Time and Again: Frequent Users of Emergency Department Services in New York City

A N

I S S U E

B R I E F

OFFICERS
J. Barclay Collins II Chairman James R. Tallon, Jr. President Patricia S. Levinson Frederick W. Telling, PhD Vice Chairmen Sheila M. Abrams Treasurer Sheila M. Abrams David A. Gould Sally J. Rogers Senior Vice Presidents Michael Birnbaum Deborah E. Halper Vice Presidents Stephanie L. Davis Corporate Secretary

DIRECTORS
Richard A. Berman Jo Ivey Boufford, MD Rev. John E. Carrington Philip Chapman J. Barclay Collins II Richard Cotton William M. Evarts, Jr. Michael R. Golding, MD Josh N. Kuriloff Patricia S. Levinson Howard P. Milstein Susana R. Morales, MD Robert C. Osborne Peter J. Powers Mary H. Schachne John C. Simons Michael A. Stocker, MD, MPH Most Rev. Joseph M. Sullivan James R. Tallon, Jr. Frederick W. Telling, PhD Mary Beth C. Tully Howard Smith Chairman Emeritus

United Hospital Fund

The United Hospital Fund is a health services research and philanthropic organization whose primary mission is to shape positive change in health care for the people of New York. We advance policies and support programs that promote high-quality, patient-centered health care services that are accessible to all. We undertake research and policy analysis to improve the financing and delivery of care in hospitals, health centers, nursing homes, and other care settings. We raise funds and give grants to examine emerging issues and stimulate innovative programs. And we work collaboratively with civic, professional, and volunteer leaders to identify and realize opportunities for change.

HONORARY DIRECTORS
Donald M. Elliman Douglas T. Yates Honorary Chairmen Herbert C. Bernard John K. Castle Timothy C. Forbes Barbara P. Gimbel Rosalie B. Greenberg Allan Weissglass

Time and Again: Frequent Users of Emergency Department Services in New York City
Maria Raven, MD, MPH, MSc
ASSISTANT PROFESSOR OF EMERGENCY MEDICINE UNIVERSITY OF CALIFORNIA SAN FRANCISCO

David A. Gould, PhD

SENIOR VICE PRESIDENT UNITED HOSPITAL FUND
FOR

PROGRAM

UNITED

HOSPITAL

FUND

Supported in part by a HEAL 9 grant.

Copyright 2012 by United Hospital Fund ISBN 1-933881-27-5

Free electronic copies of this report are available at the United Hospital Funds website, www.uhfnyc.org.

Contents
INTRODUCTION EMERGENCY DEPARTMENT USE IN NEW YORK CITY The Neighborhood Effect Neighborhood Characteristics and ED Use FREQUENT USERS OF EMERGENCY DEPARTMENT SERVICES Definitions Service Use by Frequent ED Users Neighborhood Matters Frequent ED Use and Hospitalization The Age of Frequent Users Residential Mobility EMERGENCY DEPARTMENT SUPER-USERS What Is a Super-User? Who Are the Super-Users? Why Do Super-Users Visit the ED? Inpatient Utilization Which Hospitals Treat Super-Users? DISCUSSION MAPS TABLES 1 2 2 2 4 4 4 4 5 5 6 7 7 7 7 8 9 10 12 14

iii

iv

Introduction
The use of Emergency Department (ED) services has served as a barometer for the performance of the health care system. ED use has informed an important public health function by helping identify emerging epidemics ranging from flu to toxic drug use. It also has been employed by health services researchers to document the impact of not having health insurance; the shortage of accessible primary care; the health-seeking behaviors of different sub-populations; and more.1-3 The United Hospital Fund has been a leader in the field, having conducted pioneering studies of ED utilization, beginning with a collaboration with John Billings of New York University to document and analyze New York City patterns of utilization at a community level. These studies have largely focused on measuring visits for conditions that were preventable with appropriate primary care services. In addition to helping frame the call for primary care development, the reports contributed to New York States expansion of the Statewide Planning and Research Cooperative System (SPARCS) database to include ED services in 2005. This issue brief builds on that foundational work and breaks important new ground. With support of a HEAL 9 grant from the New York State Department of Health, Fund researchers and consultants were able for the first time to link all visits made by individuals, and analyze patterns of utilization at an individual level. As described in a methodological appendix available on the Funds website, researchers were able to examine the characteristics of persons who use an ED once a year compared to those of frequent users, who use the ED often over the course of a year. The study also examines a group of super-users, who make frequent ED visits over a period of three years, 2006 to 2008. The ability to distinguish one-time from more frequent ED users has significant implications for planning more responsive health care services. It also is important to take into consideration small area variations in utilization across New York City. Therefore this analysis examines patterns of ED utilization at a neighborhood level. While a more extensive report, Patterns of Emergency Department Utilization in New York City, 2008, available at the UHF website, www.ufhnyc.org, analyzes utilization for one-time and all types of frequent users in all New York City neighborhoods, this issue brief will focus mainly on the characteristics of frequent users and super-users, exploring how their patterns of utilization could inform the reshaping of health care services.

1 Institute of Medicine. 2007. Hospital-Based Emergency Care: At the Breaking Point. Washington, DC: National Academy Press. 2 Pitts SR, et al. 2010. Where Americans Get Acute Care: Increasingly, Its Not at Their Doctors Office. Health Affairs 29(9): 1620-9. 3

Tang N, et al. 2010. Trends and Characteristics of US Emergency Department Visits, 1997-2007. JAMA 304(6): 664-70.

