (Figure F).

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Figure F

XIV. Residential Mobility and ED Use One characteristic of frequent ED users is that they appear to have unstable housing situations. On average, 11% of all NYC ED users with two or more visits had at least one move between UHF neighborhoods (Table 19). The number of movers increases dramatically with increasing numbers of ED visits. Table 19 shows that as the number of ED visits increase, the likelihood that an ED user resided in more than one UHF neighborhood in the same year also increases. While 7% of all ED users with two ED visits reported living in more than one UHF neighborhood, almost onequarter (24%) of ED users with five to ten visits lived in more than one neighborhood in the year. There was a near linear relationship between number of annual ED visits and the likelihood of at least one move between UHF neighborhoods. A full 67% of those with very high numbers of annual visits (30 or more in 2008) had at least one move that year.

XIV. Super-users As policy makers, planners, and health care providers and payers attempt to control health care spending, super-users of health services have recently been a hot topic of coverage in the lay press.9-10 Despite this coverage, much remains to be answered about this population of very heavy health services users. To determine how many frequent ED users remained frequent users from year to year, we isolated the subset of people with five or more visits in
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2006, and tracked their ED utilization in the following two years. There were 37,460 people with five or more visits in 2006 (0.5% of the population, 2% of all ED users). Of this population, only 4,147 (11%) remained frequent users in the subsequent two years, 2007 and 2008. This high degree of regression to the mean in the frequent user population points to the importance of using predictive modeling or other tools to best target the small but significant segment of the population whose frequent use will be sustained, and benefit from intervention. Limited health care dollars must be directed carefully, as most frequent users do not remain frequent users over time.

1. Demographics We also examined demographics and payer mix for super-users. 47.4% were nonHispanic Blacks, 26.6% were Hispanic, 14.4% were white non-Hispanic, and 16.7% were categorized as other. Most were aged 18-39 (35.6%) or 40-64 (47.4%) with smaller percentages of the population distributed among the 0-4 and 5-17 age groups (5.8% and 4.5%) and those 65 and older (6.8%). 51% were female and 49% male, which is reflective of the general NYC population (Table 20). These numbers reflect lower numbers of super-users at the extremes of age, yet as mentioned previously, applies only to treat and release visits and not to ED use that leads to inpatient hospitalizations. The majority of super-users (72.2%) were categorized as safety-net patients (uninsured and Medicaid beneficiaries).

2. Diagnoses To examine this small subpopulation in greater detail, we evaluated the reasons for their visits using Clinical Classifications Software (CCS) categorizations developed by the Agency for Healthcare Research and Quality (AHRQ). (Table 21) This system aggregates codes from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) into clinically related groups that can be employed in many types of projects analyzing data on diagnoses and procedures.11 Not surprisingly, ED visit categorizations among the super-users varied notably from those with just one ED visit in 2008. The top three categorizations among those with a single visit in 2008 were 1) symptoms, signs, and ill-defined conditions (9.2%), 2) respiratory infections (7.5%), and 3) superficial injury; contusion (5.7%).

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Among super-users the top three categorizations were alcohol related disorders (13%), asthma (11%), and, tied for third, symptoms, signs, and ill-defined conditions and psychiatric disorders (6% each). Diagnoses related to mental health accounted for only 2% of one-time users, ranked 16th of all categorizations, and asthma accounted for 2.3% of all visits in one-time users, ranked 15th. While alcohol-related disorders were the most common ED diagnosis among super-users, these disorders accounted for only 1.6% of visits among one-time users in 2008 Table 21). The implications of these findings are that the subgroup of super-users is a population with very different needs than those with fewer visits, and are affected by high rates of mental illness and substance use for which they are seeking frequent ED care. The predominant diagnoses in this small but important subset of ED users stand in stark contrast to the rest of the population whose use of the ED to address behavioral health conditions is much lower. In addition, asthma, a disease for which timely and effective outpatient care should prevent hospital admissions, is a common reason for seeking ED care in the super-user population. Our findings highlight the need to improve connections to appropriate ambulatory care settings and other health and social services via care management and other interventions.

