Houston Hospitals Emergency Department Use Study

HOUSTON HOSPITALS EMERGENCY DEPARTMENT USE STUDY

January 1, 2010 through December 31, 2010

FINAL REPORT

Prepared By

School of Public Health University of Texas Health Science Center at Houston Charles Begley, Patrick Courtney, Keith Burau

June 2012

TABLE OF CONTENTS

I. Executive Summary ...... 3

II. Purpose ...... 14

III. Methods ...... 15

IV. Results ……………………………,…...... 18

A. Total ED Visits………….……………...…...…..…………..…....……...18

B. Primary Care Related ED Visits…………………….……………...….22

C. ED Visits by Month, Day, and Time…………………...….……..….…25

D. ED Visits by Patient Characteristics…………………….…...….…..…32

E. Health Conditions of Patients with ED Visits………….…..…...……..50

F. Behavioral Health Related ED Visits…………………….……...…….50

G. Length of Stay in the ED……….……………………….…….……..…54

H. Estimated Cost of Primary Care Related ED Visits…………….……54

I. Geographic Distribution of Patients with ED Visits………………………….…….…..…………...... …………....60

J. Trends in ED Visits Over Time…………………………….………….74

V. Limitations……………………………....………………..…….……...……83

VI. Acknowledgements………………………………………………….……...84

2 I. EXECUTIVE SUMMARY

The University Of Texas School Of Public Health collects and analyzes emergency department (ED) visit data in Harris County hospitals and monitors primary care related (PCR) use of the ED. The main purpose of this report is to provide information on the frequency and type of ED visits in Houston hospitals in 2010, the medical conditions for which visits are made, the characteristics of patients that visit the ED, and the trends in ED use over the last several years.

Data and Analysis

Twenty five general hospitals with EDs that serve the public of Harris County (provide hospital-based ED care and accept 911 ambulance deliveries) participated in the 2010 hospital

ED study. They include: two hospitals of the Harris County Hospital District (Ben Taub General and Lyndon B. Johnson General); nine hospitals of the Memorial Hermann Health Care System

(Hermann/Texas Medical Center, Southwest, Southeast, Northeast, Northwest, The Woodlands,

Memorial City, Katy, and Sugar Land); three hospitals of the Hospital Corporation of America

(Bayshore Medical Center, East Houston Regional Medical Center, and West Houston Medical

Center); Spring Branch Medical Center; St. Joseph Medical Center; Texas Children’s Hospital; two hospitals of CHRISTUS Gulf Coast (St. Catherine and St. John); two hospitals of the St.

Luke’s hospital system (Episcopal Hospital and Community Medical Center); and four hospitals of the Methodist Hospital System (Methodist/Texas Medical Center, San Jacinto Methodist,

Methodist Willowbrook, and Methodist Sugar Land).

Each hospital supplied the following information on each ED visit during calendar year

2010:

1. Date and time of admission to ED 2. Primary and all secondary discharge diagnoses

3 3. Discharge date and time 4. Payment source 5. Patient age 6. Patient gender 7. Patient race/ethnicity 8. Patient ZIP code 9. Where discharged (e.g. home, nursing home, etc.) 10. Mode of transport (e.g. ambulance, self, other)

Based on this information, the number, type, and rate of ED visits to all Houston hospitals for various population groups was estimated and the number and percentage of primary care-related ED (PCRED) visits was estimated by applying the New York University ED

Algorithm to each visit. The NYU Algorithm determines the likelihood that a visit is one of the following types.

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 demographic, coverage, and health conditions of patients with ED visits and PCRED visits was determined. ED visits were mapped by ZIP code, population-based PCRED visit rates were calculated, and the pattern over time of ED visits and PCRED visits was summarized and assessed.

4 2010 Highlights

1. Total ED Visits

a. During 2010, 1,044,738 ED visits were made to all 25 participating hospitals. Of this total, 97.11% of visits were made by residents of the eight county area (including Harris

County), and 84.13% were made by Harris County residents alone. Of all 2010 ED visits reported, 852,677, or 81.62% were by residents of the eight county area who were discharged home or elsewhere. Of all 2010 ED visits reported, 739,979, or 70.83% were by Harris County residents who were discharged home or elsewhere (Table 1a).

b. The ED visits of participating hospitals represented 67.83% of all ED visits reported to the Texas Department of State Health Services by all hospitals in Harris County in 2010. Using this percentage for extrapolation, an estimated 1,295,814 ED visits were made by Harris County residents to all hospitals in the county. This translates into an ED visit rate for Harris County residents of 31.66 per 100 residents, minimally lower than the rate of 31.84 in 2009 (Table 1a).

2. Primary Care Related ED Visit Percentages

A little over 40% (40.9%) of ED visits by Harris County residents were PCR in 2010.

This includes non-urgent, primary care treatable, and primary care preventable visits. The 2009 percentage compares to 41.0% in 2009 and 39.1% in 2008 (Table 2).

3. ED Visit Rates by Population Sub-Group

Females had a higher rate than males for both total visits and PCRED visits over the last two years. Persons age 65 and over had the highest rate of total ED visits for the last two years

(46.98 per 100 elderly in 2010). Children and adolescents had the highest rate of PCRED visits

(15.67 per 100 children in 2010) (Table 1b). Persons enrolled in Medicare in 2010 had the highest rate of total ED visits (114.49 per 100 Medicare enrollees), and also the highest rate of

5 PCRED visits (34.79 per 100 Medicare enrollees enrollees).1 Persons of other race or ethnicity had the highest rates of total visits and PCRED visits. Among those defined as one race, persons who were Black non-Hispanic had the highest rate of total visits in 2010 (49.28 per 100 Black persons) and PCRED visits (22.58 per 100 Black persons) (Table 1c).

4. ED Visits by Month, Day, and Time

The number of ED visits by Harris County residents was highest in March through May

(Figure 3). The percentage of ED visits that led to hospitalizations was also relatively constant over the year. The peak day of the week for ED visits was Friday (Figure 4). The percentage of

ED visits leading to hospitalizations remained relatively level each day.

ED visits by children peaked between 7-8 PM, with a secondary peak at 11 AM-12 PM

(Figure 5a). ED visits by adults age 18 to 64 peaked at noon, dropped slightly and remained fairly level until 7 PM (Figure 5b). ED visits by adults age 65 and over peaked at 12 PM, then dropped during the evening (Figure 5c). Relatively few ED visits by children resulted in a hospitalization, in contrast to adults age 65 and over.

5. PCRED and non PCRED Visits by Patient Characteristics

a. Payer source: The uninsured accounted for 24.0% of PCRED visits and 23.4% of non-

PCRED visits. Medicaid covered individuals made up 29.2% of PCRED visits and 22.6% of non-PCRED visits. Children on CHIP made up 3.6% of PCRED visits (Figures 6 & 7). Patients with commercial insurance accounted for 29.6% of PCRED visits and 29.0% of non-PCRED visits. Nearly five in ten ED visits made by persons on Medicaid (48.0%) were PCR, and a smaller percentage of all ED visits by persons on CHIP (47.0%) were PCR. Medicare enrollees had the highest percentage of hospitalized ED visits (29.4%) (Figure 8).

1 Please see technical note on Medicare after the final page of this report.

6 b. Race/Ethnicity: Two thirds (66.8%) PCRED visits were by persons who were

Black or Hispanic, but only 59.1% of non-PCRED visits were by persons who were Black or

Hispanic. By contrast, persons who were White accounted for 26.3% of PCRED visits and

33.3% of non-PCRED visits (Figures 9 & 10). More than four in ten of all ED visits by persons who were black or Hispanic were PCR. Asians and Whites were most likely to have an ED visits resulting in a hospitalization (Figure 11).

c. Age: Children age 17 and under made up one third (33.9%) of all PCRED visits, and just over one fourth (27.9%) of non-PCRED visits. Adults age 65 and over were almost twice as likely to have non-PCRED visits than a PCRED visit. More than four in ten (44.4%) of all

PCRED visits were by adults age 26 to 64, and they made up a comparable percentage of non

PCRED visits (45.1%) (Figures 12 & 13). More than three in ten (31.4%) ED visits by adults age

65 resulted in a hospitalization (Figure 14).

d. Gender: Almost six in ten (59.8%) PCRED visits were by females and 40.2% by males

(Figure 15). Of non-PCRED visits, 52.9% were by females and 47.1% by males (Figure 16). The percentage of ED visits resulting in a hospitalization was only slightly higher among males

(15.8%) than females (15.1) (Figure 17).

e. Transport: Fewer than one in ten (8.6%) PCRED visits were by persons with an ambulance transport to the ED. By contrast, nearly one in five (18.4%) non-PCRED visits were by persons with an ambulance transport to the ED (Tables 7a & 7b; Figures 18 & 19). More than one fourth (27.5%) of ambulance transports to the ED eventually resulted in a hospitalization

(Table 7c and Figure 20).

7 6. Health Conditions of Patients with PCRED and non PCRED Visits

The most common discharge diagnoses of patients with PCRED visits for the last three years has been acute upper respiratory infection not otherwise specified, and for two years the second most common PCRED discharge diagnosis has been urinary tract infection not otherwise specified (Table 8). Chest pain not otherwise specified has been the leading non-PCRED diagnosis for three years (Table 9).

7. Behavioral Health-Related ED Visits

The percentage of behavioral health visits dropped from 8.3% in 2008 to 7.7% in 2009, then rose to 8.5% in 2010. The number of persons who were seen with an alcohol-related diagnosis and no other behavioral diagnosis has risen steadily for three years. In 2010, the number of persons who were seen primarily with a mental health diagnosis, but no secondary behavioral diagnosis, was at its highest level in three years (Table 10).

8. Length of Stay in the ED

The mean length of stay of ED visits (measured from time of admission to the ED to time of discharge from the ED) was calculated for visits of less than 24 hours each. The mean LOS for PCRED visits has been declining for the last three years (3.54 hours in 2010). Non hospitalized behavioral health visits continue to last longer than non hospitalized medical visits

(5.83 hours vs. 4.14 hours in 2010) (Table 11).

8. Estimated Cost-Savings from Reduction in PCRED Visits

Applying national estimates of the unit cost of ED visits to Houston ED visits suggests that the greatest potential cost savings from diverting PCRED visits would be among adults age

18 to 44, whether insured or uninsured (Table 12 and 13, Figures 21and 22). However, these

8 estimates do not account for the variability that may occur among treating chronic vs. acute conditions.

9. Geographic Distribution of Patients with ED and PCRED Visits

The following ZIP code clusters had the highest number of ED visits: 1) the intersection of Highway 59 and the North Loop East; 2) the Ship Channel and the area along Interstate 10 and the East Belt; 3) an area just east of Highway 288 and on both sides of the South Loop; 4) an area along the Southwest Freeway and between the West Loop and West Belt; 5) the intersection of Interstate 10 and Highway 6; and 6) an area along Highway 290 and just outside the North

Loop West (Map 1a). Most areas of Harris County saw decreases in visits from 2009 to 2010

(Map 1b).