Frequent Emergency Department Use in New York City

Emergency Department Use in New York City

Before looking closely at frequent users of ED services, we must establish some context of the more general use of these services. In the decade from 1999 through 2008, the number of ED visits in New York City increased by 15.7 percent, rising to 3,842,548 from 3,322,235.4 One in five of the 3.8 million visits New York City residents made in 2008 resulted in an inpatient admission. But 3 million visits, which accounted for 79.6 percent of all visits, did not. These treat and release (T&R) visits are the subject of this study. the population, we found a citywide average of 36 visits per 100 people (Table 2). There was an almost seven-fold difference in age- and sexadjusted use rates among neighborhoods, from a low of 13 per 100 on the Upper East Side to a high of 83 per 100 in nearby East Harlem. The 10 neighborhoods with the highest ED visit rates, which represent 34 percent of the total population, accounted for nearly 46 percent of citywide ED visits. In addition to familiar neighborhood hot spots, distinct borough patterns also emerged. For example, in the Bronx, six of seven neighborhoods had use rates that were above the city average, with the exception of Kingsbridge/Riverdale. Of Brooklyns 11 neighborhoods, eight had lower than average use, but three (Central Brooklyn, East New York/New Lots, and Bushwick/Williamsburg) had use rates significantly above the citywide average of 36 visits per 100 people. Manhattan showed a mixed picture among its 10 neighborhoods, with some of the most dramatic variation encompassing not only neighborhoods with the highest use (Central Harlem and East Harlem) but also the lowest (Upper East Side). Neighborhoods in Queens and Staten Island had mostly below-average ED use, with a few exceptions that did not depart too greatly from average.

The Neighborhood Effect

Citywide, 22 percent of the population made at least one T&R visit in 2008. But ED utilization varies considerably by neighborhood, ranging from a low of 8 percent in the Upper East Side to a high of 41 percent in East Harlem (Table 1). The percent of the population making at least one visit in 2008 is displayed in Map 1 (see page 12), which divides New Yorks neighborhoods into three groups: high-use neighborhoods, with a rate of use more than 10 percent above the city average; middle-use neighborhoods, with a rate within 10 percent of the city average; and loweruse neighborhoods, with a rate of use more than 10 percent under the city average. For neighborhood boundaries, we used the 42 city neighborhoods defined by UHF for past analyses. The 42 UHF neighborhoods consist of adjoining zip code areas with similar characteristics, designated to approximate New York City Community Planning Districts, and based on the demographic, economic, and social diversity found there. When utilization was adjusted for age and sex of
4 5

Neighborhood Characteristics and ED Use

These utilization patterns are generally consistent with studies of health and health care in New York Citys neighborhoods.5,6 The associations between neighborhoods ED use and their population and health system

Authors analysis of Hospital Watch reports.

Billings JC, N Parikh, and T Mijanovich. 2000. Emergency Room Use:The New York Story. New York: The Commonwealth Fund.
6 Billings J, N Parikh, and T Mijanovich. 2000. Issue Brief: Emergency Department Use in New York City: A Substitute for Primary Care? New York: New York University and The Commonwealth Fund.

United Hospital Fund

characteristics are displayed in Figure 1, which divides the neighborhoods into three tiers by rate of ED use. The level of ED use was strongly associated with neighborhood poverty; the proportion of

uninsured residents, Blacks, and Hispanics; and residents reports of poor/fair health status, no regular doctor, and difficulty getting medical care when needed. (Statistically significant differences between neighborhood groupings are indicated at the bottom of the chart.)

Figure 1. ED Use and Neighborhood Characteristics

* Significantly different between the high-use group and the other two groups. ** Significantly different between all three groups. Data sources: Poverty and foreign-born: 2000 US Census Race/Ethnicity: 2008 DOHMH population estimates Health status and lack of insurance: Community Health Survey (avg. of 2007, 2008, and 2009) Hospitalization rates: 2008 SPARCS No regular doctor, no doctor visits last 12 months, and did not get needed care: 2008 Community Health Survey

Frequent Emergency Department Use in New York City

Frequent Users of Emergency Department Services

Turning to the analysis of frequent users of ED services, we examined their sociodemographic characteristics, the clinical issues that brought them to the ED, the possible implications of residential mobility, and related issues. We first looked at the large group of frequent users and then made a closer but preliminary examination of what we call super-userswho, though small in number, generate great and different demand for ED services. (Tables 3 and 4). However, as illustrated in Figure 2, those with more frequent use had a disproportionate impact on ED use overall. The small group of individuals making 5 or more 2008 ED visits represented 2.3 percent of all ED users, but accounted 11.4 percent of total ED visits.

Neighborhood Matters
Looking at all ED users, we found that frequent users with three or more ED visits in 2008 (176,000 people) accounted for 9.7 percent of all ED users and 27.9 percent of all ED visits (Tables 3 and 4). At the neighborhood level, the rate of population making 3 or more visits ranged from 0.4 percent of residents in Northeast Queens to 6.4 percent in East Harlem (Table 5). Once again, we find a common pattern of higher use among a familiar set of neighborhoods including East Harlem, Central Harlem, and clusters of central Brooklyn and Bronx neighborhoods, as displayed in Map 2 (page 13). The percentage of residents in each neighborhood who were frequent ED users (as defined by 3 or more visits) was highly correlated with overall neighborhood ED use rates (correlation coefficient 0.98), demonstrating that frequent ED users are concentrated in areas with high overall ED use rates.

Definitions
As there is no commonly accepted and uniform definition of frequent ED users, for the purposes of this analysis we categorized frequency of use in multiple ways. We classified frequent users as persons who made three or more visits in 2008. We also examined a subset of these frequent userspeople who made five or more visits in 2008. Lastly, we classified a group of persons, whom we call super-users, who made five or more visits in each of three consecutive years (2006, 2007, and 2008).

