Emergency care is a critical, but understudied, part of the continuum of services offered to Veterans by the VA. While the VA is committed to providing timely and high-quality emergency care, surprisingly little is known about acute care use by Veterans or about the quality of care provided. We used the emergency care sensitive condition (ECSC), a newly defined concept, as a novel framework to identify and examine variation in VA emergency care use.
The study objectives were to: 1) refine a recently defined list of ECSCs and identify the ECSCs of most import to Veterans; 2) create a VA Emergency Department (ED) visit-level database that can be used as part of a future IIR study of Veteran utilization of emergency care across VHA and non-VHA settings; and 3) calculate the prevalence and determine variation, if any, of ECSCs across all VHA EDs.
We convened a multidisciplinary expert panel of VA and non-VA physicians (n=8) to develop a list of ECSCs, building upon work to date. We used modified Delphi methods to systematically identify the conditions. For each condition group, panelists rated the subsequent impact of timely, emergency care on each condition's mortality and morbidity (scale 1-9; no impact to strong impact) and the condition's relevance to the average Veteran seeking emergent care in the VA (scale 1-9; no relevance to strong relevance). The panel members met via teleconference, reviewed the ratings, and voted again by using an iterative process of discussion over two days. Panelists suggested additional candidate conditions groups (n=5), which were rated on the second day. For the mortality and morbidity rating questions, a mean rating score of 7 or higher indicated the condition was considered an ECSC. A mean rating score of 4 or higher indicated the condition was considered of importance to the VA.
Using VA data and working within the VINCI environment, we constructed the Acute Care and Emergencies (ACE) database that includes Veterans who received VA care (including outside care paid by the VA) between FYs 2010-14. We identified Veterans who had ED visits using clinic stop codes and developed algorithms to categorize visits as either an ED visit resulting in discharge (treat-and-release), ED visit resulting in hospital admission, or ED visit resulting in death. The database also includes clinical and demographic characteristics, such as patients' diagnoses, age, race, and service-connected disability level. We calculated the prevalence of unique ED patients, ED visits, types of visits, and ECSC-related hospitalizations overall, by fiscal year, and by VA ED facility.
Among 71 candidate ECSCs, the panel rated 41 conditions as ECSCs for both mortality and morbidity (i.e., sepsis, myocardial infarction, chronic obstructive pulmonary disease), rated 10 conditions as ECSCs for morbidity only (i.e., femur fracture, volume depletion, other cardiac arrhythmia), and rated 45 as relevant to the Veteran population (i.e., diabetes mellitus - acute, alcohol withdrawal).
Of the 7,823,908 VA users identified, 2,517,472 Veterans (32.2%) had at least one ED visit at a VA facility between FYs 2010-14. In addition, 608,221 Veterans received emergency care services outside the VA during the study period, increasing the total number of Veterans with an ED visit to 2,780,918 (35.5%). Of the 9,695,764 VA ED visits, we found that 79.0% were treat-and-release visits, 21.0% resulted in hospital admission with 24 hours, and very few visits resulted in death (< 0.03%). Of the 1,695,316 non-mental health hospitalizations originating from the VA EDs, we identified 40.6% of admissions as having an ECSC as the principal admitting diagnosis. Across the 119 VA facilities with EDs, the proportion of ED visits that were ECSC hospitalizations ranged from 25.2% to 46.0%. The most prevalent ECSC-related hospitalizations included heart failure (5.6%), COPD (4.8%), and pneumonia (4.5%).
Emergency care access is particularly problematic for Veterans, in part because VA EDs are far and few between, and Veterans are often uncertain where to go when confronted with an emergency. This is particularly true for Veterans with special access issues, like those living in rural areas, those lacking housing, and women. The results from this pilot will allow us to examine utilization of emergency care within the VA and future work will expand the ACE database to include non-VA ED use. Ultimately, our results are highly actionable to our operational partners and can be directly used to improve the organization and delivery of emergency care within the VA.
- Vashi A, Carr B, Hsia R, Urech TH, Greene L, Kessler C, Asch SM. An Explicit Set of Emergency Care Sensitive Conditions. Presented at: American College of Emergency Physicians Annual Assembly; 2016 Oct 17; Las Vegas, NV.