The geographic distribution of PCRED visits by the insured and uninsured was similar to that of ED visits (Maps 2a and 3a). The Baytown area in the eastern part of the county saw the biggest increases among primary care related visits in general and the uninsured in particular

(Maps 2b and 3b).

The areas with the highest rates of ED visits, PCRED visits by all, and PCRED visits by the uninsured were the East/Northeast and South Central areas of Harris County, as well as the

Katy area in the west (Maps 4, 5, and 6). The rate of PCRED visits in the Katy area is higher among Medicaid enrollees than among CHIP enrollees. The eastern part of Harris County has high rates among both groups (Maps 7 and 8).

10. Trends in ED and PCRED Visits Over Time

To examine trends over time, the ED visits in which patients were discharged home or elsewhere of 15 hospitals were tracked over the five-year period from 2004 to 2010 (Ben Taub

General, Lyndon B. Johnson General, Memorial Hermann (MH) Hermann, MH Southwest, MH

9 Southeast, MH Northwest, MH Woodlands, MH Memorial City, MH Katy, MH Sugar Land

(formerly Fort Bend), Hospital Corporation of America (HCA) Bayshore,, HCA East Houston,

Texas Children’s Hospital, Spring Branch Medical Center, St. Luke’s Episcopal Hospital). The

ED visits of 22 hospitals were tracked over the four-year period from 2005 to 2010 (above listed hospitals, plus MH Northeast, HCA West Houston, CHRISTUS St. Catherine, CHRISTUS St.

John, St. Luke’s Community Medical Center, The Methodist Hospital, and San Jacinto

Methodist Hospital).

In both groups of hospitals the percentage of non hospitalized visits that are primary care related has fluctuated over the years, but in 2010 they were nearly identical (49.4% for 15, 49.2% for 22). The number of PCRED visits was highest in 2009. After a two year downward trend in visits that resulted in a hospitalization, the percentage of hospitalizations rose in both groups in

2010 (Tables 15 and 16).

For the first time in several years, the uninsured are no longer the most common group when PCRED visits are seen by payer source. That distinction now belongs to persons enrolled in Medicaid (Figures 23 and 24). The percentage of PCRED visits by persons with private insurance was at its peak in 2006, declined for a few years, and is back at nearly the same level as in 2006.

Hispanics continue to represent the greatest percentage of PCRED visits. However, that percentage declined in both groups in 2010 (Figures 25 & 26). Blacks represent the next largest group on a percentage basis.

Visits by children age 18 and under continue to account for the largest proportion of

PCRED visits. In 2008 that proportion dropped somewhat, increased in 2009 and dropped in

2010 (Figures 27 & 28). Adults age 26 to 44 accounted for the next largest percentage.

10 There has been little change in the gender ratio of PCRED visits over the last five years

(Figures 29 & 30).

In contrast to the grouping of 15 hospitals and 22 hospitals, all ED visits for the last three years were analyzed for transport status. For all ED visits and for PCRED visits, the majority of persons do not come by ambulance, but use some other means of transportation (Figures 31 and

32).

Conclusion

ED visits of Harris County residents in area hospitals grew at a slightly lower rate than the population resulting in a minimal decrease in the population rate of ED visits. The percentage of visits that were PCR, which rose slightly in 2009, dropped slightly in 2010. There was a decline in both total ED and PCRED visits in residents living inside the 610 loop, and an increase in PCRED visits in the Baytown and Katy areas of Harris County. The eastern side of

Harris County had a high of rate of PCRED visits among both Medicaid and CHIP enrollees.

Diversion of PCRED visits of uninsured adults age 18 to 44 have the largest potential for cost- savings. The areas with the greatest potential for cost-savings in this group are located in

Houston, Katy, and Baytown (Map 9 and Table 14).

Persons enrolled in Medicare in 2010 had the highest rate of PCRED visits. The vast majority of Medicare enrollees have usually been age 65 and over. A special report1 of 2009 ED visits by Harris County residents found that Medicare enrollees between the ages of 35 and 64

had rates of many types of ED visits that were often twice as high as rates of ED visits by

1 Courtney P. Rates for select types of emergency department visits in Harris County, Texas, 2009. May 2011. Available at https://sph.uth.tmc.edu/content/uploads/2011/12/Rates-for-select-tyopes-of-emergency-department-visits-in-Harris-County.pdf

11 Medicare enrollees age 65 and over. Further analysis is needed to see if the same pattern is true of 2010 ED visits.1

Despite continuing efforts by hospitals and the local health care safety net, many areas of

Harris County continue to have high rates of PCRED visits. In addition to the northeast and south central parts of the 610 Loop (e.g. Third and Fifth Wards), the areas of Baytown and Katy have high rates of PCRED visits among Medicaid and CHIP enrollees, as well as among the uninsured.

Continued participation by a large number of hospitals has allowed for monitoring of community-wide trends ED and PCRED utilization in Harris County. The trend analysis over the last five years suggests the continuing need for multiple diversion strategies to reduce ED and

PCRED visit rates especially for the uninsured, Medicaid, CHIP, elderly and Medicare enrollees.

The data support the need to expand access to outpatient primary and specialty care, the need for patient education about appropriate ED use, the need for after-hours clinics, especially for children, the need for hospital staffing at peak hours of ED use, and the need for efforts to link the uninsured, as well as Medicaid, CHIP, and Medicare enrollees to medical homes.

Considerable cost-savings in hospital ED use could be achieved with these and other diversion strategies.

Limitations

The NYU ED algorithm does not classify ED visits that result in hospitalization, mental health, drug/alcohol, or injury-related ED visits. It may be assumed that most hospitalized visits and a large percentage of mental health, drug/alcohol, and injury visits are not PCRED visits. To the extent that some are PCR, the estimates understate the number and percentage of total ED

1 Please see technical note on Medicare after the final page of this report.

12 visits that are PCR. This limitation does not affect the percentage or rate calculations of

classified visits. Because the data submitted is de-identified, it is not possible to identify patients who make multiple ED visits. Therefore, we are not able to identify ED or PCRED use rates of individuals.

Several providers of services to homeless persons are located in 77002 (downtown

Houston). They provide a mailing address for the people they serve to receive mail there, even though they may not be housed there. Therefore, some of the visits listed for 77002 may be homeless persons.1

1 Meyer C., St. Luke’s Episcopal Health Charities. Email communication on May 11, 2012.

13 II. PURPOSE

The increasing number of hospital ED visits, many of which are PCR, 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 PCR. To achieve this purpose, the study obtained ED data from twenty five hospitals in Houston for 2010, classified the visits of Harris County residents in terms of

PCR/non-PCR 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.

14 III. METHODS

The study initially 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. An increasing number of hospitals have participated each year. The current report uses data from 25 of the hospitals that serve the Houston 911 service area. Aggregate reports for each year are posted on the website for the Health Services Research Collaborative.

The first step in the study involves requesting the following information on ED visits in

Houston 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. Where discharged to (e.g. home, hospital, etc) 10. Mode of transport (e.g. ambulance, self, other)

Working with the hospitals, a dataset was obtained, reviewed, and cleaned comprising a full set of ED visit information for the period January 1, 2010 – December 31, 2010. Visits that did not result in a hospitalization were analyzed.

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:

15 1. Non-emergent: Immediate treatment was not required within 12 hours.

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 PCR 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 on the next page.

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 PCR use of the ED, while those in the fourth category reflect non-PCR 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.

ED CLASSIFICATION PROCESS

Step 1 Steps 2 and 3 Step 4 Not Preventable/Avoidable

ED Care Needed

Preventable/Avoidable Emergent Primary Care Treatable

Non-emergent Primary Care Treatable

Various analyses were conducted of the classified visit data to determine patterns of PCR and non-PCR 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 ZIP code of patient residence.

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 are categorized by the Algorithm. ED visits that result in a hospitalization usually encompass no more than 10-20% of total visits.1 Given these limitations in the methods, the percentage of visits that fall into the PCR categories should be interpreted as a conservative estimate. In order to get a complete picture of ED utilization, attention must also be paid to injuries, mental health and substance abuse, and hospitalized visits. In an effort to address this broader picture, the report examines not only PCR visits, but non primary care related visits as well.

1 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.

17 IV. RESULTS

A. Total ED Visits by Type

During 2010, 1,044,738 ED visits were made to all 25 participating hospitals. Of this total, 97.11% of visits were made by residents of the eight county area (including Harris

The ED visits of participating hospitals represented 67.83% of all ED visits reported to the Texas Department of State Health Services by all hospitals in Harris County in 2010. Using this percentage for extrapolation, an estimated 1,295,814 ED visits were made by Harris County residents to all hospitals in the county. This translates into an ED visit rate for Harris County residents of 31.66 per 100 residents, minimally lower than the rate of 31.84 in 2009 (Table 1a).

Females had a higher rate than males for both total visits and PCRED visits over the last two years. Persons age 65 and over had the highest rate of total ED visits for the last two years

(46.98 per 100 elderly in 2010). Children and adolescents had the highest rate of PCRED visits

(15.67 per 100 children in 2010) (Table 1b). Persons enrolled in Medicare in 2010 had the highest rate of total ED visits (114.49 per 100 Medicare enrollees), and also the highest rate of

PCRED visits (34.79 per 100 Medicare enrollees enrollees). Persons of other race or ethnicity had the highest rates of total visits and PCRED visits. Among those defined as one race, persons who were Black non-Hispanic had the highest rate of total visits in 2010 (49.28 per 100 Black persons) and PCRED visits (22.58 per 100 Black persons) (Table 1c).