Service Use by Frequent ED Users

The majority of ED users are not frequent users. Of all people using ED services in New York City in 2008, three-quarters (74 percent) had only one visit; another 16 percent had only two visits

Figure 2. ED Visit Frequency Impact on Overall ED Use

Number of ED Visits 1 visit 2 visits 3 visits 4 visits 5 or more visits % of All ED Users 74.3 16.0 5.3 2.1 2.3 % of All ED Visits 50.4 21.7 10.7 5.8 11.4

United Hospital Fund

Age Matters
The full UHF report on which this issue brief is based, Patterns of Emergency Department Utilization in New York City, 2008, examines in considerable detail how ED utilization varies by age. We found that young children age 0-4 use a disproportionate amount of ED services, accounting for 7 percent of the population but 14 percent of all visits. (See Tables 6-8 in the full report for the data supporting this illustration.) To examine differences in use rates between children and adults, whose health needs vary, we examined sex-adjusted ED use rates per 100 population among children (younger than 18) and adults (18 and older). Children had higher adjusted rates of ED visits (46 per 100) than adults (33 per 100). Given their smaller share of the population, however, children accounted for just 29 percent of total ED visits. To more closely examine ED use by children, we distinguished those aged 0-4 from those aged 5-17. Slightly less than half of the younger group (44 percent) visited the ED at least once in 2008, the highest visit rate of any age group under study. One neighborhood, West Queens, deserves further discussion. While West Queens had below-average ED use in its over-18 population (23/100 compared to the citywide average of 33/100), its under-18 population had above-average ED use (55/100 compared to the citywide average of 46/100). In West Queens, almost one-quarter of all ED visits (23 percent) were made by children aged 0-4; this was the highest neighborhood rate of ED use for this age group. This more granular analysis illustrates how ED data can document the need for further study of a neighborhoods current pediatric ambulatory capacity. It also suggests that interventions specific to the pediatric population and their caregivers may be warranted.

Frequent ED Use and Hospitalization

Importantly, more frequent ED use is associated with more frequent hospitalizations. This is of key importance, as hospitalizations are a significant driver of health care expenditures. By combining the SPARCS inpatient and ED data, we identified 234,634 people (2.8 percent of the total population) in New York City who had at least one T&R ED visit and at least one hospitalization in 2008. Among this population, the average number of hospitalizations rose with increasing numbers of T&R ED visits: those with one ED visit in 2008 had an average of 1.53 hospitalizations that year; those with two ED visits had an average of 1.66 hospitalizations; and those with three or more ED visits had an average of 2.27 hospitalizations. Figure 3 shows that these hospitalization rates increased in

keeping with ED use for both children and adults, though the relationship was more pronounced for adults.

The Age of Frequent Users

We also noted variation in the frequent user population when broken down by age group (Table 5). Citywide, 5.5 percent of all 0-4 year olds had three or more ED visits in 2008, the highest percentage of frequent ED users among any age group. In addition, this 0-4 age group had the greatest neighborhood variation: in East Harlem, 14.0 percent of 0-4 year olds were frequent ED users, while in four other neighborhoods that percentage was 1.0 or less. In contrast, all other age groups tended to have lower percentages of frequent ED usemostly between 1 and 2 percentboth citywide and by

Frequent Emergency Department Use in New York City

neighborhood. This pattern may represent more variability of resources available to the pediatric population by neighborhood, and likely reflects a lower threshold among parents of young children to turn to the emergency department for evaluation and treatment. The data undoubtedly point to a pediatric service challenge that calls for a focused response. The rate of frequent ED use among older (65+) New Yorkers was lower than the city average, likely reflecting the fact that these data are for T&R ED visits. A previous UHF study showed that elderly people presenting at the ED are far more likely to be admitted to inpatient care than younger groups.7

stability, but it is nonetheless suggestive. Its utility is supported by the observation that the incidence of residential mobility increases dramatically with increasing numbers of ED visits. As the number of ED visits increase, the likelihood that an ED user resided in more than one neighborhood in the same year also increases. While 7 percent of all ED users with two ED visits reported living in more than one neighborhood during the year, almost onequarter (24 percent) of ED users who made five to ten visits lived in more than one neighborhood during the year. There was a nearly linear relationship between number of annual ED visits and the likelihood of at least one move between neighborhoods. A full 67 percent of 370 people with 30 or more visits in 2008 had at least one move that year. This analysis greatly understates the phenomenon of residential mobility, which can range from a single move to chronic homelessness. It will be important to examine these trends with greater precision than this crude measure affords.

Residential Mobility
One characteristic associated with frequent ED users is that they appear to have less stable housing situations. On average, 11 percent of all ED users with two or more visits (a larger group than used in the previous analyses) had at least one move between neighborhoods (Table 6). This is admittedly a crude measure of housing

7 United Hospital Fund. April 2008. Use of Hospital Emergency Departments in New York City: What Does It Tell Us About Access to Care? Hospital Watch 18(2). New York: United Hospital Fund. Available at http://www.uhfnyc.org/publications/677839 (accessed August 30, 2012).

Figure 3. Relationship Between ED Visits and Hospital Admissions

United Hospital Fund

Emergency Department Super-Users

As policymakers, planners, health care providers, and payers attempt to control health care spending, super-users of health services have recently become a hot topic, as exemplified by Atul Gawandes and Malcolm Gladwells New Yorker articles on the subject.8,9 The following analysis, though preliminary, examines more closely the ED use of this important group. we examined their demographics and payer mix. Almost half (47 percent) were non-Hispanic Blacks, 27 percent were Hispanic, 14 percent were white non-Hispanic, and 12 percent were categorized as other. As shown in Figure 4, Black non-Hispanics constituted a larger proportion of super-users than of all ED users (47 percent compared to 34 percent). Conversely, Hispanics made up a smaller proportion of super-users than of all ED users (27 percent and 37 percent, respectively). Most super-users were adults aged 40-64 (47 percent), a significantly higher proportion than found in the all ED user group (26 percent). Only a small percentage of the super-users were children aged 0-17 (11 percent) compared to 29 percent in the all ED user group. People aged 65 and older constituted a small proportion of both groups (7 percent and 8 percent, respectively). The super-users were roughly evenly split by sex (51 percent female and 49 percent male), which reflects the general population of ED users. The majority of super-users (72 percent) were categorized as safety-net patients, either covered by Medicaid or uninsured.

