National Burden of Emergency Department Care for Sickle Disease: Impact of Age, Insurance Status, Income, Hospital Type and Location On Subsequent Hospital Admission.

Limited data exist about the national burden of emergency department (ED) care for patients with sickle cell disease (SCD). The proportion of patients being seen in the ED who require hospitalization and factors contributing to the above are poorly understood. We present here analysis of such potential factors from the largest nationally representative ED visit data till date.

The Nationwide Emergency Department Sample (NEDS) is one of a family of databases and software tools developed as part of the Healthcare Cost and Utilization Project (HCUP), a Federal-State-Industry partnership sponsored by the Agency for Healthcare Research and Quality. The NEDS was constructed using records from both the HCUP State Emergency Department Databases and the State Inpatient Databases. The NEDS is the largest all-payer ED database and contains almost 26 million records for ED visits for over 950 hospitals and approximates a 20-percent stratified sample of U.S. hospital-based ED's thus generating weighted estimates of over 120 million ED visits.

The following ICD-9-CM diagnosis codes were used to define SCD related hospitalizations: 28241, 28242, 2825, 28260, 28261, 28262, 28263, 28264, 28268, and 28269 and only ‘primary discharge diagnosis' patients were considered. We analyzed the NEDS data for the year 2006.

Approximately three-quarters of the total in-patient admissions for SCD in 2006 came through the emergency department. The total number of patients presenting to the ED with SCD as primary diagnosis was 166,043. Of these visits, 68,420 (41.2%) resulted in admission to the hospital.

There was a statistically significant difference (p<0.001) in the proportion of ER visits resulting in hospitalization for the following factors (each studied independently):

• 1. Children and the elderly were more likely to be admitted to the hospital: The proportion of admissions was 50.7% in 1-17 yrs, 38.7% in 18-44 yrs, 44.0% in 45-64 yrs and 69% in the 65-84 yrs age group.

• 2. Metropolitan vs. non-metropolitan hospitals: Patients were more likely to be admitted to the hospital if they were seen in an ED in a metropolitan area (42.1% vs. 33.0%).

• 3. Insurance status. Patients with insurance coverage of any type were overall more likely to be admitted to hospital as compared with those without insurance (42.3% vs.30.5%). Among the insured patients, the percentage admission was as follows: Medicare 39.9%, Medicaid 42.0% and privately insured 45.4%.

• 4. Residence in a low income area predicted a higher likelihood of subsequent hospitalization (40.0% vs. 41.8%).

• 5. Teaching hospitals were more likely to admit patients from the ED as compared to non-teaching hospitals (44.5% vs. 36.0%).

SCD is responsible for a significant burden of ED care in the US. A number of factors including of patient age, insurance status, income, hospital type and location may impact the likelihood of subsequent admission to the hospital. High quality care of uncomplicated pain crises in an ED or day hospital is believed to result in a decrease of avoidable hospitalizations. However, the multiplicity of factors independently associated with likelihood of subsequent hospitalization as demonstrated by these data suggest the need for caution in using the proportion of ED visits resulting in hospitalizations as a surrogate marker of quality of care.

No relevant conflicts of interest to declare.