18 Table 1a. Total ED Visits to Hospitals in Harris County

Study Hospital Visits 25 Hospitals 2008 24 Hospitals - 2009 25 Hospitals - 2010

Percent of Percent of Percent of Frequency Frequency Frequency first row first row first row

A Total1 (all areas)2 1,060,592 100.00% 1,127,557 100.00% 1,044,738 100.00%

B Total Discharged to Home or Self (all areas)3 931,721 87.85% 961,707 85.29% 877,062 83.95%

C Total Admitted (all areas)3 128,871 12.15% 165,850 14.71% 167,676 16.05%

D Total (eight county area)3 1,013,343 95.55% 1,094,529 97.07% 1,014,498 97.11%

E Total Discharged to Home or Self (eight county area) 3 890,817 83.99% 934,563 82.88% 852,677 81.62%

F Total Admitted (eight county area)3 122,526 11.55% 159,966 14.19% 161,821 15.49%

G Total (Harris County) 899,673 84.83% 953,395 84.55% 878,941 84.13%

H Total Discharged to Home or Self (Harris County) 789,995 74.49% 812,863 72.09% 739,979 70.83%

I Total Admitted (Harris County)3 109,678 10.34% 140,532 12.46% 138,962 13.30%

All Hospital Visits All Hospitals 2008 All Hospitals 2009 All Hospitals 2010

J Total All5 (all areas)2 1,401,423 1,522,943 1,540,247

K Total Visits as a Percentage of Total All Visits 75.68% 74.04% 67.83%

L Estimated Number of Total That Are From Harris Co.6 1,188,791 1,287,710 1,295,814

M Est. Number of Discharged That Are From Harris Co.7 1,043,867 1,097,899 1,090,944

N Est. Number of Admitted That Are From Harris Co.8 144,924 189,811 204,870

O Population of Harris County9 3,965,716 4,044,032 4,092,459

P Harris Co. ED Rate per 100 population (adm. and disch.) 29.98 31.84 31.66

Q Total Rate of Discharged ED Visits per 100 26.32 27.15 26.66

R Total Rate of Admitted ED Visits per 100 3.65 4.69 5.01

1 Total visits reported by hospitals participating in this report. 2 “All areas” = all states, all countries. 3 A number of visits each year lacked a primary ICD9 code. 4 Source: Cooperative DSHS/AHA/THA Annual Survey of Hospital and Tracking Database. 5Row J x percentage in Row G. 6Row J x percentage in Row H. 7Row J x percentage in Row I. 8 Source: 2008 & 2009 - Texas State Data Center. http://txsdc.utsa.edu/tpepp/txpopest.php; 2010 – 2010 US Census

19 Table 1b. ED Visits to Hospitals in Harris County by Gender and Age, Population Rates1 For Gender and Age

24 hospitals Males Females 2009 total population (by gender) 2,043,393 2,027,596 2009 total ED visits (by gender) 564,215 695,000 2009 total PCRED visits (by gender) 219,079 308,917 2009 total ED rate per 100 (by gender) 27.61 34.28 2009 PCRED rate per 100 (by gender) 10.72 15.24 25 hospitals Males Females 2010 total population (by gender) 2,037,405 2,055,054 2010 total ED visits (by gender) 563,086 710,025 2010 total PCRED visits (by gender) 213,273 317,336 2010 total ED rate per 100 (by gender) 27.64 34.55 2010 PCRED rate per 100 (by gender) 10.47 15.44 24 hospitals 0-17 18-34 35-64 65 and over 2009 total population (by age) 1,174,860 1,052,880 1,515,475 327,774 2009 total ED visits (by age) 394,246 462,438 250,685 151,964 2009 total PCRED visits (by age) 192,077 200,807 94,429 40,719 2009 total ED rate per 100 (by age) 33.56 43.92 16.54 46.36 2009 PCRED rate per 100 (by age) 16.35 19.07 6.23 12.42 25 hospitals 0-17 18-34 35-64 65 and over 2010 total population (by age) 1,147,835 1,075,139 1,535,998 333,487 2010 total ED visits (by age) 386,804 327,915 401,830 156,670 2010 total PCRED visits (by age) 179,907 146,130 159,759 44,837 2010 total ED rate per 100 (by age) 33.70 30.50 26.16 46.98 2010 PCRED rate per 100 (by age) 15.67 13.59 10.40 13.45

1 Denominator: Population data for 2009 comes from the 2009 American Community Survey 1 Year Estimates, Census Bureau. For 2010 population, the 2010 US Census was used instead. Numerator: ED visits for this table and the next are population estimates. Actual ED visit totals were adjusted based on data from Table 1a.

Table 1c. ED Visits to Hospitals in Harris County by Payer Source and Race, Population Rates1 For Payer Source and Race

24 hospitals Commercial Medicaid/SCHIP Medicare Uninsured 2009 total population (by payer) 2,111,270 527,469 162,607 1,093,235 2009 total ED visits (by payer) 320,499 339,107 167,192 388,030 2009 total PCRED visits (by payer) 127,637 163,654 46,287 174,820 2009 total ED rate per 100 (by payer) 15.18 64.29 102.82 35.49 2009 PCRED rate per 100 (by payer) 6.05 31.03 28.47 15.99 25 hospitals Commercial Medicaid/SCHIP Medicare Uninsured 2010 total population (by payer) 2,026,145 593,604 166,336 1,141,788 2010 total ED visits (by payer) 372,723 363,527 190,438 300,941 2010 total PCRED visits (by payer) 157,264 174,044 57,869 127,519 2010 total ED rate per 100 (by payer) 18.40 61.24 114.49 26.36 2010 PCRED rate per 100 (by payer) 7.76 29.32 34.79 11.17 24 hospitals Asian Black Hispanic Am. Indian Other White 2009 total population (by race) 232,385 730,412 1,619,426 6,455 51436 1430875 2009 total ED visits (by race) 21,997 369,233 444,330 1,022 33,098 377,567 2009 total PCRED visits (by race) 8,158 171,662 201,383 447 13,098 127,238 2009 total ED rate per 100 (by race) 9.47 50.55 27.44 15.84 64.35 26.39 2009 PCRED rate per 100 (by race) 3.51 23.50 12.44 6.92 25.47 8.89 25 hospitals Asian Black Hispanic Am. Indian Other White 2010 total population (by race) 249,853 754,258 1,671,540 8,150 59012 1349646 2010 total ED visits (by race) 21,846 371,732 422,190 1,113 30,226 386,451 2010 total PCRED visits (by race) 7,805 170,340 184,200 413 11,743 139,413 2010 total ED rate per 100 (by race) 8.74 49.28 25.26 13.66 51.22 28.63 2010 PCRED rate per 100 (by race) 3.12 22.58 11.02 5.07 19.90 10.33

1 Denominator: Population data for 2009 comes from the 2009 American Community Survey 1 Year Estimates, Census Bureau. For 2010, the 2010 US Census was used instead for race, and the 2010 ACS 1 year estimates were used for payer. Numerator: ED visits for this table and the previous are population estimates. Actual ED visit totals were adjusted based on data from Table 1a. Payer: For ED visits, commercial and other private were combined, as were Medicaid and CHIP. For ACS population, the following were combined: commercial (employer provided, direct purchase, employer and direct purchase, employer and Medicare, other private only), Medicare (Medicare only, Medicare and Medicaid). Even though ACS population is available for Tricare and VA coverage, the majority of “other government” ED visits are usually worker’s comp. The ACS data did not have a separate category for CHIP. Race: For ACS data, the following were combined: other (Native Hawaiian, Pacific Islander, some other race alone, two or more races). Please see technical note on Medicare after the final page of this report.

21 B. Primary Care Related ED Visits

A little over 40% (40.9%) of ED visits by Harris County residents were PCR in 2010.

This includes non-urgent, primary care treatable, and primary care preventable visits. The 2009 percentage compares to 41.0% in 2009 and 39.1% in 2008 (Table 2).

22 Table 2. ED visits to Hospitals by Harris County Residents

25 Hospitals 24 Hospitals 25 Hospitals Type of Visit 2008 2009 2010 Frequency TOTAL VISITS Total All Visits, Harris County (discharged and admitted)1 899,673 953,395 878,941 Total Discharged Visits (DC), Harris County1 789,995 812,863 739,979 Total Admitted Visits, Harris County1 109,678 140,532 138,962 CATEGORIZED VISITS (DC) 2 Non-Emergent 141,507 158,180 148,866 Emergent, Primary Care Treatable2 161,033 180,389 161,388 2 Emergent, ED Care Needed - Preventable/Avoidable 48,903 52,376 49,671 Total Primary Care Related Visits, Harris County 351,443 390,945 359,925 Emergent, ED Care Needed - NOT Preventable/Avoidable 94,429 95,463 91,012 Total Categorized Visits, Harris County 445,872 486,408 450,937 NON-CATEGORIZED VISITS (DC) Injury 193,591 164,243 157,535 Mental Health Related 12,382 10,227 9,380 Alcohol or Drug Related 4,389 4,973 5,442 3 Unclassified 219,902 135,390 107,196 Total Non-Categorized Visits, eight county area 430,264 314,833 279,553 Percent PERCENTAGE OF CATEGORIZED ED VISITS (DC) Non-Emergent 31.7% 32.5% 33.0% Emergent - Primary Care Treatable 36.1% 37.1% 35.8% ED Care Needed - Prev./Avoid. 11.0% 10.8% 11.0% % Categorized That Are Primary Care Related 78.8% 80.4% 79.8% ED Care Needed - NOT Prev./Avoid. 21.2% 19.6% 20.2% PERCENTAGE OF TOTAL ED VISITS Non-Emergent (DC) 15.7% 16.6% 16.9% Emergent - Primary Care Treatable (DC) 17.9% 18.9% 18.4% ED Care Needed - Prev./Avoid. (DC) 5.4% 5.5% 5.7% % Total That Are Primary Care Related 39.1% 41.0% 40.9% ED Care Needed - NOT Prev./Avoid. (DC) 10.5% 10.0% 10.4% PERCENTAGE OF TOTAL ED VISITS Injury (DC) 21.5% 17.2% 17.9% Mental Health Related (DC) 1.4% 1.1% 1.1% Alcohol or Drug Related (DC) 0.5% 0.5% 0.6% Unclassified (DC)3 24.4% 14.2% 12.2% Admitted Visits (all causes) 12.2% 14.7% 15.8% PERCENTAGE OF DISCHARGED ED VISITS Non-Emergent 17.9% 19.5% 20.1% Emergent - Primary Care Treatable 20.4% 22.2% 21.8% ED Care Needed - Prev./Avoid. 6.2% 6.4% 6.7% % Discharged That Are Primary Care Related 44.5% 48.1% 48.6% ED Care Needed - NOT Prev./Avoid. 12.0% 11.7% 12.3% PERCENTAGE OF DISCHARGED ED VISITS Injury 24.5% 20.2% 21.3% Mental Health Related 1.6% 1.3% 1.3% Alcohol or Drug Related 0.6% 0.6% 0.7% Unclassified 27.8% 16.7% 14.5%

1 May contain missing data. Therefore, percentages at the bottom will not total to 100%. 2 Primary care related. 3 The rise in unclassified visits in 2008 was due primarily to a coding problem.

23 Figure 1. 2010 Categorized ED Visits by Type (N=25)

ED Care Needed - NOT Non-Emergent, Prev./Avoid., 20.2% 33.0%

ED Care Needed - Prev./Avoid., 11.0% Emergent - Primary Care Treatable, 35.8%

Figure 2. 2010 Total ED Visits by Type (N = 25)

Admitted Visits Emergent - (all causes), Primary Care 15.8% Non- Treatable (DC), Unclassified Emergent 18.4% (DC), 12.2% (DC), 16.9%

Alcohol or Drug ED Care Needed Related (DC), - Prev./Avoid. 0.6% (DC), 5.7%

Mental Health Injury (DC), Related (DC), 17.9% 1.1% ED Care Needed - NOT Prev./Avoid.

