Posters at AAO 2021 Analyze ED Utilization for Nonemergency Ophthalmic Conditions

Emergency department (ED) utilization for nonemergent ophthalmic conditions is on the rise in the United States, but a review of presentation types in the ED revealed significant variation based on patient demographics. The research was presented in 2 posters at the American Academy of Ophthalmology 2021 meeting.

Although the Affordable Care Act (ACA) expanded health insurance coverage for Americans with the goal of increasing health care access, eye-related ED visits for non-emergent conditions continues to increase.¹

While ophthalmic care is routinely provided in the outpatient setting, lack of insurance and low socioeconomic status have been barriers to accessing outpatient care, researchers from Yale School of Medicine explained in their poster.

“Vulnerable uninsured patients are reliant on the ED for access to ophthalmic care for non-emergency eye conditions, which can often be managed in the outpatient setting,” they wrote. “These non-emergent eye-related visits pose a significant burden on the US EDs.”

They used the Nationwide Emergency Department Sample and categorized patients as pre-ACA if their care was delivered between 2010-2013 and post-ACA if between 2014-2017.

From 2010 to 2017 there were more than 16 million eye-related ED visits in the United States with 8.1 million occurring before the ACA was mandated and 8.7 million after. Slightly more than half (53.4%) of patients presenting to the ED were male and the median age was 30 years.

In the pre-ACA period, 32.8% of patients presenting to the ED had private insurance, which dipped to 30.4% in the post-ACA period. In the post-ACA period, 36.0% of patients in the ED had Medicaid, up from 29.4% in the pre-ACA period.

In both periods, patients in the lowest income quartile had the most ED visits (32.4% pre-ACA vs 34.3% post-ACA). As income quartile increased, ED visits decreased and patients in the highest income quartile accounted for only 17.7% of ED visits pre-ACA and 16.9% of ED visits post-ACA.

The researchers found teaching hospitals carry the burden of providing eye care in the ED to vulnerable populations. Before the ACA, teaching hospitals provided 46.1% of care, which increased to 58.4% after the ACA.

They also found that less than half of conditions presenting in the ED were considered non-emergent. Stratified by median annual household income, they determined about half of ED visits for households in the highest income quartile were considered emergent. In comparison, closer to 40% of ED visits for households in the lowest income quartile were considered emergent.

“After the ACA was mandated, there was initially a slight decrease in ED utilization in 2014, followed by a significant increase in eye-related ED visits,” the authors concluded. They added, “Additional measures beyond expanding insurance coverage may be necessary to provide high quality, efficient, and equitable health care to all Americans.”

In the second poster, the researchers characterized national ophthalmic ED encounters and demographics of patients using the National Hospital Ambulatory Medical Care Survey, 2010-2018.²

“A wide variety of eye conditions, both traumatic and non-traumatic, may present in the ED,” explained Suzie Kim, BS, a third-year medical student at the Cleveland Clinic Lerner College of Medicine, Case Western Reserve University, during her presentation of the poster. “In order to provide appropriate care, it is imperative for EDs to be adequately prepared and equipped to address these problems.”

There were 23.1 million weighted ED visits for ophthalmic complaints. The average age was 32.3 years and 48.1% of patients presenting to the ED were female. The most common reason to visit the ED was for conjunctiva (40.1%) and 68.4% of visits were considered non-trauma (95% CI, 66.4-70.4).

There were significant differences in patient demographics in terms of sex and age, Kim explained. Visits for sclera/cornea/ciliary body complaints were commonly male (58.7%; P = .022), while visits for visual disturbances were commonly female (57.8%; P = .012). Kim noted that this is not surprising considering females have a higher incidence of autoimmune disorders, which often have ocular presentations. In addition, visits for visual disturbances were common among patients over the age of 45 years (55.0%; P < .001).

Private insurance was the most common primary payer for most ophthalmic ED visits; however, Medicaid or CHIP was more common for conjunctiva visits (41.4%; 95% CI, 37.9-45.0; P < .001). For all other categories, the average frequency of Medicaid/CHIP as the primary payer was only 27.3%.

Kim noted that assessing the present needs may help inform valuable resources for EDs in the future and offer insight into targeting disparities in care.

“In conclusion, our study showed there were significant variations in the types of ophthalmic visits in the ED based on patient characteristics, such as age, sex, and primary payer,” she said.

References

1. Mir TA, Mehta S, Qiang K, Adelman RA Del Priore LV, Chow J. The impact of the Affordable Care Act on eye-related emergency department utilization in the United States. Presented at: AAO 2021; New Orleans, Louisiana; November 12-15, 2021. Poster PO252.

2. Kim S, Wang P, Carvalho Soares Valentim C, Muste JC, Singh RP. Characterization of ophthalmic visits to emergency departments from a national registry system. Presented at: AAO 2021; New Orleans, Louisiana; November 12-15, 2021. Poster PO251.