Edmond A. Hooker, MD, DrPH on Trends in US Emergency Department Visits and Costs

In this podcast, Edmond Hooker, MD, DrPH, talks about his research on the trends in US emergency department visits and costs between 2010 and 2016, the factors that may have affected these trends, how the trends have affected facilities across the United States. 

Additional Resources:

• Lane BH, Mallow PJ, Hooker MB, Hooker E. Trends in United States emergency department visits and associated charges from 2010 to 2016. Am J Emerg Med. 2020;38(8):1576-1581. https://doi.org/10.1016/j.ajem.2019.158423
• Hooker EA, Mallow PJ, Oglesby MM. Characteristics and trends of emergency department visits in the United States (2010-2014). J Emerg Med. 2019;56(3):344-351. https://doi.org/10.1016/j.jemermed.2018.12.025 

Edmond A. Hooker, MD, DrPH, is an assistant professor of emergency medicine and director of clinical research coordinators at UC Health in Cincinnati, Ohio.

TRANSCRIPT

Amanda Balbi: Hello everyone, and welcome to another installment of Podcasts360—your go-to resource for medical news and clinical updates. I’m your moderator, Amanda Balbi with Consultant360 Specialty Network.

Demographic shifts and care delivery system evolution affect the number of emergency department visits and associated costs. Recently, a research team investigated the aggregate trends in emergency department visit rates and charges between 2010 and 2016.

With us today to discuss this study is lead author Dr Edmond Hooker, who is an assistant professor of emergency medicine and director of clinical research coordinators at UC Health in Cincinnati, Ohio.

Thank you so much for joining me today, Dr Hooker. Let’s dive into your study.

For your study, you and your team aimed to estimate the US emergency department visit rate and charges per visit from 2010 to 2016. To start, what prompted you to conduct this review?

Edmond Hooker: Well, we wanted to look and see how emergency visits are increasing in the United States, you know, with all the health care changes and health care reform and everything. Are we continuing to increase the number of visits in the emergency departments, as well as cost? We were very interested in where is cost going. Is it getting more and more expensive? So are the visits growing? Are they growing faster than the population? And things like that.

Amanda Balbi: Absolutely. Your analysis included 30 million annual patient visits from the National Emergency Department Sample, for which you grouped visits into 144 mutually exclusive clinical categories. Can you talk more about the clinical categories and which ones had the highest compound annual growth rates?

Edmond Hooker: Yes, so this grouping system was created by myself and some other researchers because, unfortunately, the ones used by the CDC and the government are clinically not relevant. They are they're separating different abdominal pain diagnoses away from each other, which doesn't make any sense. You know, when we see someone in the emergency department, you present with abdominal pain; you don't present with “I have a gallbladder problem.”

So they make it look like that abdominal pain wasn't number one with the grouping system they use, when in actuality it is by far the highest reason someone comes to an emergency room. In previous research, we showed it was about 10% of the visits. So, it's a huge issue.

So, we created this new system, which groups clinically relevant things together. So chest pain, myocardial infarction, heart disease—those are all approached the same way as a clinician. So, they should be grouped together. They shouldn't be busted apart. So, we created this system and then applied it to this research. We had done previous research tracking emergency medicine visits.

And we used the NED [National Emergency Department] system because it's a much more robust data. It is based on 30 million visits and allows you to estimate the visits for all of the United States. It's about 1000 emergency departments and about 30 million visits. And based on some statistical methodology, they're able to estimate the total visits for the United States. The other systems are nowhere near as robust, and they're based on a one-month survey of a small number of hospitals, and then they try to estimate. So that's the reason we didn't use it.

Amanda Balbi: Yeah, so your review was really overarching for the entire United States and did a really wide analysis.

Edmond Hooker: Yes, this is a complete look at, again, it's 1000 out of about 4200 acute care hospitals. It's an all-payer database. So, it has Medicaid, Medicare, private insurance. You have to watch out, if you're looking at somebody that does something with Medicare only, well that's not reflective. You need to look at the whole population, and this did look at the whole population.

Amanda Balbi: Your team also found that the number of emergency department visits had increased from 128.97 million in 2010 to 144.82 million in 2016. What factors might have affected this trend?

Edmond Hooker: Well, if you look at some of the other data in the results, I think a lot of it has to do with Medicaid patients have increased. So who was the increase, where is it coming from? It's coming from private insurance and Medicaid.

So, as people got insurance, they have a tendency to go and use it. Especially with Medicaid where patients aren't paying a copay at all, they have a tendency to use the emergency department. And that's not necessarily wrong. Everybody wants to say, “oh, they should not have used the emergency department.”

But if you have no other place to get access care, because no private doctors are available in the evening when you're not working, or you are scared and don't know that this chest pain turns out not being something serious but you still needed to be evaluated, they were appropriate to go to the emergency department.

Everybody wants to talk about inappropriate use of the emergency department, when in reality, I think that it's appropriate if the patient is scared, has symptoms that could turn up being something serious, it's very appropriate to use the emergency department for that.

