Cross-sectional Analysis of Emergency Department and Acute Care Utilization Among Medicare Beneficiaries

Abstract

Background: We sought to develop a claims-based definition of unscheduled care to describe the use and role of the emergency department (ED) in providing unscheduled care to vulnerable older adult populations. Methods: This study was a cross-sectional analysis of national 20% sample of Medicare beneficiaries included in the 2012 Chronic Condition Warehouse data set. We measured three outcomes: the number of ED visits per 1,000 Medicare beneficiaries, the proportion of all unscheduled ED and office-based visits occurring in the ED and the number of ED and non-ED unscheduled visits adjusting for risk factors. Each outcome was estimated for vulnerable subpopulations of Medicare beneficiaries with multiple chronic conditions (MCCs), dual eligibility, hospice enrollment, and skilled nursing facility use. Results: A total of 10,717,786 Medicare beneficiaries were included with 33,696,461 potentially unscheduled care visits of which 5,192,235 (15%) occurred in the ED, 364,334 (1.1%) in facility-based urgent care, and 31,570,113 (84%) in ambulatory office settings. In regression analyses each subpopulation was more likely to visit the ED for unscheduled care services than the reference population of Medicare beneficiaries ages 65 to 80. Dual-eligible beneficiaries demonstrated higher ED visit rates and lower non-ED visit rates for unscheduled care. The subpopulation with MCCs uses both the ED and the non-ED setting for unscheduled care more so than any other group. Conclusions: Medicare beneficiaries, particularly vulnerable subpopulations, disproportionately visit the ED in comparison to physician offices for unscheduled care. Efforts to improve care coordination, measure quality, or reform payment to influence ED visitation should acknowledge these patterns and the unique availability of acute care services in the ED.