Healthcare Utilization Among Vulnerable...

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Healthcare Utilization Among Vulnerable Populations ICare 2011

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Vulnerability

• Vulnerability is a multidimensional construct with many definitions

• Vulnerable populations experience a convergence of many risk

factors (community and individual level) Low income, lack of insurance, age, race, illness

Physically vulnerable

groups

Psychologically

vulnerable groups

Socially vulnerable

groups

High risk mothers and

infants Mentally ill and disabled Abusing families

Chronically ill and

disabled

Alcohol or substance

abusers Homeless persons

Persons living with

HIV/AIDS Suicide or homicide prone Immigrants and refugees

Source: Aday, L. At Risk in America : The Health and Health Care Needs of Vulnerable

Populations in the United States. 2001

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Vulnerability

• Multiple risk factors result in a higher risk for poor health outcomes.

• Patients with poorer health outcomes place an additional burden on

healthcare systems.

• Improved access and utilization of primary care services can

decrease the burden on hospital systems, reducing medical costs

for high risk individuals.

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Study Objective

• Describe patterns of healthcare utilization among vulnerable sub-

groups of a low income, underserved population and identify

populations that could benefit from additional intervention to reduce

healthcare costs and improve quality of care.

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Integrated Care Collaboration (ICC)

• Non-profit alliance of health care safety-net providers in Central

Texas (Austin area) Multi-hospital systems

Public and private clinics

Federally qualified health centers

City public health clinics

• Organized around the medically indigent population of individuals

who are uninsured or underinsured

• Maintains a fully operational Health Information Exchange (HIE)

system Database called ICare

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ICare HIE Database

• 2011 Available Data Demographics

Encounter level data

‒ Admission and discharge dates

‒ Location/Facility

‒ Payor

‒ Provider

‒ Diagnoses (ICD-9 codes)

‒ Procedures

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Inclusion Criteria

• Timeframe: Calendar Year 2011

• ICare patients aged 0-64 years 65+ excluded due to lack of Medicare data in ICare

• Encounter types Clinic/office

Emergency department (ED)

Inpatient (IP)

Outpatient

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Vulnerable Groups

• Near Elderly Age of 60-64 years as of 12/31/2011

• Homeless Most recent address in the ICare recorded as “Homeless” or “No

Address” OR

Most recent address was associated with an agency that serves the

homeless (Salvation Army, Austin Resource Center for the Homeless,

etc.)

Past addresses are not retained by the ICare system. ‒ Patient defined as currently homeless at the time of the data pull may not

have been homeless at the time of their encounter.

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Vulnerable Groups

• Behavioral Health Diagnosis of a behavioral health condition at any encounter during 2011

Mental illness diagnoses are defined by the Healthcare Costs and

Utilization Project (HCUP) Clinical Classifications Software (CCS) for

ICD-9-CM1

‒ Codes related to tobacco use have been excluded as mental illness

diagnoses

• Disabled Diagnosis of a condition which may qualify them as having a severe and

chronic disability during 2011

Disability diagnoses are defined by ICD-9 codes that are described and

approved by the Texas Department of Aging and Disability Services

(DADS) as a condition which may qualify an individual as having a

severe and chronic disability as described in federal and state law2

1. http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp

2. http://www.dads.state.tx.us/providers/guidelines/ICD-9-CM_Diagnostic_Codes.pdf

http://www.hcup-us.ahrq.gov/toolssoftware/ccs/ccs.jsp



http://www.dads.state.tx.us/providers/guidelines/ICD-9-CM_Diagnostic_Codes.pdf





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Methods

• Descriptive statistics to describe population Distribution of vulnerable populations

Demographics (race/ethnicity, age, sex)

Healthcare utilization (ED and IP visits)

• Poisson regression to quantify risk Risk of an ED visit

Risk of an IP visit

All risk models are adjusted for all four vulnerable groups as well as

age, sex, and race/ethnicity

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Results

• Total of 279,992 patients

aged 0-64 years

• 58,624 (20.9%) of patients

were vulnerable

• 221,368 (79.1%) did not fall

into a vulnerable population

79.1%

20.9%

Distribution of Vulnerable Populations

Not Vulnerable Vulnerable

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Vulnerable Population by Group

