Common step-wise interventions improved primary care clinic visits and reduced emergency department discharge failures: a large-scale retrospective observational study

This was a single-center retrospective study. The study hospital is a publicly funded county hospital and an urban tertiary referral center. The study hospital ED is a level 1 trauma center, acute chest pain and comprehensive stroke center whose annual ED volume was approximately 120,000 visits during the study period (Jan 1, 2015 through Dec 31, 2017). The study ED also sponsors an Emergency Medicine (EM) residency program. This study was approved by the John Peter Smith Health Network Institutional Review Board (IRB number: 010713.004ex). A waived inform consent was granted due to retrospective chart review with no more than minimal risk to subjects.

Patients who presented to the study ED from Jan 1, 2015 through Dec 31, 2017 and were subsequently discharged after the index ED visit were included in this study. All enrolled patients were followed-up by reviewing their Electronic Medical Record (EMR) until Feb 1, 2018. This allowed all enrolled patients a minimum 30-day follow-up after the index ED discharge. We excluded patients during the index ED visits who were 1) admitted, 2) expired, 3) transferred to other facilities, 4) left without being seen (LWBS), eloped, or left against medical advice (AMA), and 5) prisoners.

Three interventions were already placed and performed in the study hospital ED before the initiation of this study. Therefore, this study can only provide a cross-sectional cohort comparison instead of a pre- and post- intervention comparison. Briefly, patients who had no insurance and who met the criteria listed below were eligible for hospital-based charity insurance coverage. This hospital-based charity insurance coverage is funded by the Texas State Government in United States (US) which lasted for 1 year. It is intended to be a short-term coverage and its use acts as a bridge for patients waiting to be qualified for Medicare, Medicaid, or any commercial insurance coverage . Patients approved for this insurance will need to be reevaluated annually to determine their continuous qualification. Conditional for charity insurance coverage, patients were required to provide no or minimal payment while seeking their healthcare services within the study hospital system. Enrollment eligibility criteria were: 1) patient must be a resident of the local county where hospital is located (Tarrant county); 2) the annual income of the patient or family is below 250% of the federal poverty income level (FPIL); 3) patient is a US citizen, naturalized citizen, or legal permanent resident; and 4) patient has pursued all available health insurance options prior to receiving hospital-based charity insurance coverage. Detailed qualification criteria are on the hospital website (https://​www.​jpshealthnet.​org/​for_​patients/​low_​cost_​medical_​care/​do_​i_​qualify). Only patients who obtained hospital charity insurance were qualified to be assigned a dedicated PCP. A dedicated PCP was assigned randomly based on the availability of physicians taking new patients and their available schedules. All assigned PCPs are within the hospital network system. Once a dedicated PCP was assigned, subsequent formal follow-up clinic appointments could be arranged within 1–4 months of the index ED visits. Patients were informed of PCP assignment and follow-up appointment specifics via mail (US Postal Service). A case manager performed a phone survey to address any potential patient related concerns and to remind patients of their appointments. If no one answered, a message was left to remind patients of their upcoming appointments. Patients were also encouraged to approach hospital/ED social workers or case managers if they had specific questions or concerns. All case managers in the study hospital are licensed master social workers (LMSW) with a Master’s degree in Social Work.

Patient PCP clinic follow-up compliance and ED discharge failure rates were measured as the outcomes. Patient follow-up compliance was defined as patients who visited the PCP clinic after the index ED discharge regardless of ED revisits/returns. In general, discharge failure was defined as ED revisits within a short period of time after the index ED discharge (e.g., 3 days, 7 days, 14 days, or 30 days) and/or poor patient adherence to scheduled PCP clinic follow-up. We defined patients as having no ED discharge failure if they completed a PCP clinic follow-up either before their next appropriate ED revisit or had no further ED revisits. Appropriate ED visits were determined by New York University Algorithm (NYUA), addressed in detail below. We further categorized ED discharge failure as either restricted or broad/uncertain circumstance mediated. Restricted discharge failure was considered if patients met all of the following criteria: 1) patients who returned to the ED prior to their scheduled clinic follow-up visit or returned to the ED with no scheduled clinic follow-up since the index ED visit, and 2) patients who returned to the ED, were discharged and the reasons for ED return were determined inappropriate ED utilization (i.e., non-emergent, avoidable) by NYUA. Broad/uncertain discharge failure excluded patients with restricted discharge failure that met at least one of the following criteria: 1) patients who had neither subsequent ED nor clinic visits; 2) patients who had appropriate or unclassified ED returns but did not have any PCP follow-ups from the index ED discharge; 3) patients that returned to the ED appropriately or unclassified prior to their clinic follow-ups; or 4) patients that returned to the ED after PCP visits and their ED returns were inappropriate or unclassified (A detail definition of different outcomes are listed in Additional file 1).

The New York University ED algorithm (NYUA) was used in this study to determine appropriateness of ED utilization for ED return visits [16]. Briefly, four major categories were used in NYUA: 1) emergent not avoidable considered as appropriate ED visits; 2) primary care treatable defined as care that can be safely provided in a primary care setting without the need for emergent treatment; 3) emergent care needed but preventable/avoidable defined as patients whose disease conditions can be prevented/avoided if preventive care is received in a timely fashion; and 4) non-emergent. Patient visits not meeting one of these four major categories were deemed unclassified. Appropriate ED utilization was considered if patients met the emergent not avoidable category criteria, and inappropriate utilization was determined if patients were classified within the other three categories. Uncertain ED utilization was considered if patients were unclassified. NYUA is only used to determine the appropriateness of ED utilization among ED discharged patients. In addition to NYUA, patients who revisited the ED within 30-days were considered appropriate ED utilization where patients were: 1) admitted to hospital, 2) moved to the operating room, 3) transferred to other facilities, or 4) expired.