What Is a Super-User?
We define a super-user as someone with repeat ED use in three consecutive years. To identify such people, we examined the cohort of people with five or more visits in 2006, and tracked their ED utilization in the following two years. There were 37,460 people with five or more visits in 2006 (0.5 percent of the population, 2 percent of all ED users), who could become super-users. Of this population, only 4,147 (11 percent) became super-usersmeaning they made five or more visits in each of the subsequent two years, 2007 and 2008. This high degree of attrition in the frequent user population points to the importance of using predictive modeling or other tools to target the small but significant segment of the population. Most frequent users do not remain frequent users over time and become what we call a super-user. But the small subset that does would benefit from targeted interventions, as they continue to generate significant health care costs and suffer poor health.

Why Do Super-Users Visit the ED?

To examine this small subpopulation in greater detail, we evaluated the reasons for their visits, and found that the diagnostic reasons for the ED visit varied greatly between super-users and people who made only one ED visit (Table 7).10 Our results showed the subgroup of super-users to be a population with very different needs than

Who Are the Super-Users?

Expecting this subset of super-users to differ substantially from the rest of the frequent user population and from ED users more generally,

8 Gladwell M. 2006. Million-Dollar Murray: Why Problems Like Homelessness May Be Easier to Solve than to Manage. New Yorker, February 13, 2006.

Gawande A. 2011.The Hot Spotters: Can We Lower Medical Costs by Giving the Neediest Patients Better Care? New Yorker, January 24, 2011.
9 10

Diagnoses grouped using Clinical Classifications Software categorizations developed by the Agency for Healthcare Research and Quality (AHRQ). This system aggregates codes from the International Classification of Diseases, 9th Revision, Clinical Modification (ICD-9-CM) into clinically related groups that can be employed in many types of projects analyzing data on diagnoses and procedures. AHRQ. 2008. AHRQ Health Care Innovations Exchange: Innovations and Tools to Improve Quality and Reduce Disparities. Available at http://www.innovations.ahrq.gov/content.aspx?id=516.

Frequent Emergency Department Use in New York City

Figure 4. Characteristics of ED Super-Users (N=4,147) Compared to All ED Users (N=2,977,008)

Super-Users n Race/Ethnicity White Non-Hispanic Black Non-Hispanic Hispanic Other Gender Female Male Age 0-4 years old 5-17 years old 18-39 years old 40-64 years old 65+ years old Expected Principal Reimbursement Medicare Safety Net Other 614 2,996 537 15 72 13 7 53 40 253 192 1,471 1,947 284 6 5 35 47 7 14 15 37 26 8 2,097 2,050 51 49 55 45 597 1,965 1,103 482 14 47 27 12 16 34 37 13 % % of All ED Users (Citywide)

those with fewer visits. The significant incidence of asthma among the super-users (11 percent of visits), a disease for which timely and effective outpatient care should prevent hospital admissions, underscores the importance of improving access to adequate ambulatory care. Super-users were also affected by high rates of mental illness and substance use for which they frequently sought ED care: alcohol-related disorders, psychiatric disorders, and substancerelated disorders accounted for 21 percent of their ED visits. This stands in stark contrast to the rest of the population, who seldom used the ED to address behavioral health conditions (less

than 4 percent of visits for the same three diagnoses).

Inpatient Utilization
ED super-users also utilized significant amounts of inpatient hospital services. Sixty percent of super-users also had at least one hospital admission in each year from 2006 to 2008. The majority of super-users had between one and six hospital admissions in a given year (Figure 5). However, a small subset (from 348 to 370 ED super-users in each year) had 10 or more hospital admissions in a single year. The maximum number of hospital admissions in a

United Hospital Fund

year among ED super-users ranged from 67 to 91 (Table 8). For a small subset of ED superusers, the amount of time spent in the hospital in a given year may have been greater than the amount of time spent in the community. It is also striking that roughly 40 percent of super-users were not hospitalized in a given year, even though they made at least five ED visits. This pattern suggests that these individuals were not experiencing acute illnesses comparable to the hospitalized super-users. It therefore is likely that efforts to reduce ED utilization among super-users should be differently tailored and targeted.

Which Hospitals Treat Super-Users?

Super-users were not evenly distributed among New York Citys hospitals. Half of the top ten hospitals serving super-users were Health and Hospitals Corporation facilities (Table 9). These hospitals are mainly located in hot spot neighborhoods. EMS providers may also direct super-user patients disproportionately to safetynet hospitals for various reasons, including payment, ability to care for this specific population, or patient preference. This analysis of frequent users and super-users of ED services offers some important lessons.

Figure 5. Annual Hospitalizations of ED Super-Users

Frequent Emergency Department Use in New York City

Discussion
First, what is often perceived as a single problemmisuse of EDs for conditions preventable by primary careis not always a single problem, but in fact comprises several different patterns of ED utilization. Second, the fact that some small groups of patients have a disproportionately large effect on ED utilization suggests the usefulness of interventions tightly targeted to meet special needs and circumstances. Clearly, this is not a one size fits all opportunity for reform of the delivery system. As is typical of how health care services are used in New York City, we found significant variation by neighborhood. The maps showing poor system performance in terms of ED use in more vulnerable neighborhoods such as the South Bronx, Harlem, and Central Brooklyn came as no surprise. The complex interplay of health status, socioeconomic circumstances, health care resources, care-seeking behaviors, and other factors drive these distinct neighborhood patterns. This type of small area analysis is an important component of the planning process to develop and target new resources and to put in place the mechanisms and messaging critical to promoting their use. The analysis of ED use underscores the need for system reform. But it is important to distinguish between two types of use and to consider two different change strategies. The overuse of EDs is common across the city, even though it is more intense in some neighborhoods. Without setting a standard how much truly-non-emergent use is acceptable?it is fair to say that some of the care provided in EDs to people who come once or twice a year (90 percent of all ED users) could be provided at lower costs and yield improved outcomes in primary care settings. Therefore, the current movement to create patient-centered medical homes is especially promising. The greater availability of primary carethe number of providers and sites, and the hours they are open for businesscan make a significant difference in the care-seeking choices of adults and parents of children. The potential to redirect the flow of traffic to EDs, much of it after-hours and on weekends, however, will be realized only to the extent that people in need have meaningful access to a primary care team, or at least round-the-clock communication with it. To overcome the perception that the ED is the easier place to get a full range of services will require new primary care services that are well structured and well sited, as well as effective supporting mechanisms, such as a 24-hour call-in service, that enable people to change long-held attitudes and behaviors. It will also likely require health system payment reform that incentivizes and adequately compensates primary care physicians to provide needed care and to coordinate effectively with other sites and providers. The brief examination of frequent users, and especially super-users, sheds important light on a very different problem and the need to tailor a very different response. A small number of patients (10 percent of all ED users who account for 27 percent of visits) drive disproportionate costs and experience poor health outcomes. Here we find a striking interplay of multiple, complex physical and behavioral health problems with troubling socioeconomic circumstances especially residential instability and likely homelessnessgenerating intense use of ED services as well as inpatient care. A patientcentered medical home strategy is necessarybut not, by itself, sufficient to meet the challenge of these patients. Fortunately, the