(DC), 10.4%

24 C. ED Visits by Month, Day, and Time

The number of ED visits by Harris County residents was highest in March through May

(Figure 3). The percentage of ED visits that led to hospitalizations was also relatively constant over the year. The peak day of the week for ED visits was Friday (Figure 4). The percentage of

ED visits leading to hospitalizations remained relatively level each day.

ED visits by children peaked between 7-8 PM, with a secondary peak at 11 AM-12 PM

25 Figure 3

26 Figure 4

27 Figure 5. All ages

28 Figure 5a. Age 0-17

29 Figure 5b. Age 18-64

30 Figure 5c. Age 65 and over

31 D. ED Visits by Patient Characteristics

Tables 3a, 4a, 5a, and 6a represent the frequency counts for ED visits by payer source, race, age, and gender (respectively). Tables 3b, 4b, 5b, and 6b represent percentages of these characteristics when summed horizontally (e.g. total hospitalized visits by payer source). Tables

3c, 4c, 5c, and 6c represent percentages of these characteristics in four broad categories when summed vertically (e.g. total visits by persons who are Hispanic).

Payer source: The uninsured accounted for 24.0% of PCRED visits and 23.4% of non-

Race/Ethnicity: Two thirds (66.8%) PCRED visits were by persons who were Black or

Hispanic, but only 59.1% of non-PCRED visits were by persons who were Black or Hispanic. By contrast, persons who were White accounted for 26.3% of PCRED visits and 33.3% of non-

PCRED visits (Figures 9 & 10). More than four in ten of all ED visits by persons who were black or Hispanic were PCR. Asians and Whites were most likely to have an ED visits resulting in a hospitalization (Figure 11)..

Age: Children age 17 and under made up one third (33.9%) of all PCRED visits, and just over one fourth (27.9%) of non-PCRED visits. Adults age 65 and over were almost twice as likely to have non-PCRED visits than a PCRED visit. More than four in ten (44.4%) of all

PCRED visits were by adults age 26 to 64, and they made up a comparable percentage of non

32 PCRED visits (45.1%) (Figures 12 & 13). More than three in ten (31.4%) ED visits by adults age

65 resulted in a hospitalization (Figure 14).

Gender: Almost six in ten (59.8%) PCRED visits were by females and 40.2% by males

(Figure 15). Of non-PCRED visits, 52.9% were by females and 47.1% by males (Figure 16). The percentage of ED visits resulting in a hospitalization was only slightly higher among males

(15.8%) than females (15.1) (Figure 17).

33 Table 3a. Frequency of ED Visit Types by Payment Source (N=25)

Type of Visit Comm SCHIP M'Caid M'care Other Gov. Other Priv. Unins Unk All

Total Visits (hospitalized & non hospitalized) 252,815 27,395 219,183 129,173 27,370 116 204,126 3,436 863,614 Total Hospitalized Visits 24,748 2,088 27,427 37,989 3,944 4 35,393 1,531 133,124 Total Primary Care Related 106,671 12,864 105,189 39,252 8,458 7 86,495 989 359,925 Total Injury/BH/Unclass. Visits 88,418 10,099 68,652 36,857 12,860 85 61,808 774 279,553 Tot. non Primary Care Related (Total minus PCR) 146,144 14,531 113,994 89,921 18,912 109 117,631 2,447 503,689 Non-Emergent 43,922 5,249 42,476 14,434 4,147 5 38,132 500 148,866 Emergent-Primary Care Treatable 49,636 5,902 47,947 17,176 3,395 2 37,049 282 161,388 Emergent Care Needed-Preventable/Avoidable 13,113 1,713 14,766 7,642 915 0 11,314 207 49,671 Emergent Care Needed-NOT Prev./Av. 32,978 2,344 17,915 15,075 2,108 20 20,430 142 91,012 TOTAL Categorized Visits 139,649 15,208 123,104 54,327 10,566 27 106,925 1,131 450,937

Table 3b. Percentage of ED Visit Types by Payment Source (read horizontally)

Type of Visit Comm SCHIP M'Caid M'care Oth. Gov Oth. Priv Unins All

Total Visits (hospitalized & non hospitalized) 29.3% 3.2% 25.4% 15.0% 3.2% 0.0% 23.6% 100.0% Total Hospitalized Visits 18.6% 1.6% 20.6% 28.5% 3.0% 0.0% 26.6% 100.0% Total Primary Care Related* 29.6% 3.6% 29.2% 10.9% 2.3% 0.0% 24.0% 100.0% Total Injury/BH/Unclass. Visits 31.6% 3.6% 24.6% 13.2% 4.6% 0.0% 22.1% 100.0% Tot. non Primary Care Related (Total minus PCR)* 29.0% 2.9% 22.6% 17.9% 3.8% 0.0% 23.4% 100.0% Non-Emergent 29.5% 3.5% 28.5% 9.7% 2.8% 0.0% 25.6% 100.0% Emergent-Primary Care Treatable 30.8% 3.7% 29.7% 10.6% 2.1% 0.0% 23.0% 100.0% Emergent Care Needed-Preventable/Avoidable 26.4% 3.4% 29.7% 15.4% 1.8% 0.0% 22.8% 100.0% Emergent Care Needed-NOT Prev./Av. 36.2% 2.6% 19.7% 16.6% 2.3% 0.0% 22.4% 100.0% TOTAL Categorized Visits 31.0% 3.4% 27.3% 12.0% 2.3% 0.0% 23.7% 100.0%

* Reflected in figures on following page.

34 Figure 6. PCR ED Visits by Payment Source (N=25)

Unins, 24.0% Comm. 29.6%

Oth. Priv. 0.0% SCHIP Oth. Govt. 3.6% 2.3%

Medicare Medicaid 10.9% 29.2%

Figure 7. All Other1 ED Visits by Payment Source (N=25)

Comm. Unins, 23.4% 29.0%

Oth. Priv. 0.0%

Oth. Govt. SCHIP 3.8% 2.9% Medicare 17.9%

Medicaid 22.6%

1 Non PCR non-hospitalized visits and hospitalized visits.

35 Table 3c. Percentage of ED Visit Types by Payment Source (read vertically)

Type of Visit Commerc. SCHIP Medicaid Medicare Other Gov. Other Priv. Uninsured Unk All Percentage Primary Care Related 42.2% 47.0% 48.0% 30.4% 30.9% 5.7% 42.4% 28.8% 41.7% Percentage ED Care Needed, Not Prev. 13.0% 8.6% 8.2% 11.7% 7.7% 17.6% 10.0% 4.1% 10.5% Percentage Injury/BH/Unclass. 35.0% 36.9% 31.3% 28.5% 47.0% 73.3% 30.3% 22.5% 32.4% Percentage Hospitalized 9.8% 7.6% 12.5% 29.4% 14.4% 3.4% 17.3% 44.6% 15.4% T o tal 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Figure 8. Payment Source by ED Visit Type (N=25)

100% 90% 80% 70% Percentage Hospitalized 60% 50% Percentage Injury/BH/Unclass. 40%

30% Percentage ED Care Needed, Not 20% Prev. 10% Percentage Primary Care Related 0%

36 Table 4a. Frequency of ED Visit Types by Race/Ethnicity (N=25)

Type of Visit Asian Black Hispanic Am. Indian Other Unk White All

Total Visits (hospitalized & non hospitalized) 14,818 252,143 286,368 755 20,502 26,901 262,127 863,614 Total Hospitalized Visits 2,786 38,295 37,778 133 3,190 2,780 48,162 133,124 Total Primary Care Related 5,294 115,541 124,941 280 7,965 11,341 94,563 359,925 Total Injury/BH/Unclass. Visits 5,093 73,060 94,266 239 7,124 10,056 89,715 279,553 Tot. non Primary Care Related (Total minus PCR) 9,524 136,602 161,427 475 12,537 15,560 167,564 503,689 Non-Emergent 2,205 49,072 51,777 111 3,251 4,574 37,876 148,866 Emergent-Primary Care Treatable 2,354 49,780 57,315 136 3,688 5,260 42,855 161,388 Emergent Care Needed-Preventable/Avoidable 736 16,689 15,850 33 1,025 1,507 13,832 49,671 Emergent Care Needed-NOT Prev./Av. (dc) 1,645 25,247 29,383 103 2,223 2,724 29,687 91,012 TOTAL Categorized Visits 6,939 140,788 154,324 383 10,188 14,065 124,250 450,937

Table 4b. Percentage of ED Visit Types by Race/Ethnicity (read horizontally)

Type of Visit Asian Black Hispanic Am. Indian Other Unk White All

Total Visits (hospitalized & non hospitalized) 1.7% 29.2% 33.2% 0.1% 2.4% 3.1% 30.4% 100.0% Total Hospitalized Visits 2.1% 28.8% 28.4% 0.1% 2.4% 2.1% 36.2% 100.0% Total Primary Care Related* 1.5% 32.1% 34.7% 0.1% 2.2% 3.2% 26.3% 100.0% Total Injury/BH/Unclass. Visits 1.8% 26.1% 33.7% 0.1% 2.5% 3.6% 32.1% 100.0% Tot. non Primary Care Related (Total minus PCR)* 1.9% 27.1% 32.0% 0.1% 2.5% 3.1% 33.3% 100.0% Non-Emergent 1.5% 33.0% 34.8% 0.1% 2.2% 3.1% 25.4% 100.0% Emergent-Primary Care Treatable 1.5% 30.8% 35.5% 0.1% 2.3% 3.3% 26.6% 100.0% Emergent Care Needed-Preventable/Avoidable 1.5% 33.6% 31.9% 0.1% 2.1% 3.0% 27.8% 100.0% Emergent Care Needed-NOT Prev./Av. (dc) 1.8% 27.7% 32.3% 0.1% 2.4% 3.0% 32.6% 100.0% TOTAL Categorized Visits 1.5% 31.2% 34.2% 0.1% 2.3% 3.1% 27.6% 100.0%

* Reflected in figures on following page.