14.5%

4.1%

71.0%

25.1%

0

20

40

60

80

Near Elderly Homeless Behavioral Health Disabled

Perc

en

t o

f V

uln

era

ble

Pati

en

ts

*Groups are not mutually exclusive

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Vulnerable Group Overlap

Condition Near Elderly Homeless Behavioral

Health Disabled

Near Elderly 8,512 106 1,982 961

Homeless 106 2,401 1,145 215

Behavioral

Health 1,982 1,145 41,642 4,758

Disabled 961 215 4,758 14,689

1,145 / 2,401 = 0.477

47.7% of Homeless patients also have a Behavioral Health Diagnosis

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Demographic Distributions

30.9 28.2

41.4

10.6 10.7 10.1

52.2 54.7

42.8

6.3 6.5 5.6

0

20

40

60

All Patients Non-Vulnerable Vulnerable

Perc

en

t o

f P

ati

en

ts

Race/Ethnicity Distribution by Vulnerable Status

White Black Hispanic Other

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45.2 49.6

43.3

36.3

9.0

15.4

10.2 8.8

36.9 33.0

41.6

49.1

8.8

2.1 4.9 5.8

0

20

40

60


Perc

en

t o

f P

ati

en

ts

Race/Ethnicity Distribution by Vulnerable Group

White Black Hispanic Other

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39.0

44.0

20.4

43.6 43.8 42.9

17.4

12.3

36.7

0

10

20

30

40

50

All Patients Non-Vulnerable Patients Vulnerable Patients

Perc

en

t o

f P

ati

en

ts

Age Distribution by Vulnerable Status

Age <18 Age 18-44 Age 45-64

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4.7

19.5

32.6

49.3 50.2

37.7

46.0

30.2 29.7

0

15

30

45

60

Homeless Behavioral Health Disabled

Perc

en

t o

f P

ati

en

ts

Age Distribution by Vulnerable Group

Age <18 Age 18-44 Age 45-64

*Near elderly has been omitted from chart, 100% fall into “Age 45-64”.

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44.3 43.8 46.0

55.8 56.2 54.0

0

15

30

45

60

All Patients Non-Vulnerable Patients Vulnerable Patients

Perc

en

t o

f P

ati

en

ts

Sex Distribution by Vulnerable Status

Male Female

18


43.7

77.7

45.6 43.8

56.3

22.3

54.4 56.2

0

20

40

60

80

100


Perc

en

t o

f P

ati

en

ts

Sex Distribution by Vulnerable Group

Male Female

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Demographics Summary

• Race/Ethnicity A higher proportion of vulnerable patients are White and a lower

proportion are Hispanic compared to non-vulnerable patients

Homeless patients have a higher proportion of White and Black

Disabled patients have a higher proportion of Hispanic

• Age Homeless had the lowest proportion of children <18

• Sex Overall, vulnerable patients are distributed similarly to non-vulnerable

patients

Homeless is the only group where men are more predominant than

women

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Emergency Department Utilization

53.9% 54.0% 53.6%

1.8 1.6

2.5

0.0

0.5

1.0

1.5

2.0

2.5

3.0

20

30

40

50

60

Total Patients Not Vulnerable Vulnerable

Avera

ge N

um

ber

of

ED

Vis

its

Perc

en

t w

ith

ED

Vis

it

ED Utilization by Vulnerable Status

% With at Least One ED Visit Avg Number of ED Visits

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Emergency Department Utilization

33.5%

82.5%

54.3% 60.4%

1.8

3.3

2.8 2.6

0.0

0.5

1.0

1.5

2.0

2.5

3.0

3.5

0

20

40

60

80

100

Near Elderly Homeless Behavioral Health

Disabled

Avera

ge N

um

ber

of

ED

Vis

its

Perc

en

t w

ith

ED

Vis

it

ED Utilization by Vulnerable Group

% With at Least One ED Visit Avg Number of ED Visits

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Frequent Emergency Department Users

0.4%

1.4%

9.0%

4.5%

3.3% 9.3

13.6 13.2 13.9

15.5

0.0

3.0

6.0

9.0

12.0

15.0

18.0

0.0

2.0

4.0

6.0

8.0

10.0

Not Vulnerable


Disabled

Avera

ge N

um

ber

of

ED

Vis

its

Perc

en

t o

f E

D U

sers

% Frequent User Avg Number of ED Visits

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Inpatient Utilization and Length of Stay

11.7%

15.5% 15.2%

17.7% 18.1%

3.6

4.9 4.6

4.9

5.7

0

2

4

6

8

0

4

8

12

16

20

Not Vulnerable


Disabled

Avera

ge L

en

gth

of

Sta

y (

days)

Perc

en

t w

ith

IP

Vis

it

% With IP Visit Average LOS (days)

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Utilization Summary

• A similar proportion of vulnerable and non-vulnerable patients had

at least one ED visit; however, vulnerable ED users had a higher

average number of ED visits.

• Homeless patients had the highest rate of ED use and the greatest

average number of ED visits among ED users. They also had the

highest rate of frequent ED utilization among ED users.

• Near elderly patients had a lower rate of ED utilization than the

overall and non-vulnerable populations.

• Disabled patients had the highest rate of IP utilization and the

longest average length of stay among IP users. Disabled frequent

users had the greatest average number of ED visits.