3. Use of Inpatient Services ED super-users also utilized inpatient hospital services. In each year from 2006-2008, 60% of super-users also had at least one hospital admission. The majority of super-users had between one and six hospital admissions in a given year. However, a small subset (from 348370 ED super-users each year) had 10 or more hospital admissions in a single year. Each year, the maximum number of annual hospital admissions among ED super users ranged from 67 to 91. (Table 22) This indicates that for a small subset of ED super-users, the amount of time spent in the hospital in a given year may have been greater than the amount of time spent in the community. The financial implications of this extent of acute health services use are enormous for both payers and hospitals. While a financial analysis is beyond the scope of this report, interventions aimed at addressing the health and social factors related to such heavy health services use could pay for themselves through use of alternative, less costly sites of care and, for the homeless, stable supportive housing.

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Super-users were not evenly distributed among NYC hospitals. Among the top ten hospitals serving those with five or more visits each year from 2006-2008, half were HHC facilities. (Table 23) It may be that EMS providers direct super-user patients disproportionately to safety-net hospitals for various reasons including payment, ability to care for this specific population, or patient preference. Improved coordination between EMS providers and hospitals that care disproportionately for super-users could improve care for this population.

XV. NYU ED Study The NYU ED algorithm was developed by John Billings and colleagues from the NYU Center for Health and Public Service Research as a mechanism to help classify ED utilization. 12 The algorithm was developed with the advice of a panel of ED and primary care physicians, and it is based on an examination of a sample of almost 6,000 full ED records. The algorithm first excludes several categories of visits that it does not classify (injuries, mental illness, alcohol/drug abuse, and medical conditions for which samples of medical charts were too small to includeabout a third of visits in New York City) and then classifies the remaining two-thirds of visits, which fall under the broad category of general medicine. The algorithm classifies these general medicine ED visits into one of the following categories:

Non-emergent - The patient's initial complaint, presenting symptoms, vital signs, medical history, and age indicated that immediate medical care was not required within 12 hours;

Emergent/Primary Care Treatable - Based on information in the record, treatment was required within 12 hours, but care could have been provided effectively and safely in a primary care setting. The complaint did not require continuous observation and no procedures were performed or resources used that are not available in a primary care setting (e.g., CAT scan or certain lab tests);

Emergent, ED Care Needed-Preventable/Avoidable - ED care was required based on the complaint or procedures performed/resources used, but the emergent nature of the condition was potentially preventable/avoidable if timely and effective ambulatory care had been received during the episode of illness (e.g., the flare-ups of asthma, diabetes, congestive heart failure, etc.); and

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Emergent, ED Care Needed-Not Preventable/Avoidable - ED care was required and ambulatory care treatment could not have prevented the condition (e.g., trauma, appendicitis, myocardial infarction, etc.).

We applied the NYU ED algorithm to our 2008 SPARCS ED data to determine whether the above visit categorizations differed by neighborhood or were correlated with overall ED use rates (Table 24). Bearing in mind that injury and behavioral health diagnoses are excluded, non-emergent was the most frequent visit classification (39%). On average, 35% of all visits were categorized as emergent, primary care treatable; 11% emergent, ED care neededpreventable/avoidable; and 15% as emergent, not preventable/avoidable. Notably, we found that UHF neighborhoods with the lowest ED use rates had the most visits categorized by the algorithm as being Emergent,ED Care Needed. Adjusted ED use rates were highly negatively correlated with this categorization (correlation coefficient 0.81). This indicates that not only the amount of utilization, but also the type and urgency of utilization, varies by neighborhood. These results are consistent with our findings in the ED Diagnoses section, which found that rates of non-preventable visits (diagnoses categorized as injuries) were highest in neighborhoods with the lowest rates of population-level ED use. In addition, adjusted ED rates were moderately negatively correlated with the EmergentPreventable/Avoidable categorization (correlation coefficient 0.63), so that in neighborhoods with higher levels of ED use, visits occurred significantly more often for conditions that could have been effectively treated in the ambulatory setting. Again, in a familiar subset of neighborhoods, ED use may be serving as a substitute for timely ambulatory care as evidenced by higher levels of visits for ambulatory sensitive conditions, and should be studied in more depth (Table 24). We noted much less variation in visits for Primary Care Treatable and NonEmergent conditions, which did not vary significantly across neighborhoods. Whether a visit is truly preventable is necessarily influenced by the fact that off-hours generally indicates less access to ambulatory care. As a result, we ran the NYU ED algorithm separately for visits made during off- and on-hours. On average, there was little difference in citywide NYU ED algorithm classifications for off- vs. on-hours (Tables 24a and 24b). When broken down by neighborhood, the variation in off- and on-hours use was similar to that in Section XII, subheading 3.