37 Figure 9. Primary Care-Related ED Visits by Race/Ethnicity (N=25)

Asian, 1.5%

White, 26.3% Black, 32.1%

Unk, 3.2%

Other, 2.2%

Am. Indian, Hispanic, 34.7% 0.1%

Figure 10. All Other1 ED Visits by Race/Ethnicity (N=25)

Asian, 1.9%

Black, 27.1% White, 33.3%

Unk, 3.1%

Other, 2.5%

Am. Indian, 0.1% Hispanic, 32.0%

1 Non PCR non-hospitalized visits and hospitalized visits.

38 Table 4c. Percentage of ED Visit Types by Race/Ethnicity (read vertically)

Type of Visit Asian Black Hispanic Am.Indian Other Unk White All Percentage Primary Care Related 35.7% 45.8% 43.6% 37.1% 38.9% 42.2% 36.1% 41.7% Percentage ED Care Needed, Not Prev. 11.1% 10.0% 10.3% 13.6% 10.8% 10.1% 11.3% 10.5% Percentage Injury/BH/Unclass. 34.4% 29.0% 32.9% 31.7% 34.7% 37.4% 34.2% 32.4% Percentage Hospitalized 18.8% 15.2% 13.2% 17.6% 15.6% 10.3% 18.4% 15.4% Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Figure 11. Race/Ethnicity by ED Visit Type (N=25)

100% 90% 80% 70% Percentage Hospitalized 60% 50% Percentage Injury/BH/Unclass. 40% 30% Percentage ED Care Needed, Not 20% Prev. 10% Percentage Primary Care Related 0%

39 Table 5a. Frequency of ED Visit Types by Age (N=25)

Type of Visit 0-17 18-25 26-44 45-64 65+ All Total Visits (hospitalized & non hospitalized) 262,366 109,587 212,240 173,153 106,268 863,614 Total Hospitalized Visits 29,449 13,505 26,589 30,244 33,337 133,124 Total Primary Care Related 122,030 49,196 91,723 66,563 30,413 359,925 Total Injury/BH/Unclass. Visits 94,582 34,844 66,364 53,516 30,247 279,553 Tot. non Primary Care Related (Total minus PCR) 140,336 60,391 120,517 106,590 75,855 503,689 Non-Emergent 46,834 22,429 40,500 27,852 11,249 148,866 Emergent-Primary Care Treatable 57,058 21,399 40,884 28,929 13,117 161,388 Emergent Care Needed-Preventable/Avoidable 18,137 5,368 10,338 9,781 6,046 49,671 Emergent Care Needed-NOT Prev./Av. (dc) 16,305 12,042 27,564 22,830 12,271 91,012 TOTAL Categorized Visits 138,335 61,238 119,287 89,393 42,684 450,937

Table 5b. Percentage of ED Visit Types by Age (read horizontally)

Type of Visit 0-17 18-25 26-44 45-64 65+ All Total Visits (hospitalized & non hospitalized) 30.4% 12.7% 24.6% 20.0% 12.3% 100.0% Total Hospitalized Visits 22.1% 10.1% 20.0% 22.7% 25.0% 100.0% Total Primary Care Related* 33.9% 13.7% 25.5% 18.5% 8.4% 100.0% Total Injury/BH/Unclass. Visits 33.8% 12.5% 23.7% 19.1% 10.8% 100.0% Tot. non Primary Care Related (Total minus PCR)* 27.9% 12.0% 23.9% 21.2% 15.1% 100.0% Non-Emergent 31.5% 15.1% 27.2% 18.7% 7.6% 100.0% Emergent-Primary Care Treatable 35.4% 13.3% 25.3% 17.9% 8.1% 100.0% Emergent Care Needed-Preventable/Avoidable 36.5% 10.8% 20.8% 19.7% 12.2% 100.0% Emergent Care Needed-NOT Prev./Av. (dc) 17.9% 13.2% 30.3% 25.1% 13.5% 100.0% TOTAL Categorized Visits 30.7% 13.6% 26.5% 19.8% 9.5% 100.0%

* Reflected in figures on following page.

40 Figure 12. PCR ED Visits by Age (N=25)

65+, 8.4% 45-64, 18.5% 0-17, 33.9%

26-44, 25.5%

18-25, 13.7%

Figure 13. All Other1 ED Visits by Age (N=25)

65+, 15.1%

0-17, 27.9% 45-64, 21.2%

18-25, 12.0% 26-44, 23.9%

1 Non PCR non-hospitalized visits and hospitalized visits.

41 Table 5c. Percentage of ED Visit Types by Age (read vertically)

Type of Visit 0-17 18-25 26-44 45-64 65+ All Percentage Primary Care Related 46.5% 44.9% 43.2% 38.4% 28.6% 41.7% Percentage ED Care Needed, Not Prev. 6.2% 11.0% 13.0% 13.2% 11.5% 10.5% Percentage Injury/BH/Unclass. 36.0% 31.8% 31.3% 30.9% 28.5% 32.4% Percentage Hospitalized 11.2% 12.3% 12.5% 17.5% 31.4% 15.4% Total 100.0% 100.0% 100.0% 100.0% 100.0% 100.0%

Figure 14. Age by ED Visit Type (N=25)

100% 90% 80% 70% Percentage Hospitalized 60% Percentage Injury/BH/Unclass. 50%

40% Percentage ED Care Needed, Not 30% Prev. 20% Percentage Primary Care Related 10% 0% 0-17 18-25 26-44 45-64 65+ All

42 Table 6a. Frequency of ED Visit Types by Gender (N=25)

Type of Visit Female Male Unk All Total Visits (hospitalized & non hospitalized) 481,605 381,937 72 863,614 Total Hospitalized Visits 72,798 60,314 12 133,124 Total Primary Care Related 215,247 144,662 16 359,925 Total Injury/BH/Unclass. Visits 139,991 139,524 38 279,553 Tot. non Primary Care Related (Total minus PCR) 266,358 237,275 56 503,689 Non-Emergent 92,515 56,345 6 148,866 Emergent-Primary Care Treatable 94,890 66,491 7 161,388 Emergent Care Needed-Preventable/Avoidable 27,842 21,826 3 49,671 Emergent Care Needed-NOT Prev./Av. (dc) 53,569 37,437 6 91,012 TOTAL Categorized Visits 268,816 182,099 22 450,937

Table 6b. Percentage of ED Visit Types by Gender (read horizontally)

Type of Visit Female Male Unk All Total Visits (hospitalized & non hospitalized) 55.8% 44.2% 0.0% 100.0% Total Hospitalized Visits 54.7% 45.3% 0.0% 100.0% Total Primary Care Related* 59.8% 40.2% 0.0% 100.0% Total Injury/BH/Unclass. Visits 50.1% 49.9% 0.0% 100.0% Tot. non Primary Care Related (Total minus PCR)* 52.9% 47.1% 0.0% 100.0% Non-Emergent 62.1% 37.8% 0.0% 100.0% Emergent-Primary Care Treatable 58.8% 41.2% 0.0% 100.0% Emergent Care Needed-Preventable/Avoidable 56.1% 43.9% 0.0% 100.0% Emergent Care Needed-NOT Prev./Av. (dc) 58.9% 41.1% 0.0% 100.0% TOTAL Categorized Visits 59.6% 40.4% 0.0% 100.0%

* Reflected in figures on following page.

43 Figure 15. Primary Care Related ED Visits by Gender (N=25)

Male, 40.2%

Female, 59.8%

Figure 16. All Other1 ED Visits by Gender (N=25)

Male, 47.1% Female, 52.9%

1 Non PCR non-hospitalized visits and hospitalized visits.

44 Table 6c. Percentage of ED Visit Types by Gender (read vertically)

Type of Visit Female Male Unk All Percentage Primary Care Related 44.7% 37.9% 22.5% 41.7% Percentage ED Care Needed, Not Prev. 11.1% 9.8% 8.1% 10.5% Percentage Injury/BH/Unclass. 29.1% 36.5% 52.8% 32.4% Percentage Hospitalized 15.1% 15.8% 16.7% 15.4% Total 100.0% 100.0% 100.0% 100.0%

Figure 17. Gender by ED Visit Type (N=25)

100% 90% 80% 70% Percentage Hospitalized 60% Percentage Injury/BH/Unclass. 50%

40% Percentage ED Care Needed, Not 30% Prev. 20% Percentage Primary Care Related 10% 0% Female Male Unk All

45 ED Visits by Method of Transporation to the ED

Visits were classified according to the following groupings: ambulance (any form of ground or air ambulance), self (automobile, walk in, public transporation), other (e.g. police, newborns), and unknown (field was empty or missing). Even though the hospitals invited to take part in the study are primarily the ones serving the Houston 911 service area, non HFD ambulance transports are reflected in these results as well.

Fewer than one in ten (8.6%) PCRED visits were by persons with an ambulance transport to the ED. By contrast, nearly one in five (18.4%) non-PCRED visits were by persons with an ambulance transport to the ED (Tables 7a & 7b; Figures 18 & 19). More than one fourth (27.5%) of ambulance transports to the ED eventually resulted in a hospitalization (Table 7c and Figure

20).

46 Table 7a. Frequency of ED Visit Types by Transport (N=25)

Type of Visit Ambulance Self Other Unk All Total Visits (hospitalized & non hospitalized) 123,472 599,855 13,215 127,072 863,614 Total Hospitalized Visits 33,952 75,732 4,096 19,344 133,124 Total Primary Care Related 30,895 272,079 4,050 52,901 359,925 Total Injury/BH/Unclass. Visits 45,766 187,437 4,298 42,052 279,553 Tot. non Primary Care Related (Total minus PCR) 92,577 327,776 9,165 74,171 503,689 Non-Emergent 10,507 114,224 1,779 22,356 148,866 Emergent-Primary Care Treatable 13,358 122,247 1,722 24,061 161,388 Emergent Care Needed-Preventable/Avoidable 7,029 35,609 549 6,484 49,671 Emergent Care Needed-NOT Prev./Av. (dc) 12,859 64,607 771 12,775 91,012 TOTAL Categorized Visits 43,754 336,686 4,821 65,676 450,937

Table 7b. Percentage of ED Visit Types by Transport (read horizontally)

Type of Visit Ambulance Self Other Unk All Total Visits (hospitalized & non hospitalized) 14.3% 69.5% 1.5% 14.7% 100.0% Total Hospitalized Visits 25.5% 56.9% 3.1% 14.5% 100.0% Total Primary Care Related* 8.6% 75.6% 1.1% 14.7% 100.0% Total Injury/BH/Unclass. Visits 16.4% 67.0% 1.5% 15.0% 100.0% Tot. non Primary Care Related (Total minus PCR)* 18.4% 65.1% 1.8% 14.7% 100.0% Non-Emergent 7.1% 76.7% 1.2% 15.0% 100.0% Emergent-Primary Care Treatable 8.3% 75.7% 1.1% 14.9% 100.0% Emergent Care Needed-Preventable/Avoidable 14.2% 71.7% 1.1% 13.1% 100.0% Emergent Care Needed-NOT Prev./Av. (dc) 14.1% 71.0% 0.8% 14.0% 100.0% TOTAL Categorized Visits 9.7% 74.7% 1.1% 14.6% 100.0%

* Reflected in figures on following page.