Amanda Balbi: Absolutely. And is there something to say about rural areas of the United States that emergency departments may be the only option for those people?

Edmond Hooker: Yes, that is true. But interestingly, if you look at the more rural areas and some of the data, they actually were not going up that much. So it's kind of interesting that it was more in the metropolitan areas, which is where most of the emergency visits are. You know, like 85% of the people in the current sample in 2016 were from metropolitan areas. It's just where people live, so that's where you're going to have most of your emergency visits from.

Amanda Balbi: That makes sense. And I'm sure motor vehicle accidents happen more often in the city, too.

Edmond Hooker: Absolutely. And you know the highways. Even if you have an accident in a more rural area, you may end up in a metropolitan area, because that's where the trauma centers are.

Amanda Balbi: That definitely makes sense. You mentioned before that another part of this analysis was assessing costs, for which you also saw an increase of 9.31% from 2010 to 2016. What factors might have affected this trend? And do you think this trend would ever reverse in the United States?

Edmond Hooker: So total over the 6-year period, the number of visits went up by about 7.3%, but costs went up by 55%. And so that could be from a multitude of things, but the most likely one is they actually just raised the price.

Because if you look at the actual use of more-sophisticated technology, that certainly would have some impact if people are using more cat scanners. Those are very expensive. But in actuality, if you look at the patients who presented with, like, upper respiratory tract things, those people didn't get CAT scans and yet their cost of care went up just about the same as the patients who presented with abdominal pain. So, I think that it has to do with hospitals are continuing to raise the price of the care delivered in the emergency department.

Amanda Balbi: What clinical pearls can emergency medical professionals take away from your review? What is the take home message here?

Edmond Hooker: Well, I think that the take-home messages are that abdominal pain is going to be your number one reason for showing up and that you're going to need to be ready to take care of these.

One of the things that also is in the top list is mental health. That to me is a big issue with previous research we did, and this research showed that mental health is one of the top 10 reasons people come to the emergency department, and yet the availability of mental health resources after the emergency department—you know, where are you going to admit them if they need to be admitted? Where can they get follow-up if they don't need to be admitted?—are woefully inadequate.

Facilities across the United States—we have closed down so many mental health facilities that it is so hard for a patient to find care now for mental health. There are hospitals—I won't name any of them. It's not my hospital but they are hospitals that I know of—that are holding patients sometimes 1 and 2 weeks in the emergency department, trying to find a mental health facility to admit them to. So that, to me, was one of the biggest things; that keeps growing every year, yet we keep taking more and more resources away from mental health.

Amanda Balbi: What other research are you working on in this area?

Edmond Hooker: They update this NED set every year. And we will continue to use that data set to see if trends are changing, because both with the effects of the pandemic as well as the effects of health care reform and it all its many things, I think that a lot of people are trying to push people away from emergency departments to alternate sites of care. So far it has not had an effect, but it'll be interesting to see if it has an effect over the next year or two.

Amanda Balbi: Yeah, for sure, especially with the pandemic, and who knows when that's going to end.

Edmond Hooker: Right. We have seen, just yet our hospital because we're a safety net hospital, our visits are back to where they were. We are still seeing that we're seeing as many as we were seeing before the pandemic. Now, during the height of it here in Ohio, our visits were off 50%, but a lot of hospitals have not recovered. Their emergency visits are still remaining off.

But ours, because again we are seeing a lot of people with no access to care other than through our emergency department; they can't get to a primary care doctor; there's no primary doctor care doctor will see them, especially if they have no money, no ability to pay. We see everybody.

And that's part of the issue in the United States and appropriately so. We made a federal law back in the 1980s that said, if you show up in an emergency room, you have to be cared for. Period. No discussion. That was a good law, and it was what needed to happen.

But because of that, patients understand that they can go to an emergency room, and they will be seen. Whereas, if you go to a primary care doctor or a family doctor and you have no money, you're not going to get seen. If you need an orthopedic surgery and you have no money, you're going to be told, “We're not doing it. You can go to the University Hospital and see what they can do for you, because they take care of people with no money.”

So, it's a huge issue that as long as patients can come to the emergency room and have no other access to care, I don't think we're going to see any decrease in emergency visits, as the government is now more than a 50% payer in the United States—more than 50% of the patients in the United States are paid for by the government, either Medicare or Medicaid. Most of those have absolutely no limitations on your use of the emergency department.

I'm not sure how you're going to limit it unless there's some way to have the patients be responsible for something if they use the emergency department, which I'm not necessarily advocating for but I'm just saying I don't think you're going to change it.

When a patient with private insurance looks at a $250 copay, they may think twice about using the emergency department. But if you have absolutely no copay at all, then it's hard to convince anybody that they're not going to use it.

Amanda Balbi: Right, absolutely. Thank you so much for speaking with me today and answering my questions about your study.

Edmond Hooker: Oh, you're very welcome. I enjoyed doing this study with my coresearchers, and I think it just shows that emergency visits continue to go up and go up at a very rapid rate, and the cost of these visits keeps going up even faster than that.