Use of the emergency department for less-urgent care among type 2 diabetics under a disease management program

Abstract

BackgroundThis study analyzed the likelihood of less-urgent emergency department (ED) visits among type 2 diabetic patients receiving care under a diabetes disease management (DM) program offered by the Louisiana State University Health Care Services Division (LSU HCSD).MethodsAll ED and outpatient clinic visits made by 6,412 type 2 diabetic patients from 1999 to 2006 were extracted from the LSU HCSD Disease Management (DM) Evaluation Database. Patient ED visits were classified as either urgent or less-urgent, and the likelihood of a less-urgent ED visit was compared with outpatient clinic visits using the Generalized Estimating Equation methodology for binary response to time-dependent variables.ResultsPatients who adhered to regular clinic visit schedules dictated by the DM program were less likely to use the ED for less urgent care with odds ratio of 0.1585. Insured patients had 1.13 to 1.70 greater odds of a less-urgent ED visit than those who were uninsured. Patients with better-managed glycated hemoglobin (A1c or HbA1c) levels were 82 times less likely to use less-urgent ED visits. Furthermore, being older, Caucasian, or a longer participant in the DM program had a modestly lower likelihood of less-urgent ED visits. The patient's Charlson Comorbidity Index (CCI), gender, prior hospitalization, and the admitting facility showed no effect.ConclusionPatients adhering to the DM visit guidelines were less likely to use the ED for less-urgent problems. Maintaining normal A1c levels for their diabetes also has the positive impact to reduce less-urgent ED usages. It suggests that successful DM programs may reduce inappropriate ED use. In contrast to expectations, uninsured patients were less likely to use the ED for less-urgent care. Patients in the DM program with Medicaid coverage were 1.3 times more likely to seek care in the ED for non-emergencies while commercially insured patients were nearly 1.7 times more likely to do so. Further research to understand inappropriate ED use among insured patients is needed. We suggest providing visit reminders, a call centre, or case managers to reduce the likelihood of less-urgent ED visit use among DM patients. By reducing the likelihood of unnecessary ED visits, successful DM programs can improve patient care.

Chronic Care Model Strategies In The United States And Germany Deliver Patient-Centered, High-Quality Diabetes Care

“…This finding is in concordance with results of previous studies that evaluated the Barmer and Geisinger structured care programs. 8,[22][23][24][25] In Germany, however, for process quality this effect was modulated by duration of diabetes and age of patients. If German patients' duration of diabetes was greater than ten years, they reported higher quality of care for five out of six items related to process quality, regardless of whether they belonged to the control or the intervention group.…”

Illustrating Informed Presence Bias in Electronic Health Records Data: How Patient Interactions with a Health System Can Impact Inference

“…That is, patients who have their HbA1c measured in the ED may have differential risk for MI as compared to patients who have their HbA1c measured in an outpatient setting. In our example, patients with unmanaged diabetes (high HbA1c) may be more likely to have a non-urgent ED visit as compared to patients with managed diabetes who visit the ED [25]. Therefore, where someone seeks care can be informative of their health status.…”

Smoking Relapse and Type 2 Diabetes Mellitus–Related Emergency Department Visits Among Senior Patients with Diabetes

“…a Adjusted for age, race, insurance type, type 2 diabetes mellitus outpatient visits, diabetes mellitus inpatient visits, Charlson comorbidity index (21), congestive heart failure, peripheral vascular disease, cerebrovascular disease, and chronic pulmonary disease.…”

“…Numerous control variables were considered in this study. Patient characteristics used in this study were age, sex, race (20), and insurance type (commercial, free care, Medicare, Medicaid, and self-pay) (21). Although patient educational level or household income may have affected health care outcomes (20), the HCSD claims data set did not provide this information.…”

“…Therefore, insurance type was used as a proxy for socioeconomic status. In addition, health status and comorbidity may affect ED use (20); therefore, the Charlson comorbidity index (CCI) (21), number of ambulatory visits and hospitalizations for diabetes (21), congestive heart failure (CHF), peripheral vascular disease (PVD), cerebrovascular disease (CVD), and chronic pulmonary disease (CPD) (5,22) were included if they occurred during the year before the index date. CCI was calculated for each patient according to outpatient or inpatient care by using the Quan adaptation of the Elixhauser comorbidities (22).…”