10

United Hospital Fund

federal impetus behind the Health Home model offers a promising, though challenging, opportunity to make a real difference. The recognition of the complex care needs and fragile social circumstances of these especially highneed patients has stimulated fresh thinking about aggressive outreach, intense coordination of services by integrated care teams, and the need for nonmedical resources such as supportive housing, all of which could likely help curb the cost of health care. As noted, the implementation of Health Homes remains a daunting challenge. In addition to requiring health care providers to organize services differently, the model calls for other significant changes. The adoption of robust

health information technology, such as electronic medical records, should enable care managers to monitor service use, including pharmacy and primary careservices critical to making and sustaining real improvement in patient care. At the same time, health care providers will need to develop new and effective approaches to engaging these super-users in helping to manage their care. Without such a change, a likely outcome will be the continued provision of costly rescue care services. Lastly, the new model will function best in the context of population health management in which providers share the risk and rewards of caring for these especially high-need patients. Well-aligned financing structures can build and sustain the new model of care that is so sorely needed.

Frequent Emergency Department Use in New York City

11

Map 1. Percent of Population with 1 ED Visit, by Neighborhood, 2008

Legend
<19.8% 19.8%-24.2% >24.2%

12

United Hospital Fund

Map 2. Percent of Population with 3+ ED Visits, by Neighborhood, 2008

Legend <1.9% 1.9%-2.4% >2.4%

Frequent Emergency Department Use in New York City

13

Table 1. Percent of Population With at Least One Visit, Compared to NYC Average

All NYC residents

22% 19% 27% 33% 27% 36% 39% 38% 14% 19% 29% 32% 20% 13% 23% 20% 11% 14% 34% 25% 40% 41% 12% 8% 16% 13% 9% 15% 20% 17% 21% 12% 9% 16% 15% 21% 28% 19% 24% 25% 22% 14% 15%

0.2

0.1 3.1%

0.1

0.2

B R O N X

Kingsbridge and Riverdale Northeast Bronx Fordham and Bronx Park Southeast Bronx Central Bronx Highbridge and Morrisania Hunts Point and Mott Haven Greenpoint Northwest Brooklyn Central Brooklyn East New York and New Lots Sunset Park Borough Park Flatbush Canarsie and Flatlands Southwest Brooklyn Southern Brooklyn Bushwick and Williamsburg Inwood and Washington Heights Central Harlem East Harlem Upper West Side Upper East Side Chelsea and Clinton Gramercy Park and Murray Hill Greenwich Village and SoHo Lower East Side Lower Manhattan Northwest Queens West Queens North Queens Northeast Queens West Central Queens Central Queens Southwest Queens Jamaica Southeast Queens Rockaways Port Richmond Stapleton and St George Mid Island The South Shore

5.2% 11.3% 5.1% 14.8% 17.4% 16.3% 7.8% 3.1% 7.7% 10.4% 1.2% 8.8% 1.5% 1.9% 10.4% 7.3% 12.8% 3.6% 18.4%

B R O O K L Y N

M A N H A T T A N

9.2% 13.7% 5.4% 8.6% 13.0% 6.6% 1.2% 4.8% 1.0% 9.5% 12.4% 5.2% 6.3% 0.9% 6.0% 2.5% 2.6% 3.0% 0.0% 8.0% 6.4%

19.6%

Q U E E N S

S I

14

United Hospital Fund

Table 2. ED Visit Rate per 100 Population Compared to NYC Average*

All NYC residents

B R O N X

Kingsbridge and Riverdale Northeast Bronx Fordham and Bronx Park Southeast Bronx Central Bronx Highbridge and Morrisania Hunts Point and Mott Haven Greenpoint Northwest Brooklyn Central Brooklyn East New York and New Lots Sunset Park Borough Park Flatbush Canarsie and Flatlands Southwest Brooklyn Southern Brooklyn Bushwick and Williamsburg Inwood and Washington Heights Central Harlem East Harlem Upper West Side Upper East Side Chelsea and Clinton* Gramercy Park and Murray Hill Greenwich Village and SoHo Lower East Side Lower Manhattan Northwest Queens West Queens North Queens Northeast Queens West Central Queens Central Queens Southwest Queens Jamaica Southeast Queens Rockaways Port Richmond Stapleton and St George Mid Island The South Shore

36 33 49 60 49 65 70 68 20 30 52 51 32 20 40 33 17 23 57 46 77 83 23 13 30 21 13 26 35 26 29 18 13 22 23 29 39 28 48 34 32 19 21

50 2.5

50

100

12.9 24.5 12.6 29.2 33.7 32.1 15.6 5.8 16.2 15.1 3.9 16.1 4.2 3.4 18.6 12.6 21.1 9.7 41.2 47.3 13.4 23.2 6.3 14.7 23.3 9.9 1.0 9.6 7.3 17.8 22.9 14.1 12.5 7.1 2.9 8.0 12.0 1.7 3.9 17.3 14.9

B R O O K L Y N

M A N H A T T A N

Q U E E N S

S I

*ED rates were age- and sex-adjusted.