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Risk of ED Utilization by Vulnerable Group

Group Risk Ratio (RR) % Increase p-Value

Near Elderly 0.67 -50% <0.001

Homeless 1.48 48% <0.001

Behavioral Health 1.00 0% 0.994

Disabled 1.12 12% <0.001

• Near Elderly patients had a 50% lower risk of having an ED visit, compared

to patients who were not near elderly.

• Homeless patients had a 48% greater risk and Disabled patients had a

12% greater risk of having an ED visit, compared to patients who were not

homeless or disabled, respectively.

• Behavioral Health patients had no change in risk compared to non-

Behavioral Health patients.

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Behavioral Health Results

• Result that BH patients had no increased risk of an ED visit was

unexpected Further analysis necessary for explanation

• Looked at ED utilization by Behavioral Health sub-group

BH Subgroup

Adjustment disorders Mood disorders

Anxiety disorders Personality disorders

ADHD/Disruptive behavior Psychotic disorders

Dementia Alcohol-related

Developmental disorders Substance-related

Disorders usually diagnosed in

childhood

Suicide/intentional injury

Impulse control Miscellaneous mental disorders

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BH Exploratory Analysis

BH Subgroup % w ED Visit BH Subgroup % w ED Visit

Adjustment disorders 47.9 Mood disorders 59.3

Anxiety disorders 57.7 Personality disorders 59.3

ADHD/Disruptive

behavior 43.6

Psychotic disorders 68.6

Dementia 61.8 Alcohol-related 74.2

Developmental disorders 63.6 Substance-related 72.1

Disorders usually

diagnosed in childhood 39.6

Suicide/intentional

injury 90.0

Impulse control 50.6

Miscellaneous mental

disorders 66.4

• Utilization quite different by Behavioral Health sub-group

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• Looked at correlation between rates of ED utilization and clinic

utilization among BH sub-groups

• Groups with high ED utilization had low clinic utilization

R² = 0.7938

0

20

40

60

80

100

0 20 40 60 80 100

% w

ith

ED

Vis

it

% with Clinic Visit

Correlation Between ED and Clinic Utilization

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• Re-defined Behavioral Health group to include only the following

sub-groups Anxiety disorders

Delirium, dementia, amnesic and other cognitive disorders

Personality disorders

Schizophrenia and other psychotic disorders

Alcohol-related disorders

Substance-related disorders

Suicide and intentional self-inflicted injury

• Re-ran risk analysis using new BH group

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Risk of ED Utilization by Vulnerable Group

BH Group 1 BH Group 2

Group RR

%

Increase p-Value RR

%

Increase p-Value

Near Elderly 0.67 -50% <0.001 0.66 -52% <0.001

Homeless 1.48 48% <0.001 1.40 40% <0.001

Behavioral

Health 1.00 0% 0.994 1.25 25% <0.001

Disabled 1.12 12% <0.001 1.09 9% <0.001

• Risk of an ED visit remained similar for Near Elderly, Homeless, and

Disabled groups

• New group of BH patients have a 25% greater risk of having an ED visit

than patients not in group

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Risk of Inpatient Utilization by Vulnerable Group

Group Risk Ratio (RR) % Increase p-Value

Near Elderly 1.10 10% 0.002

Homeless 1.26 26% <0.001

Behavioral Health 1.89 89% <0.001

Disabled 1.52 52% <0.001

• All vulnerable groups had an increased risk of having an inpatient visit

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Risk of IP Utilization by Vulnerable Group

BH Group 1 BH Group 2

Group RR

%

Increase p-Value RR

%

Increase p-Value

Near Elderly 1.10 10% 0.002 1.12 12% <0.001

Homeless 1.26 26% <0.001 1.18 18% <0.001

Behavioral

Health 1.89 89% <0.001 2.21 121% <0.001

Disabled 1.52 52% <0.001 1.56 56% <0.001

• Risk of an IP visit remained similar for Near Elderly, Homeless, and

Disabled groups

• Limited group of BH patients have a 121% greater risk of having an IP visit

than patients not in group

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Risk Summary

• Homeless and disabled patients had an increased risk of ED

utilization.

• Near elderly patients had a decreased risk of ED utilization.

• Behavioral health patients overall had neither an increased or

decreased risk of ED utilization. A limited group of more severe

behavioral health patients had an increased risk of ED utilization.

• All vulnerable groups had an increased risk of inpatient utilization.

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Limitations

• Homeless status is only accurate as of last encounter captured in

ICare

• Results can only be generalized to patients under age 65

• Study population is limited to patients who are publically insured or

uninsured Entire study population may be considered “Vulnerable”.

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Discussion

• Questions?

• Thoughts?

• Email [email protected] for electronic copy

mailto:[email protected]

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