47 Figure 18. Primary Care Related ED Visits by Transport (N=25)

Unk, 14.7% Ambulance, 8.6% Other, 1.1%

Self, 75.6%

Figure 19. All Other1 ED Visits by Transport (N=25)

Unk, 14.7% Ambulance, 18.4% Other, 1.8%

Self, 65.1%

1 Non PCR non-hospitalized visits and hospitalized visits.

48 Table 7c. Percentage of ED Visit Types by Transport (read vertically)

Type of Visit Ambulance Self Other Unk All Percentage Primary Care Related 25.0% 45.4% 30.6% 41.6% 41.7% Percentage ED Care Needed, Not Prev. 10.4% 10.8% 5.8% 10.1% 10.5% Percentage Injury/BH/Unclass. 37.1% 31.2% 32.5% 33.1% 32.4% Percentage Hospitalized 27.5% 12.6% 31.0% 15.2% 15.4% Total 100.0% 100.0% 100.0% 100.0% 100.0%

Figure 20. Transport by ED Visit Type (N = 25)

100% 90% 80%

70% Percentage Hospitalized 60% 50% Percentage Injury/BH/Unclass. 40% 30% Percentage ED Care Needed, 20% Not Prev. 10% Percentage Primary Care 0% Related

49 E. Health Conditions of Patients with ED Visits

Categorized (primary and non primary care related) ED visits

F. Behavioral Health Related ED Visits

50 Table 8. Most Frequent Conditions of Patients with PCR ED Visits

2008 visits 2009 visits 2010 visits 25 hospitals 24 hospitals 25 hospitals icd COUNT Description ICD COUNT Description Icd COUNT Description

4659 15,118 acute uri nos 4659 26,401 acute uri nos 4659 19,323 acute uri nos 3829 11,934 otitis media nos 5990 14,559 urin tract infection nos 5990 17,101 urin tract infection nos 7806 11,790 fever 3829 12,517 otitis media nos 3829 13,096 otitis media nos 462 10,652 acute pharyngitis 78900 12,450 abdmnal pain unspcf site 78900 12,550 abdmnal pain unspcf site 5589 9,249 noninf gastroenterit nec 7999 11,195 viral infection nos 7840 11,116 headache 78900 8,341 abdmnal pain unspcf site 7840 11,115 headache 78703 9,380 vomiting alone 486 7,938 pneumonia, organism nos 462 9,868 acute pharyngitis 462 9,317 acute pharyngitis 49392 7,674 asthma nos w(ac) exacerb 78703 8,462 vomiting alone 64893 7,221 oth curr cond-antepartum 7295 7,109 pain in limb 486 7,767 pneumonia, organism nos 486 7,107 pneumonia, organism nos 78703 7,063 vomiting alone 5589 7,490 noninf gastroenterit nec 5589 6,991 noninf gastroenterit nec 78659 6,816 chest pain nec 64893 7,238 oth curr cond-antepartum 4019 5,971 hypertension nos 6826 6,815 cellulitis of leg 490 6,672 bronchitis nos 7999 5,943 viral infection nos 7242 6,436 lumbago 49392 6,617 asthma nos w(ac) exacerb 7242 5,916 lumbago 7804 6,398 dizziness and giddiness 78659 5,982 chest pain nec 49392 5,865 asthma nos w(ac) exacerb 64893 6,317 oth curr cond-antepartum 7242 5,852 lumbago 6826 5,681 cellulitis of leg 4019 6,091 hypertension nos 6826 5,673 cellulitis of leg 490 5,296 bronchitis nos 7840 5,323 headache 4871 5,587 flu w resp manifest nec 7804 5,288 dizziness and giddiness 490 5,219 bronchitis nos 7295 5,572 pain in limb 78659 4,884 chest pain nec 78909 4,951 abdmnal pain oth spcf st 4660 5,533 acute bronchitis 7295 4,508 pain in limb 5990 4,746 urin tract infection nos 4019 5,402 hypertension nos 4660 4,478 acute bronchitis 78039 4,565 convulsions nec 7804 5,374 dizziness and giddiness 78909 4,451 abdmnal pain oth spcf st 78652 4,323 painful respiration 78909 5,065 abdmnal pain oth spcf st 64003 4,389 threaten abort-antepart 78701 4,300 nausea with vomiting 7862 4,490 cough 78650 4,253 chest pain nos 64003 4,255 threaten abort-antepart 78650 4,421 chest pain nos 340 3,738 strep sore throat 7862 4,067 cough 64003 4,172 threaten abort-antepart 49390 3,605 asthma w/o status asthm

51 Table 9. Most frequent Conditions of Patients with Non PCR ED Visits

2008 visits 2009 visits 2010 visits 25 hospitals 24 hospitals 25 hospitals icd COUNT Description ICD COUNT Description Icd COUNT Description

78650 4,635 chest pain nos 78650 9,225 chest pain nos 78650 8,877 chest pain nos 5921 4,607 calculus of ureter 78900 6,140 abdmnal pain unspcf site 78900 6,189 abdmnal pain unspcf site 7802 4,382 syncope and collapse 5921 4,024 calculus of ureter 5921 4,378 calculus of ureter 78659 4,338 chest pain nec 78659 3,807 chest pain nec 7802 3,591 syncope and collapse 78900 4,113 abdmnal pain unspcf site 7802 3,719 syncope and collapse 78659 3,108 chest pain nec 7806 2,876 fever 78909 2,498 abdmnal pain oth spcf st 78909 2,195 abdmnal pain oth spcf st 78909 2,442 abdmnal pain oth spcf st 64003 2,086 threaten abort-antepart 64003 2,194 threaten abort-antepart 7999 2,270 unkn cause morb/mort nec 4871 1,862 flu w resp manifest nec 78703 2,010 vomiting alone 78605 2,242 shortness of breath 78703 1,813 vomiting alone 5770 1,843 acute pancreatitis 64003 2,127 threaten abort-antepart 7840 1,659 headache 57420 1,792 cholelithiasis nos 42731 1,911 atrial fibrillation 57420 1,531 cholelithiasis nos 7840 1,659 headache 5409 1,908 acute appendicitis nos 46619 1,504 acu brnchlts d/t oth org 5920 1,655 calculus of kidney 56211 1,684 dvrtcli colon w/o hmrhg 42731 1,495 atrial fibrillation 42731 1,572 atrial fibrillation 7851 1,680 palpitations 7851 1,459 palpitations 7851 1,477 palpitations 46619 1,648 acu brnchlts d/t oth org 5920 1,452 calculus of kidney 56211 1,375 dvrtcli colon w/o hmrhg 4359 1,572 trans cereb ischemia nos 56211 1,331 dvrtcli colon w/o hmrhg 53550 1,298 gstr/ddnts nos w/o hmrhg 78703 1,513 vomiting alone 4644 1,294 croup 7243 1,291 sciatica 41071 1,314 subendo infarct, initial 78605 1,265 shortness of breath 46619 1,275 acu brnchlts d/t oth org 5789 1,298 gastrointest hemorr nos 5770 1,262 acute pancreatitis 5789 1,231 gastrointest hemorr nos 43491 1,292 crbl art ocl nos w infrc 7999 1,256 viral infection nos 4644 1,221 croup 28262 1,261 hb-s disease with crisis 53550 1,226 gstr/ddnts nos w/o hmrhg V715 1,177 observ following rape 7243 1,218 sciatica 5409 1,219 acute appendicitis nos 41071 1,098 subendo infarct, initial V715 1,207 observ following rape V715 1,183 observ following rape 5409 1,079 acute appendicitis nos 78609 1,142 respiratory abnorm nec 5789 1,159 gastrointest hemorr nos 43491 1,021 crbl art ocl nos w infrc 7295 1,016 pain in limb 7243 1,105 sciatica 28262 993 hb-s disease with crisis

52 Table 10. Total Behavioral Health1 Visits To Harris County Area Hospitals

Frequency - Primary diagnosis and any other diagnosis 2008 2009 2010 N = 25 N = 24 N = 25 Total Visits2 899,673 953,395 878,941 Total Visits With Any Behavioral Health Diagnosis 74,672 73,383 74,401 Total Visits With No Behavioral Health Diagnosis 825,001 880,012 804,540 Total Visits With a Behavioral Health Diagnosis as the primary diagnosis 3 9,021 10,311 12,371 Total Visits With a Behavioral Health Diagnosis as both primary and any other diagnosis 3 9,134 8,211 7,939 Total Visits With a Behavioral Health Diagnosis as any other diagnosis 3,4 56,287 54,861 54,091 Percentage of First Row Total Visits 100.0% 100.0% 100.0% Total Visits With Any Behavioral Health Diagnosis 8.3% 7.7% 8.5% Total Visits With No Behavioral Health Diagnosis 91.7% 92.3% 91.5% Total Visits With a Behavioral Health Diagnosis as the primary diagnosis 1.0% 1.1% 1.4% Total Visits With a Behavioral Health Diagnosis as both primary and any other diagnosis 3 1.0% 0.9% 0.9% Total Visits With a Behavioral Health Diagnosis as any other diagnosis 3,4 6.3% 5.8% 6.2% Frequency - Primary and secondary diagnoses Total Visits With a Mental Health Diagnosis as the primary diag. & no secondary behavioral diag. 5 2,674 2,761 3,474 Total Visits With an Alcohol Related Diagnosis as the primary diag. & no secondary behavioral diag. 5 585 1,079 1,649 Total Visits With a Drug Related Diagnosis as the primary diag. & no secondary behavioral diag. 5 226 137 167 Total Visits With a medical diagnosis as the primary diag. & Mental Health as the secondary diag. 5 11,028 11,155 10,943 Total Visits With a medical diagnosis as the primary diag. & Alcohol Related as the secondary diag. 5 2,417 3,689 3,322

1 “Behavioral Health” = mental health, alcohol, or drug related. 2 Harris County, all diagnoses, all discharge dispositions. 3 “Primary diagnosis” = first ICD code. “Any other diagnosis” = ICD codes 2 through 10. 4 A medical diagnosis is the primary diagnosis. 5 Unlike above, “secondary diagnosis” in this case refers only to the second ICD code. Person may or may not have a secondary medical diagnosis.

53 G. Length of Stay in the ED

(5.83 hours vs. 4.14 hours in 2010) (Table 11).

H. Estimated Cost of Primary Care Related ED Visits

Applying national estimates of the unit cost of ED visits to Houston ED visits suggests that the greatest potential cost savings from diverting PCRED visits would be among adults age

18 to 44, whether insured or uninsured (Table 12 and 13, Figures 21and 22). However, these estimates do not account for the variability that may occur among treating chronic vs. acute conditions.

1 1Machlin, S.R. Trends in health care expenditures: 2006 versus 1996. Statistical Briefs #253-256. August 2009. Agency for Healthcare Research and Quality, Rockville, MD. Available at http://www.meps.ahrq.gov/mepsweb/data_stats/MEPS_topics.jsp?topicID=5Z-1. 2006 estimates were used for this report. These national estimates are based on all payer sources (e.g. insured and uninsured). They may not reflect actual hospital charges or procedures administered during treatment. Outpatient estimate may or may not cover both primary care and specialty care. MEPS estimates were adjusted for inflation to reflect 2007 to 2009 expenses.