Frequent Emergency Department Use in New York City

15

Table 3. ED Users by Number of Visits by Neighborhood

% of Users with 1 Visit
NYC residents

2 Visits 16.0% 14.9% 17.3% 18.3% 17.3% 18.4% 18.4% 18.6% 14.0% 14.8% 17.1% 16.6% 15.4% 14.0% 15.6% 14.4% 12.8% 14.2% 17.3% 16.5% 18.7% 18.9% 14.2% 11.4% 11 4% 13.0% 11.6% 10.3% 15.7% 13.7% 14.7% 15.1% 13.5% 11.1% 13.2% 14.6% 14.6% 15.6% 14.3% 16.2% 17.0% 16.7% 13.8% 14.0% 12.1%

3 Visits 5.3% 4.8% 5.7% 6.8% 5.8% 6.6% 6.6% 6.8% 4.3% 4.5% 5.8% 5.8% 5.0% 3.9% 4.6% 4.2% 3.7% 4.3% 6.3% 5.4% 7.3% 7.6% 4.7% 2.9% 2 9% 4.2% 3.5% 2.7% 5.3% 3.8% 4.5% 4.7% 3.8% 2.5% 3.5% 4.1% 4.3% 5.0% 3.9% 5.5% 5.8% 5.6% 3.7% 3.4% 3.2%

4 Visits 2.1% 1.8% 2.5% 2.7% 2.4% 2.9% 2.9% 2.9% 1.8% 2.0% 2.5% 2.3% 1.9% 1.5% 1.8% 1.4% 1.3% 1.6% 2.7% 2.1% 3.2% 3.5% 1.9% 1.0% 1 0% 1.8% 1.4% 1.0% 2.2% 1.5% 1.7% 1.8% 1.3% 1.0% 1.3% 1.4% 1.6% 2.0% 1.4% 2.1% 2.5% 2.2% 1.4% 1.3% 0.7%

5 + Visits 2.3% 1.8% 2.3% 3.1% 2.4% 3.2% 3.2% 3.3% 1.8% 2.4% 2.8% 2.3% 2.1% 1.5% 1.8% 1.5% 1.4% 1.8% 3.2% 2.1% 4.2% 4.3% 2.7% 1.2% 1 2% 2.7% 2.4% 1.6% 2.7% 2.9% 1.6% 1.6% 1.3% 0.5% 1.3% 1.5% 1.5% 1.9% 1.4% 2.3% 2.8% 2.7% 1.3% 1.1% 1.0%

74.3% 76.7% 72.1% 69.1% 72.2% 68.8% 68.9% 68.5% 78.1% 76.3% 71.8% 72.9% 75.6% 79.1% 76.1% 78.5% 80.8% 78.1% 70.6% 73.9% 66.6% 65.7% 76.5% 83.5% 83 5% 78.3% 81.1% 84.4% 74.1% 78.1% 77.4% 76.7% 80.2% 84.9% 80.7% 78.4% 77.9% 75.6% 79.1% 74.0% 71.9% 72.8% 79.8% 80.1% 83.0%

B R O N X

Kingsbridge and Riverdale Northeast Bronx Fordham and Bronx Park Southeast Bronx Central Bronx Highbridge and Morrisania Hunts Point and Mott Haven Greenpoint Northwest Brooklyn Central Brooklyn East New York and New Lots Sunset Park Borough Park Flatbush Canarsie and Flatlands Southwest Brooklyn Southern Brooklyn Bushwick and Williamsburg Inwood and Washington Heights Central Harlem East Harlem Upper West Side Upper East Side Chelsea and Clinton Gramercy Park and Murray Hill Greenwich Village and SoHo Lower East Side Lower Manhattan Northwest Queens West Queens North Queens Northeast Queens West Central Queens Central Queens Southwest Queens Jamaica Southeast Queens Rockaways Port Richmond Stapleton and St George Mid Island The South Shore Neighborhood 999

B R O O K L Y N
M A N H A T T A N

Q U E E N S

S I

Note: Neighborhood 999 pools the small subset of records of SPARCS records with a New York City county code but an incomplete or missing 5-digit ZIP code.

16

United Hospital Fund

Table 4. Share of ED Visits by Frequency

% of ED Visits Accounted for by Person with
NYC residents

1 Visit 50.4% 54.1% 47.9% 43.6% 48.0% 43.0% 43.2% 42.7% 56.3% 52.1% 46.8% 48.8% 52.3% 58.1% 53.7% 57.5% 60.8% 56.4% 44.9% 50.6% 39.5% 37.8% 52.1% 64.9% 64 9% 52.6% 57.3% 64.0% 48.8% 52.4% 56.0% 55.3% 60.4% 69.6% 61.3% 57.8% 56.9% 53.1% 58.5% 50.0% 47.0% 48.1% 59.9% 60.6% 65.3%

2 Visits 21.7% 21.0% 23.1% 23.1% 23.0% 23.0% 23.1% 23.2% 20.0% 20.2% 22.3% 22.3% 21.2% 20.6% 22.0% 21.3% 19.1% 20.6% 22.0% 22.6% 22.2% 21.8% 19.2% 17.7% 17 7% 17.4% 16.3% 15.5% 20.7% 18.2% 21.1% 21.6% 20.4% 18.2% 20.0% 21.6% 21.3% 21.7% 21.4% 22.1% 22.4% 22.1% 20.8% 21.3% 19.1%

3 Visits 10.7% 10.1% 11.4% 12.8% 11.5% 12.3% 12.3% 12.6% 9.2% 9.4% 11.3% 11.7% 10.4% 8.6% 9.8% 9.3% 8.4% 9.3% 12.0% 11.1% 12.9% 13.2% 9.7% 6.7% 6 7% 8.6% 7.3% 6.1% 10.4% 7.7% 9.9% 10.3% 8.5% 6.1% 8.1% 9.0% 9.5% 10.5% 8.6% 11.1% 11.5% 11.0% 8.4% 7.8% 7.6%