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XVI. Prevention Quality Indicators Analysis Because of increasing emphasis being placed on preventable and avoidable hospital admissions, and because for many hospitals the ED is a main channel for inpatient stays, we examined admission rates for Prevention Quality Indicators (PQIs), developed by the federal AHRQ, in each UHF neighborhood to determine if ED use was correlated with other potential markers for suboptimal outpatient care. We evaluated PQIs in the adult population aged 18 and over, as PQIs for the pediatric population differ from those in adults (Table 25). PQIs are measures based on inpatient discharge data developed by AHRQ to allow policy makers, investigators, and care providers to track hospital admissions for conditions that should be amenable to outpatient treatment, thereby identifying potential problem areas in the outpatient care delivery system. PQIs include conditions such as bacterial pneumonia, congestive heart failure, and adult asthma. Previous research has shown that frequent ED users have high rates of behavioral health issues such as mental health and substance use diagnoses, and these data are not captured with PQIs, which focus on non-behavioral health medical diagnoses. PQIs can be collapsed into three composite measures: Overall PQI, Acute PQI, and Chronic PQI.13 Acute disease indicators comprise the Acute PQI score and include perforated appendicitis, dehydration, bacterial pneumonia, and urinary infections. The Chronic PQI score is composed of chronic disease indicators including chronic obstructive pulmonary disease, angina without procedure, and adult asthma. In this analysis, neighborhood level Acute and Chronic PQIs were correlated with adult neighborhood ED use rate, so that neighborhoods with higher adjusted population level ED use rates also had higher PQI admissions rates, markers for higher rates of potentially preventable admissions to the hospital. Acute PQIs were moderately correlated with adjusted neighborhood ED use rates (0.68) and chronic PQIs were highly correlated (0.95). The composite of measure of all PQIs, Overall PQI, was also highly correlated with neighborhood ED use rates (0.92). The chronic PQI categorization comprises ongoing health conditions that require consistent and effective outpatient care for proper control: this significant correlation with ED use rates is yet another marker for specific neighborhoods in New York City deserving of special attention due to deficiencies in the outpatient care system.

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Beyond their relationship with ED use, PQIs can serve as important markers for potential problems within the health care delivery system such as inadequate patient education or discharge planning. PQIs may also help identify issues within communities related to poverty and access to care that directly affect health services use, including limited access to outpatient care, suboptimal living environments, and difficulty affording necessary prescription medications.

XVII. ED Use and Payer Status The influence of poverty on ED use can be seen, without the desired precision, in payer data reported to SPARCS. We conducted a city level analysis of ED use by payer, and divided payers into Safety-Net (Medicaid and Self-Pay), Medicare, and All Other (commercial insurance). The data are problematic because a considerable but indefinable portion of the Commercial and Other category are in fact persons enrolled in Medicaid Managed Care plans, thus leading to an undercount of Medicaid and in turn the Safety-Net category. Another problem arises from the belief that a greater proportion of Medicare beneficiaries are admitted to inpatient services and therefore deleted from the treat and release data base.14 Previous work by the United Hospital Fund showed that rates of admission to the hospital from the ED, or conversion rates in the 65 and over population are high (27 ED admissions per 100 population) compared to two admissions per 100 for the 5-17 age group and 11 admissions per 100 for the 40-64 age group. As a result, this analysis underreports overall ED utilization for both Medicaid and Medicare. With these caveats, Safety Net populations constituted 44% of the general population but had the majority (65%) of all treat and release ED visits in NYC in 2008 (Table 5). This high rate is certainly an undercount, due to the fact that Medicaid beneficiaries enrolled in managed care plans are reported in the Commercial and Other category. At the neighborhood level, payer mix for ED visits was unsurprising, with safety net payers the major contributor in low-income neighborhoods, and commercial insurance (other) contributing larger percentages in wealthier neighborhoods.