54 Table 11. Hospitals in the Houston 911 Service Area. Mean length of stay (in hours) in the emergency department for visits of less than 24 hours.

Residence Discharge status 2008 Mean (sd) 2009 Mean (sd) 2010 Mean 25 hospitals 24 hospitals (sd) 25 hospitals Harris County All Visits1 4.55 (4.20) 4.54 (4.27) 4.44 (4.13)

Harris County Primary care 3.86 (3.65) 3.70 (3.49) 3.54 (3.30) related1

Harris County All non- 4.44 (4.10) 4.34 (4.04) 4.20 (3.82) hospitalized1 Harris County Other1,2 5.91 (5.11) 6.84 (5.83) 6.63 (5.95)

Harris County Non-hospitalized 4.48 (4.09) 4.28 (3.94) 4.14 (3.70) medical3 Harris County Non-hospitalized 5.52 (4.64) 6.01 (5.02) 5.83 (4.94) behavioral3

1 All diagnoses 2 Admitted, transferred to another facility, etc. 3 Medical or behavioral as the primary discharge diagnosis.

55 Table 12. Estimated costs of primary care related emergency room visits, estimated costs of treating those same patients in an outpatient setting – all payer sources1

2008 (24 hospitals)

17 and under 118,936 $541 $64,397,681 $144 $17,085,099 $47,312,582

18 to 44 120,347 $705 $84,843,269 $199 $23,936,973 $60,906,297

45 to 64 58,343 $1,046 $61,052,356 $229 $13,345,130 $47,707,226

65 and over 25,411 $719 $18,279,868 $199 $5,054,341 $13,225,527

Total Primary Care Visits 323,037 na2 $228,573,174 na2 $59,421,542 $169,151,632

2009 (24 hospitals)

17 and under 142,210 $568 $80,832,363 $151 $21,445,321 $59,387,042

18 to 44 148,674 $740 $110,030,654 $209 $31,043,131 $78,987,523

45 to 64 69,914 $1,099 $76,801,513 $240 $16,787,659 $60,013,854

65 and over 30,147 $755 $22,766,132 $209 $6,294,783 $16,471,349

Total Primary Care Visits 390,945 na2 $290,430,662 na2 $75,570,894 $214,859,768

2010 (24 hospitals)

17 and under 122,030 $598 $72,949,373 $159 $19,353,915 $53,595,457

18 to 44 140,919 $778 $109,686,071 $220 $30,945,913 $78,740,157

45 to 64 66,563 $1,155 $76,902,377 $253 $16,809,706 $60,092,670

65 and over 30,413 $794 $24,154,478 $220 $6,678,657 $17,475,820

2 2 Total Primary Care Visits 359,925 na $283,692,298 na $73,788,192 $209,904,105

56 Figure 21. Estimated savings for treating all PCRED visits in an outpatient setting – all payer sources (final column of previous table)

$90,000,000 $80,000,000 $70,000,000 $60,000,000 17 and under $50,000,000 18 to 44 $40,000,000 45 to 64 $30,000,000 $20,000,000 65 and over $10,000,000 $0 2008 2009 2010

57 Table 13. Estimated costs of primary care related emergency room visits, estimated costs of treating those same patients in an outpatient setting – uninsured only1

2008

17 and under 19,168 $541 $10,378,779 $144 $2,753,554 $7,625,225

18 to 44 60,691 $705 $42,786,562 $199 $12,071,444 $30,715,118

45 to 64 22,296 $1,046 $23,331,535 $229 $5,099,924 $18,231,611

65 and over 1,634 $719 $1,175,146 $199 $324,925 $850,220

Total Primary Care Visits 103,789 na2 $77,672,021 na2 $20,249,846 $57,422,175

2009

17 and under 24,221 $568 $13,767,256 $151 $3,652,537 $10,114,719

18 to 44 76,425 $740 $56,560,747 $209 $15,957,578 $40,603,170

45 to 64 27,009 $1,099 $29,669,421 $240 $6,485,291 $23,184,131

65 and over 1,779 $755 $1,343,279 $209 $371,413 $971,865

Total Primary Care Visits 129,434 na2 $101,340,703 na2 $26,466,819 $74,873,884

2010

17 and under 11,116 $598 $6,644,930 $159 $1,762,941 $4,881,989

18 to 44 52,723 $778 $41,037,529 $220 $11,577,986 $29,459,543

45 to 64 21,073 $1,155 $24,346,815 $253 $5,321,849 $19,024,966

65 and over 1,583 $794 $1,257,171 $220 $347,605 $909,566

2 2 Total Primary Care Visits 86,495 na $73,286,444 na $19,010,380 $54,276,064

58 Figure 22. Estimated savings for treating all PCRED visits in an outpatient setting – uninsured (final column of previous table)

$45,000,000 $40,000,000 $35,000,000 $30,000,000 17 and under $25,000,000 18 to 44 $20,000,000 45 to 64 $15,000,000 65 and over $10,000,000 $5,000,000 $0 2008 2009 2010

59 I. Geographic Distribution of Patients with ED Visits

Loop West (Map 1a). Most areas of Harris County saw decreases in visits from 2009 to 2010

(Map 1b).

(Maps 2b and 3b).

The areas with the highest rates of ED visits, PCRED visits by all, and PCRED visits by the uninsured were the East/Northeast and South Central areas of Harris County, as well as the

Map 9 shows the estimated cost of PCRED visits among uninsured adults age 18 to 44.

60 Map 1a

61 Map 1b

62 Map 2a

63 Map 2b

64 Map 3a

65 Map 3b

66 Map 4

67 Map 5

68 Map 6

69 Map 7

70 Map 8

71 Map 9

72 Table 14. Top five most expensive ZIP codes for PCRED visits among uninsured adults, age 18 to 44, in 2010 (compare with Map 9)1

Visits for Total est. cost of PCRED visits ZIP Post Office this group Est. cost per visit for this group 77036 Houston 1,379 $778 $1,072,784 77449 Katy 1,336 $778 $1,039,175 77093 Houston 1,184 $778 $921,518 77520 Baytown 1,170 $778 $910,034 77084 Houston 1,056 $778 $821,420

1 Please refer to Table 13 of this report for background information.

73 J. Trends in ED Visits Over Time

To examine trends over time, the ED visits in which patients were discharged home or elsewhere of 15 hospitals were tracked over the five-year period from 2004 to 2010 (Ben Taub

General, Lyndon B. Johnson General, Memorial Hermann (MH) Hermann, MH Southwest, MH

Southeast, MH Northwest, MH Woodlands, MH Memorial City, MH Katy, MH Sugar Land

(formerly Fort Bend), Hospital Corporation of America (HCA) Bayshore,, HCA East Houston,

Texas Children’s Hospital, Spring Branch Medical Center, St. Luke’s Episcopal Hospital). The

ED visits of 22 hospitals were tracked over the four-year period from 2005 to 2010 (above listed hospitals, plus MH Northeast, HCA West Houston, CHRISTUS St. Catherine, CHRISTUS St.

John, St. Luke’s Community Medical Center, The Methodist Hospital, and San Jacinto

Methodist Hospital).

2010 (Tables 15 and 16).

Hispanics continue to represent the greatest percentage of PCRED visits. However, that percentage declined in both groups in 2010 (Figures 25 & 26). Blacks represent the next largest

74 group on a percentage basis.

Visits by children age 18 and under continue to account for the largest proportion of

PCRED visits. In 2008 that proportion dropped somewhat, increased in 2009 and dropped in

2010 (Figures 27 & 28). Adults age 26 to 44 accounted for the next largest percentage.

There has been little change in the gender ratio of PCRED visits over the last five years

(Figures 29 & 30).

32).

75 Table 15. 2004-2010 ED Visits at 15 Hospitals by Harris County Residents

Type of Visit 2004 2005 2006 2007 2008 2009 2010

Number 15 15 15 15 15 15 15 CATEGORIZED NON HOSPITALIZED VISITS Non-Emergent 131,895 108,241 116,210 99,256 88,747 126,632 105,304 Emergent, Primary Care Treatable 131,694 114,835 124,253 11,595 96,710 140,846 113,642 Emergent, ED Care Needed - Preventable/Avoidable 43,384 38,771 43,223 40,179 27,612 40,044 35,191 Total Primary Care Related Visits, Harris County 306,973 261,847 283,686 151,030 213,069 307,522 254,136 Emergent, ED Care Needed - NOT Preventable/Avoidable 62,039 54,530 64,662 57,642 56,381 72,619 63,545 Total Categorized Visits, Harris County 369,011 316,377 348,348 208,672 269,450 380,141 317,681 NON-CATEGORIZED NON HOSPITALIZED VISITS Injury 126,305 103,492 119,022 106,278 106,482 117,569 108,391 Mental Health Related 8,412 5,858 6,207 6,227 5,905 7,188 6,188 Alcohol or Drug Related 3,907 3,263 3,784 3,756 2,349 3,962 4,054 Unclassified 52,923 41,656 52,803 68,660 125,733 88,768 78,191 Total Non-Categorized Non Hosp. Visits, Harris County 191,547 154,269 181,816 184,921 240,469 217,487 196,824 Total Non Hospitalized Visits, Harris County 560,558 470,646 530,164 393,593 509,919 597,628 514,505

Percent NON HOSPITALIZED VISITS - CATEGORIZED Non-Emergent 35.7% 34.2% 33.4% 47.6% 32.9% 33.3% 33.1% Emergent - Primary Care Treatable 35.7% 36.3% 35.7% 5.6% 35.9% 37.1% 35.8% ED Care Needed - Prev./Avoid. 11.8% 12.3% 12.4% 19.3% 10.2% 10.5% 11.1% % Categorized That Area Primary Care Related 83.2% 82.8% 81.4% 72.4% 79.1% 80.9% 80.0% ED Care Needed - NOT Prev./Avoid. 16.8% 17.2% 18.6% 27.6% 20.9% 19.1% 20.0%