4 Visits 5.8% 5.1% 6.7% 6.9% 6.4% 7.3% 7.3% 7.2% 5.3% 5.5% 6.5% 6.1% 5.3% 4.3% 5.2% 4.0% 4.0% 4.5% 6.8% 5.7% 7.6% 8.0% 5.2% 3.0% 3 0% 4.9% 4.0% 3.0% 5.7% 4.0% 4.9% 5.2% 4.0% 3.2% 3.9% 4.2% 4.6% 5.6% 4.0% 5.7% 6.6% 5.9% 4.1% 3.9% 2.4%

5+ Visits 11.4% 9.6% 10.9% 13.5% 11.1% 14.4% 14.1% 14.2% 9.2% 12.9% 13.1% 11.0% 10.7% 8.3% 9.3% 7.9% 7.8% 9.2% 14.4% 9.9% 17.9% 19.3% 13.9% 7.6% 7 6% 16.5% 15.0% 11.4% 14.4% 17.7% 8.2% 7.6% 6.7% 2.9% 6.7% 7.4% 7.7% 9.1% 7.5% 11.1% 12.4% 12.9% 6.8% 6.4% 5.7%

B R O N X

Kingsbridge and Riverdale Northeast Bronx Fordham and Bronx Park Southeast Bronx Central Bronx Highbridge and Morrisania Hunts Point and Mott Haven Greenpoint Northwest Brooklyn Central Brooklyn East New York and New Lots Sunset Park Borough Park Flatbush Canarsie and Flatlands Southwest Brooklyn Southern Brooklyn Bushwick and Williamsburg Inwood and Washington Heights Central Harlem East Harlem Upper West Side Upper East Side Chelsea and Clinton Gramercy Park and Murray Hill Greenwich Village and SoHo Lower East Side Lower Manhattan Northwest Queens West Queens North Queens Northeast Queens West Central Queens Central Queens Southwest Queens Jamaica Southeast Queens Rockaways Port Richmond Stapleton and St George Mid Island The South Shore Neighborhood 999

B R O O K L Y N
M A N H A T T A N

Q U E E N S

S I

Note: Neighborhood 999 pools the small subset of records of SPARCS records with a New York City county code but an incomplete or missing 5-digit ZIP code.

Frequent Emergency Department Use in New York City

17

Table 5. Population with 3 or More ED Visits by Age

Age NYC residents 0-4 5.5% 4.3% 6.8% 9.6% 6.8% 10.1% 10.9% 10.4% 1.8% 3.5% 5.8% 6.3% 4.9% 1.8% 4.1% 2.8% 1.4% 2.4% 8.6% 6.8% 13.0% 14.0% 2.4% 0.5% 0 5% 3.4% 1.5% 0.5% 4.1% 2.4% 4.0% 9.6% 2.4% 0.8% 3.5% 2.8% 4.7% 7.4% 2.6% 4.5% 6.5% 5.2% 1.7% 1.0% 5-17 1.5% 1.2% 2.1% 2.7% 1.7% 2.6% 2.6% 2.3% 0.6% 1.2% 1.8% 1.6% 1.0% 0.5% 1.1% 0.6% 0.4% 0.7% 2.4% 2.0% 5.0% 5.1% 1.2% 0.4% 0 4% 1.1% 0.7% 0.1% 1.5% 1.2% 1.2% 2.0% 0.7% 0.3% 0.8% 0.8% 1.0% 1.6% 0.7% 1.2% 1.9% 1.7% 0.5% 0.6% 18-39 2.5% 1.9% 4.1% 4.6% 3.7% 5.5% 5.7% 6.0% 1.2% 1.6% 4.3% 4.7% 2.2% 1.2% 2.5% 2.2% 1.0% 1.6% 5.0% 2.3% 5.8% 6.5% 1.1% 0.4% 0 4% 1.2% 0.8% 0.4% 1.5% 1.5% 1.4% 1.3% 0.9% 0.6% 1.3% 1.5% 1.9% 3.2% 2.0% 3.5% 3.5% 2.8% 1.3% 1.4% 40-64 1.7% 1.3% 2.2% 3.7% 2.4% 4.0% 4.6% 4.7% 1.1% 1.6% 3.1% 2.8% 1.4% 0.7% 1.6% 1.1% 0.6% 0.9% 3.9% 1.9% 6.0% 6.5% 1.0% 0.4% 0 4% 1.6% 1.2% 0.6% 1.4% 2.1% 1.1% 0.8% 0.5% 0.3% 0.6% 0.7% 1.1% 1.8% 1.0% 2.2% 2.2% 2.0% 0.7% 0.7% 65+ 1.0% 0.9% 1.1% 1.9% 1.2% 2.5% 2.9% 3.2% 1.0% 1.2% 1.4% 1.5% 1.0% 0.6% 1.2% 0.8% 0.5% 0.6% 2.0% 1.6% 2.9% 3.0% 1.1% 0.6% 0 6% 1.3% 0.8% 0.6% 0.8% 1.1% 0.6% 0.6% 0.5% 0.3% 0.5% 0.7% 0.8% 1.0% 0.6% 1.1% 1.0% 1.0% 0.7% 0.7%

All Ages 2.1% 1.6% 2.8% 4.2% 2.8% 4.6% 4.9% 4.9% 1.1% 1.7% 3.3% 3.4% 1.9% 0.9% 1.9% 1.4% 0.7% 1.1% 4.2% 2.4% 5.9% 6.4% 1.2% 0.4% 0 4% 1.4% 0.9% 0.5% 1.5% 1.7% 1.3% 1.7% 0.8% 0.4% 1.0% 1.1% 1.5% 2.4% 1.3% 2.4% 2.7% 2.3% 0.9% 0.9%