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XVIII. Frequency of ED Use and Hospitalization Neighborhood ED use rates were highly correlated with neighborhood inpatient use rates (correlation coefficient 0.94). Both UHF neighborhood ED and inpatient use rates were also correlated with neighborhood self-reported poor health status. 234,634 people (2.8% of the total population) in NYC in the SPARCS dataset had at least one ED visit and hospitalization in 2008. Of those individuals, 85% were adults (18 and over). Among this population with both ED and inpatient use, the average number of hospitalizations increased with increasing numbers of ED visits. For example, those with one ED visit in 2008 had an average of 1.53 hospitalizations that year. Those with two ED visits had an average of 1.66 hospitalizations, and those with three or more ED visits had an average of 2.27 hospitalizations. Most of the average increase in hospitalizations could be accounted for by the adult population: average hospitalizations among children 0-17 remained more constant (Tables 26-29). When isolating this population of people with both ED and inpatient use, average numbers of hospital admissions among the population did not vary as much among UHF neighborhoods: for example, in East Harlem, those with 3 or more ED visits had an average of 2.82 hospital admissions, and those on the Upper East Side had an average of 2.6. However, a disproportionate share of this population resided in East Harlem (n=1,961) compared to the Upper East Side (n=330). This indicates that UHF neighborhoods with high ED use and higher poverty levels also have higher numbers of people with heavy health services use more generally. Future work that examines in-depth characteristics of this population with concomitant ED and inpatient use will be important, as this is likely an especially high need, high cost population.