NON HOSPITALIZED VISITS - CAT. & NON CAT. Non-Emergent 23.5% 23.0% 21.9% 25.2% 17.4% 21.2% 20.5% Emergent - Primary Care Treatable 23.5% 24.4% 23.4% 2.9% 19.0% 23.6% 22.1% ED Care Needed - Prev./Avoid. 7.7% 8.2% 8.2% 10.2% 5.4% 6.7% 6.8% % Non Hosp. That Are Primary Care Related 54.8% 55.6% 53.5% 38.4% 41.8% 51.5% 49.4% ED Care Needed - NOT Prev./Avoid. 11.1% 11.6% 12.2% 14.6% 11.1% 12.2% 12.4% % Non Hosp. That Are Categorized 65.8% 67.2% 65.7% 53.0% 52.8% 63.6% 61.7% Injury 22.5% 22.0% 22.5% 27.0% 20.9% 19.7% 21.1% Mental Health Related 1.5% 1.2% 1.2% 1.6% 1.2% 1.2% 1.2% Alcohol or Drug Related 0.7% 0.7% 0.7% 1.0% 0.5% 0.7% 0.8% Unclassified 9.4% 8.9% 10.0% 17.4% 24.7% 14.9% 15.2% % All Non Hospitalized ED Visits 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% HOSPITALIZED AND NON HOSPITALIZED VISITS Hospitalized Visits 112,791 87,792 87,792 93,423 Non-Hospitalized Visits 518,545 532,322 532,322 523,023 Total Visits 631,336 620,114 620,114 616,446 HOSPITALIZED AND NON HOSPITALIZED VISITS Hospitalized Visits 17.9% 14.2% 14.2% 15.2% Non-Hospitalized Visits 82.1% 85.8% 85.8% 84.8% Total Visits 100.0% 100.0% 100.0% 100.0%

76 Table 16. 2005-2010 ED Visits at 22 Hospitals by Harris County Residents

Type of Visit 2005 2006 2007 2008 2009 2010

Number 22 22 22 22 22 22 CATEGORIZED NON HOSPITALIZED VISITS Non-Emergent 138,584 146,388 134,776 118,715 148,078 140,328 Emergent, Primary Care Treatable 149,730 16,116 153,374 132,876 168,197 152,022 Emergent, ED Care Needed - Preventable/Avoidable 51,555 55,797 53,502 38,881 48,944 46,941 Total Primary Care Related Visits, Harris County 339,869 218,301 341,652 290,472 365,219 339,292 Emergent, ED Care Needed - NOT Preventable/Avoidable 71,899 83,452 78,728 77,086 89,265 86,656 Total Categorized Visits, Harris County 411,768 301,753 420,380 367,557 454,483 425,948 NON-CATEGORIZED NON HOSPITALIZED VISITS Injury 144,260 165,430 151,735 151,349 152,939 147,163 Mental Health Related 8,236 8,803 9,049 9,009 9,594 8,930 Alcohol or Drug Related 4,245 5,004 5,517 3,405 4,803 5,249 Unclassified 57,758 92,382 95,324 174,447 130,248 102,683 Total Non-Categorized Non Hosp. Visits, Harris County 214,499 271,619 261,625 338,210 297,584 264,025 Total Non Hospitalized Visits, Harris County 626,267 573,372 682,005 705,767 752,067 689,973

Percent NON HOSPITALIZED VISITS - CATEGORIZED Non-Emergent 33.7% 48.5% 32.1% 32.3% 32.6% 32.9% Emergent - Primary Care Treatable 36.4% 5.3% 36.5% 36.2% 37.0% 35.7% ED Care Needed - Prev./Avoid. 12.5% 18.5% 12.7% 10.6% 10.8% 11.0% % Categorized That Area Primary Care Related 82.5% 72.3% 81.3% 79.0% 80.4% 79.7% ED Care Needed - NOT Prev./Avoid. 17.5% 27.7% 18.7% 21.0% 19.6% 20.3%

NON HOSPITALIZED VISITS - CAT. & NON CAT. Non-Emergent 22.1% 25.5% 19.8% 16.8% 19.7% 20.3% Emergent - Primary Care Treatable 23.9% 2.8% 22.5% 18.8% 22.4% 22.0% ED Care Needed - Prev./Avoid. 8.2% 9.7% 7.8% 5.5% 6.5% 6.8% % Non Hosp. That Are Primary Care Related 54.3% 38.1% 50.1% 41.2% 48.6% 49.2% ED Care Needed - NOT Prev./Avoid. 11.5% 14.6% 11.5% 10.9% 11.9% 12.6% % Non Hosp. That Are Categorized 65.7% 52.6% 61.6% 52.1% 60.4% 61.7% Injury 23.0% 28.9% 22.2% 21.4% 20.3% 21.3% Mental Health Related 1.3% 1.5% 1.3% 1.3% 1.3% 1.3% Alcohol or Drug Related 0.7% 0.9% 0.8% 0.5% 0.6% 0.8% Unclassified 9.2% 16.1% 14.0% 24.7% 17.3% 14.9% % All Non Hospitalized ED Visits 100.0% 100.0% 100.0% 100.0% 100.0% 100.0% HOSPITALIZED AND NON HOSPITALIZED VISITS Hospitalized Visits 156,268 118,894 118,894 130,322 Non-Hospitalized Visits 703,502 728,169 728,169 699,379 Total Visits 859,770 847,063 847,063 829,701 HOSPITALIZED AND NON HOSPITALIZED VISITS Hospitalized Visits 18.2% 14.0% 14.0% 15.7% Non-Hospitalized Visits 81.8% 86.0% 86.0% 84.3% Total Visits 100.0% 100.0% 100.0% 100.0%

77 Figure 23. PCRED Visit Percentages by Payer Source – 15 Hospitals

45% 40% 35% Commerc. 30% SCHIP 25% Medicaid 20% Medicare 15% Other Gov. 10% Other Priv. 5% Uninsured 0% 2004 2005 2006 2007 2008 2009 2010

Figure 24. PCRED Visit Percentages by Payer Source – 22 Hospitals

40%

35% Commerc. 30% SCHIP 25% Medicaid 20% Medicare 15% Other Gov. 10% Other Priv. 5% Uninsured 0% 2005 2006 2007 2008 2009 2010

78 Figure 25. PCRED Visit Percentages by Race/Ethnicity – 15 Hospitals

45% 40% 35% Asian 30% Black 25% Hispanic 20% Am. Indian 15% Other 10% Unknown 5% White 0% 2004 2005 2006 2007 2008 2009 2010

Figure 26. PCRED Visit Percentages by Race/Ethnicity – 22 Hospitals

45% 40% 35% Asian 30% Black 25% Hispanic 20% Am. Indian 15% Other 10% Unknown 5% White 0% 2005 2006 2007 2008 2009 2010

79 Figure 27. PCRED Visit Percentages by Age – 15 Hospitals

45% 40% 35% 30% 0-17 25% 18-25 20% 26-44 15% 45-64 10% 65 + 5% 0% 2004 2005 2006 2007 2008 2009 2010

Figure 28. PCRED Visit Percentages by Age – 22 Hospitals

45% 40% 35% 30% 0-17 25% 18-25 20% 26-44 15% 45-64 10% 65 + 5% 0% 2005 2006 2007 2008 2009 2010

80 Figure 29. PCRED Visit Percentages by Gender – 15 Hospitals

70%

60%

50%

40% Female 30% Male 20%

10%

0% 2004 2005 2006 2007 2008 2009 2010

Figure 30. PCRED Visit Percentages by Gender – 22 Hospitals

70%

60%

50%

40% Female 30% Male 20%

10%

0% 2004 2005 2006 2007 2008 2009 2010

81 Figure 31. Total (hospitalized and non-hospitalized) ED Visit Percentages by transport1

90% 80% 70% 60% Ambulance 50% Self 40% Other 30% Unk 20% 10% 0% 2008 2009 2010

Figure 32. PCRED Visit Percentages by transport

100% 90% 80% 70% 60% Ambulance 50% Self 40% Other 30% Unk 20% 10% 0% 2008 2009 2010

1 25 hospitals in 2008, 24 hospitals in 2009, 25 hospitals in 2010

82 Limitations:

The NYU ED algorithm does not classify hospitalized visits, mental health, drug/alcohol, and injury-related visits. It may be assumed that most hospitalized visits and a large percentage of mental health, drug/alcohol, and injury visits are not PCRED visits. To the extent that some are PCR, the estimates understate the number of PCRED visits. This limitation does not affect the percentage or rate calculations. Because the data submitted is de-identified, it is not possible to identify patients who make multiple ED visits. Therefore, we are not able to identify frequent users of the ED. In past years it was believed that Medicaid ED visits also included CHIP. A review of the 2007 data has revealed that most CHIP visits were counted as commercial or private insurance by participating hospitals. Because some of the commercial visits could not be separated from CHIP visits, actual CHIP visits may be slightly higher in frequency than reported.

Several providers of services to homeless persons are located in 77002 (downtown

A greater than expected number of visits for the uninsured were marked as “unknown” for their discharge/hospitalization status (even though they had discharge diagnoses and were therefore treated). Because results for PCRED visits are only reported based on nonhospitalized visits, this group of uninsured visits were classified as hospitalized. Therefore, the frequency and rate of PCRED visits for the uninsured (e.g. Table 1c) may be an undercount/underestimate.

1 Meyer C., St. Luke’s Episcopal Health Charities. Email communication on May 11, 2012.

83 Acknowledgements:

We would like to express our gratitude to the hospitals that took part in this report.

Without their continued support through data and funding, this project would not exist. Funding from the hospitals has allowed us to create both this aggregate report as well as the individual hospital reports made for the participating hospitals. The IT staff at the various institutions have worked with us tirelessly to ensure that a common data set can be used.

Special thanks also to the Houston Endowment for past financial support of this project.

84 IMPORTANT TECHNICAL NOTE ON MEDICARE ENROLLMENT

Patrick Courtney, UT School of Public Health, June 2012

The process of relating payer source enrollment to ER data is difficult. ER data is usually listed in terms of “either/or.” In other words, the visit was covered by either Medicaid OR Medicare OR private insurance, etc. In reality, persons often have “both/and.” In particular, Medicare enrollees, depending on their age, income, and disability status, may have no secondary payer, be enrolled in Medicaid, or have what is commonly called a “Medigap” policy. In addition, there are several parts of Medicare, and not everyone may be enrolled in all of them. The American Community Survey variable that was used in Table 1c (page 21) of this report is “B27010: Types of Health Insurance Coverage By Age.” It sums together all estimated coverages in one variable, and it breaks down Medicare as follows: 1) with Medicare coverage only, 2) with employer based and Medicare coverage, 3) with direct purchase and Medicare coverage, 4) with Medicare and Medicaid/means-tested coverage. Because of the way in which each subgrouping was named, for the purposes of this report 1 and 4 were grouped under Medicare, and 2 and 3 were grouped under commercial insurance.

However, another ACS variable looked only at Medicare enrollment: “B27006: Medicare Coverage By Sex By Age.” This particular variable does not include any reference to whether the enrollee also has a secondary payer source. The following table presents Medicare estimates using both variables. The first column of data is from Table 1c (page 21) of this report, the second column instead uses B27006.

25 hospitals ACS B27010 ACS B27006

2010 total population Medicare 166,336 376,567

2010 total ED visits Medicare 190,438 190,438

2010 total PCRED visits Medicare 57,869 57,869

2010 total ED rate per 100 Medicare 114.49 50.57

2010 PCRED rate per 100 Medicare 34.79 15.37