Total 176,329 1,355 5,360 10,797 8,408 9,866 10,176 6,696 1,482 3,748 10,212 6,006 2,375 3,094 5,979 2,788 1,509 3,363 8,460 6,283 8,397 6,796 2,840 992 2,002 1,294 430 3,332 620 2,961 8,660 2,126 331 2,376 1,015 4,257 7,032 2,517 2,630 2,026 2,997 794 1,718

B R O N X

Kingsbridge and Riverdale Northeast Bronx Fordham and Bronx Park Southeast Bronx Central Bronx Highbridge and Morrisania Hunts Point and Mott Haven Greenpoint Northwest Brooklyn Central Brooklyn East New York and New Lots Sunset Park Borough Park Flatbush Canarsie and Flatlands Southwest Brooklyn Southern Brooklyn Bushwick and Williamsburg Inwood and Washington Heights Central Harlem East Harlem Upper West Side Upper East Side Chelsea and Clinton Gramercy Park and Murray Hill Greenwich Village and SoHo Lower East Side Lower Manhattan Northwest Queens West Queens North Queens Northeast Queens West Central Queens Central Queens Southwest Queens Jamaica Southeast Queens Rockaways Port Richmond Stapleton and St George Mid Island The South Shore

B R O O K L Y N
M A N H A T T A N

Q U E E N S

S I

18

United Hospital Fund

Table 6. ED Use and Residential Mobility Between Neighborhoods by Users with 2+ visits
# of Visits 2 3 4 5-10 11-29 30+ Total 2+ Total 3+ ED Users 289,459 95,241 38,747 38,387 3,584 370 465,788 176,329 # of "Movers" 20,357 11,377 6,238 9,063 1,642 247 48,924 28,567 % of "Movers" 7% 12% 16% 24% 46% 67% 11% 16%

Frequent Emergency Department Use in New York City

19

Table 7. Leading Diagnoses for One-Time ED Users and Super-Users

1 ED Visit # Symptoms; signs; and ill-defined conditions Respiratory infections Superficial injury; contusion Open wounds Sprains and strains Other injuries/external causes Ear conditions Diseases of the heart Diseases of the urinary system Pregnancy-related visits Spondylosis; intervertebral disc disorders; other back problems Asthma Psychiatric disorders Alcohol-related disorders Substance-related disorders 123,018 100,247 76,982 75,721 61,074 56,190 49,292 44,241 42,177 40,295 39,684 30,316 28,849 21,362 Super-Users # % 3,159 2,085 890 710 552 910 1,919 1,158 1,039 1,879 5,299 3,126 6,176 764 6.4 4.2 1.8 <1.0 1.4 1.1 1.8 3.9 2.3 2.1 3.8 10.8 6.3 12.5 2.0

% 9.2 7.5 5.7 5.6 4.6 4.2 3.7 3.3 3.1 3.0 3.0 2.3 2.0 1.6 <1.0

20

United Hospital Fund

Table 8. Hospitalizations of Super-Users

# Super-Users Hospitalized Number of Hospitalizations 0 1 2 3 4 5 6 7 8 9 10-14 15+ Maximum # of hospitalizations TOTAL 2006 # 1,658 729 418 285 206 147 130 88 69 47 196 174 71 2,489 % 40% 17% 10% 7% 5% 4% 3% 2% 2% 1% 5% 4% 2007 # 1,676 713 439 272 179 162 125 82 93 58 179 169 67 2,471 % 40% 17% 11% 7% 4% 4% 3% 2% 2% 1% 4% 4% 2008 # 1,705 711 409 267 223 151 111 83 82 54 179 172 91 2,442 % 41% 17% 10% 6% 5% 4% 3% 2% 2% 1% 4% 4%

Frequent Emergency Department Use in New York City

21

Table 9. Hospitals Serving People with 5+ ED Visits, 2006-2008

Hospital Name Lincoln Medical and Mental Health Ctr (HHC) St. Barnabas Hospital Harlem Hospital (HHC) Woodhull (HHC) Montefiore Medical Center Kings County Hospital (HHC) Beth Israel Mount Sinai Medical Center St. Luke's Roosevelt / St. Luke's Bellevue (HHC) CMC Mary Immaculate North General Bronx Lebanon Concourse Division Brookdale Hospital Jacobi Medical Center (HHC) Brooklyn Hospital @ Downtown Campus St. Luke's Roosevelt / Roosevelt Jamaica Hospital Medical St. Vincent's Long Island College Hospital St. Vincent's Richmond NewYork Presbyterian NewYork-Presbyterian / Columbia IMC St. John's Episcopal Elmhurst (HHC) Metropolitan (HHC) Montefiore Medical Center / Einstein Queens Hospital Center (HHC) SIU-North The New York Methodist North Central Bronx (HHC) Lutheran Maimonides Our Lady of Mercy Medical Center Wyckoff Heights Hospital NYU Downtown Coney Island Hospital (HHC) New York Hospital Medical Center NewYork-Presbyterian / Weill Cornell Other # 2,689 2,235 2,059 1,807 1,768 1,758 1,657 1,602 1,598 1,591 1,521 1,463 1,440 1,375 1,187 1,172 1,142 1,070 1,040 1,005 985 972 944 937 888 828 779 717 713 686 683 683 640 620 614 604 521 518 5,575 % 5.4 4.5 4.1 3.6 3.5 3.5 3.3 3.2 3.2 3.2 3.0 2.9 2.9 2.7 2.4 2.3 2.3 2.1 2.1 2.0 2.0 1.9 1.9 1.9 1.8 1.7 1.6 1.4 1.4 1.4 1.4 1.4 1.3 1.2 1.2 1.2 1.0 1.0 11.1

22

United Hospital Fund

Shaping New Yorks Health Care: Information, Philanthropy, Policy.

1411 Broadway 12th Floor New York, NY 10018 (212) 494-0700 http://www.uhfnyc.org ISBN 1-933881-27-5