Patient general characteristics including patient age, gender, and race/ethnicity were collected in this study. Other patient and clinical variables were listed as follows: 1) mode of arrival: divided into two categories (healthcare-assisted arrival including ambulance or hospital/healthcare facility-arranged transportation versus others including private car, public transportation, taxi, wheelchair, ambulatory, police, or unknown), 2) level of acuity: divided into two categories based on ESI (Emergency Severity Index) level including high-to-moderate (ESI 1–2-3) and low (ESI 4–5) acuities, 3) homeless status, 4) patient last vital signs upon disposition (including heart rate, respiratory rate, blood pressure, oxygenation, and temperature) divided into two categories of patients who had normal vital signs versus patients with any abnormal vital signs (e.g., heart rate < 50 or > 100, respiratory rate < 8 or > 20, systolic blood pressure < 90 mmHg or > 140 mmHg, diastolic blood pressure < 60 mmHg or > 90 mmHg, pulse oximetry < 94%, temperature > 100.4F° or < 96.8F°), 5) immediate subsequent healthcare visits (e.g., ED, PCP clinic, or none) and its time interval from the index ED discharge, 6) whether patients had their PCP assigned, 7) number of medications prescribed upon the index ED discharge, 8) insurance type divided into five categories including a) hospital-based charity insurance; b) Medicare; c) Medicaid; d) commercial; and e) no insurance coverage; and 9) patient’s chronic disease conditions: divided into two categories including patients with chronic disease(s) and those without. Chronic disease conditions were determined using the chronic condition indicator (CCI) for the International Classification of Diseases Tenth Edition, Clinical Modification (ICD-10-CM). It was developed as part of the Healthcare Cost and Utilization Project (HCUP) by the Agency for Healthcare Research and Quality (AHRQ) [17].

To determine whether interventions improved patient PCP clinic follow-up compliance, we measured patient PCP clinic follow-up after interventions and compared patients relative to five different insurance coverages (e.g., charity versus Medicare versus Medicaid versus commercial versus no insurance). Furthermore, among patients who complied with their PCP visits, we divided patients into five groups based on differences of their insurance coverage along with three different discharge failure outcomes (e.g., no discharge failure, restricted discharge failure, and broad/uncertain discharge failure). Lastly, the association between the urgency of PCP visits (within 3 days, 7 days, 14 days, and 30 days) and restricted discharge failures were drawn and compared across cohorts of patients with different insurance statuses.

A total of 227,627 ED discharged patients were retrieved from the EMR. Of these, 41,427 (18%) patients received hospital-based charity insurance coverage with 21,695 (10%) patients eventually following up through a PCP clinic compared to 7293 (3%) patients experiencing restricted discharge failures (Fig. 1). Overall, 30% (67,674/227,627) of patients had at least one clinic follow-up visit after the index ED discharge, 18% (41,333/227,627) of patients were considered restricted discharge failures and only 10% (23,322/227,627) of ED discharged patients had no discharge failure. Table 1 describes general information among different insurances. Patients with no insurance or commercial coverage tended to be younger with less chronic disease conditions, less likely homeless, and less likely to have a primary care physician (PCP) assigned in comparison to ones with other insurance coverages (Table 1).

Figure 2 shows that 58% (24,178/41,427) of patients who received charity insurance followed-up with a PCP clinic in comparison to only 23% (43,483/186,200) among patients who had no-charity insurance coverage (p < 0.001). Furthermore, 77% (21,695/28,068) of patients who received charity insurance with a dedicated PCP assignment completed clinic follow-ups in comparison to only 4.5% (5325/119,607) among patients who had no charity insurance and no dedicated PCP assignment (p < 0.001). Additionally, despite gradually decreased participant percentages with step-wise interventions, clinic follow-up compliance remained highest among patients who received charity insurance coverage and dedicated PCP assignment (Fig. 3).

Simultaneously, the percentage of patients with no discharge failure was also increased with the implementation of step-wise interventions. Increased no-discharge-failure rates were seen with the addition of dedicated PCP assignments and subsequent PCP visits. This was noted not only among patients with charity insurance but also ones without such benefits (Table 2). Meanwhile, restricted-discharge-failure rates were also reduced with the step-wise interventions specifically among patients receiving charity, Medicare, and Medicaid insurances (Table 2).

When focused on patients who had clinic follow-up visits, we divided patients into 5 different groups based on the different urgencies of their PCP visits ranging from PCP visits ≤3 days from the index ED discharge to > 30 days. Urgent PCP clinic visits seemed to reduce patients with restricted discharge failures regardless of their insurance statuses (Table 3).

To avoid the potential confounders, a multivariate logistic regression was performed, adjusted with all potential independent variables. When using patients with no insurance and no PCP assignment as the reference, our study found that insurance coverage and PCP assignment are tightly associated with patient clinic follow-up visits at both individual and combination levels (Table 4). The same model was used to determine the association between interventions and ED restricted discharge failure. We found that patients with either charity or commercial insurance and who completed PCP visits were associated with less ED restricted discharge failure if analyzed individually (Table 5). However, when three interventions were analyzed with interactions to further predict restricted ED discharge failures, insurance coverage with charity, Medicare, or Medicaid itself did not seem to reduce ED discharge failure. However, such outcome benefits occurred with the combinations of step-wise interventions even after adjusted with all the confounders (Table 5).