XIX. Discussion We found significant neighborhood variation in ED use across New York Citys neighborhoods. Our analysis showed that neighborhood level ED use variation is highly correlated (0.73) with safety net payer status (0.73); poverty (0.81); education/not graduating high school (0.73); and fair or poor health status (0.64). The fact that several measures of socioeconomic status were correlated with ED use indicates an important connection between resource availability, access to services, and health services use. Such connections have been
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documented previously15,16 but this analysis presents a slightly different look by examining these links at the smaller, neighborhood level. Neighborhood use rates were moderately correlated with reported neighborhood health status defined as the percentage of residents reporting poor or fair health in the New York City Community Health Survey (correlation coefficient 0.63). We used 2000 census data to determine whether UHF neighborhood poverty rates and education level were correlated with neighborhood ED use rates. The percent of neighborhood residents at or below poverty level was highly correlated (correlation coefficient 0.810) as was the percentage not graduating high school (0.731). Our ANOVA analysis took this one step further, and determined that the level of ED use in 2008 was strongly associated with neighborhood poverty, proportion of uninsured, fraction of Blacks and Hispanics, and residents reporting poor/fair health status, no regular doctor and problems with getting medical care when needed. These findings underscore the fact that neighborhood characteristics, in addition to factors such as access to care, are likely interrelated and important issues that affect ED use. In neighborhoods with high overall ED use rates, community leaders, and policy makers can evaluate existing non-ED resources and determine the need to invest in additional resources, community education and outreach, or both. The issue of payer is quite important. Our analysis is in line with recent literature showing that Medicaid beneficiaries4, 8 are disproportionately driving the nationwide increase in ED utilization. Interventions and demonstrations aimed at curbing ED use would be best focused on this population. Relatively heavy ED use by children ages 0-17 in comparison to the adult population was a significant finding. Adjusting for their smaller share of the total population, children were 40% more likely than adults to use an ED. Furthermore, ED use rates were higher amongst children compared with adults in nearly all UHF neighborhoods, and varied more by neighborhood than in the adult population. The fact that the heaviest ED use was concentrated within the same 17 neighborhoods among 0-4 and 5-17 year-olds suggests that within those communities, interventions specific to the pediatric population and their caregivers regarding ED use may be warranted. In addition, a thorough evaluation of existing and needed health and social resources for children in these communities may uncover neighborhood-specific factors contributing to higher rates of ED use.
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We report interesting and novel data regarding patterns of ED use by date and time that demonstrates a relationship between resource availability and health seeking behaviors. The neighborhood variations in daily ED volume have important implications for EDs and healthcare systems that aim to staff appropriately and efficiently based on patient volume. As it is likely that such patterns vary by facility, individual EDs could examine similar data in order to establish the most efficient staffing patterns to correlate with periods of high and low patient volume. In groups of neighborhoods with higher income and presumably more resources, we noted that the visit volume at peak hours is less extreme than that in neighborhoods with lower income and fewer resources or less access to care. Among the populations residing in lower income neighborhoods, ED use at peak hours is disproportionately higher. There is a clear need to further evaluate, at the neighborhood level, which communities would benefit from potential solutions, such as extended clinic and office hours, and those that could benefit from strengthening the primary care and outpatient safety net system more generally. The relationship between residential mobility and ED visits demonstrated that the number of moves between UHF neighborhoods increased with increasing numbers of ED visits. This mobility, which may be an important proxy for unstable housing or homelessness, must be taken into account when designing interventions targeted at high users, and could complicate patient outreach and engagement. However, the fact that such patients are likely to touch the system frequently could be used as an opportunity for outreach and engagement within the healthcare system and through partnerships with community organizations. The NYU ED algorithm re-emphasized that the majority of ED visits are not emergent and many may be primary care treatable. A familiar grouping of UHF neighborhoodsthose with lower baseline level ED use and also lower poverty levels-- had a significantly higher percentage of Emergent, ED care needed visits and lower percentages of visits for conditions categorized as Emergent, Preventable/Avoidable, a proxy for ambulatory care sensitive conditions. These results are consistent with our findings from the PQI analysis, discussed below. There was less neighborhood variation among ED use for primary care treatable conditions. Results may indicate that populations in neighborhoods with lower baseline ED use-the same neighborhoods with lower poverty levels-have more access to ambulatory care services that can manage chronic disease and avoid ED visits for preventable issues (e.g. asthma flares, congestive heart failure exacerbations) during both off- and on-hours, as we noticed little
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difference between the two analyses. As we did not control for the general health of the population, it may also be that in certain neighborhoods, prevalence of chronic disease is simply higher and results in more ED visits related to the progression or exacerbation of chronic disease. If this is the case, increased access to primary care services during both off- and on-hours will be even more important. It is important to remember that the NYU ED algorithm only classifies general medicine visits, and thus our results do not include visits for injury or behavioral health conditions. However, in Section X-ED Diagnoses, we explain that the overall proportion of visits for behavioral health conditions was quite significant in the frequent ED user population; visits for these conditions did not vary much by neighborhood in overall population of NYC ED users. Below, we include a more detailed discussion of our analysis of ED by time of day and day of week, which took all visit types into account. We found important connections between ED use and use of inpatient services: those with higher numbers of annual ED visits also had increasing numbers of hospitalizations. In contrast to ED visits not resulting in hospitalization, which were more prevalent in the 0-17 population, the adult population (18 and older) accounted for the majority of the hospitalizations that increased with increasing annual ED visits. This is of key importance for hospitals, policy makers, and planners, as hospitalizations are currently a main source of revenue or expenditures, depending on ones perspective. The fact that neighborhood level PQI admission rates, or preventable medical admissions, were moderately to highly correlated with neighborhood ED use rates indicates that improvements in access to appropriate outpatient care varies at the neighborhood level as evidenced not only by high levels of treat and release ED visits, but also by potentially preventable hospital admissions. Further study is needed to determine whether these variations are due to health care system gaps or failures, challenges encountered by the people living in these neighborhoods with navigating an incomplete and complex delivery system, or a combination. It should be emphasized again that PQIs do not encompass behavioral health diagnoses, and may thus underestimate or fail to capture the issue of preventable hospital admissions in their entirety. We felt it important to delineate subsets of frequent users within the ED user population more generally, and thus had a particular focus on what we named super-users,
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those with 5 or more annual ED visits for three consecutive years. This group was in fact distinct from other ED user groups, with much higher prevalence of psychiatric and substance use diagnoses, as well as residential moves and use of inpatient services. Future studies should link super-users to other areas of the health care system, including pharmacy data, to determine if prescriptions are being provided and filled and if appropriate outpatient care is accessed by this population. In addition, to best reach and engage this population, interventions should tailor services to address these particular needs and focus on the safety net population. Currently, there is intense focus on the highest users of health care services as they are thought to exert significant pressure on an overtaxed health care system and can generate high costs to the health and social care system. The New York State Medicaid Redesign Team, which is developing plans to implement health homes and other proposals designed to better integrate health care with housing stability, is appropriately attempting to target these frequent users of ED services, especially those who remain frequent users over time and generate concomitant high expenditures. In anticipation of health reform implementation in 2014 there is an increasing emphasis on Patient Centered Medical Homes, Health Homes (to provide care coordination services), and a movement towards Accountable Care Organizations at both the state and federal levels. These new mechanisms for care delivery present real opportunities to improve care and will reward providers for delivering the right care via enhanced reimbursements. Each will require an emphasis on ambulatory service delivery: community-level evaluations of ED use for primary care treatable and ambulatory care sensitive conditions such as this, in addition to local evaluation of primary care capacity will be fundamental if true improvements in the health delivery system are to be made.

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