Study Outlines Disparities in ED Use for Patients With Diabetes

Despite health reforms implemented throughout the past decade in the United States, findings of a serial cross-sectional study revealed disparities in diabetes-related emergency department (ED) visits not resulting in hospitalization between 2008 and 2017.

Results were published in JAMA Network Open and found differences in ED use rates based on race and ethnicity, rural or urban location, and insurance status both within and across states, and nationally. Based on the findings, authors called for more geographic and demographic-specific analyses to better understand sources of inequity and for policy action to address barriers to health care access and underlying social determinants of health (SDOH).

On an annual basis, diabetes costs the United States approximately $237 billion in direct costs, representing about $1 in every $4 spent on health care. As Black and Hispanic patients account for a disproportionate share of diabetes cases, greater costs have been observed in racial and ethnic minority groups. Diabetes-related morbidity and mortality is also greater in rural regions.

“From 1990 to 2018, the number of US patients with diagnosed diabetes more than quadrupled, from 6.5 million to 26.8 million,” authors wrote, noting events such as the Great Recession, the passage of the Affordable Care Act (ACA), and rural hospital closures all likely impacted incidence and management of the disease during the period studied.

“Because ED use is recognized as a proxy for lack of access to care, quantifying trends in diabetes-related ED use provides an assessment of the fragmented US health care system’s ability to address the increased prevalence of diabetes,” they added.

To better elucidate ED use among those with diabetes, researchers assessed all-payer data from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) and from State Emergency Department Databases (SEDD). SEDD data included information from Arizona, Florida, Iowa, Kentucky, Maryland, Nebraska, New Jersey, New York, North Carolina, Utah, and Vermont.

Females accounted for the majority of all-cause diabetes ED visits throughout the study window (56.8%) and mean patient age at the time of visit was 58.4 years. A total of 32,433,015 all-cause diabetes visits were assessed.

Between 2008 and 2017, all-cause diabetes ED visits per 10,000 adults increased 55.6% from 257.6 to 400.8, respectively. “The rate of diabetes-specific ED visits per 10,000 adults increased from 17.2 in 2008 to 25.9 in 2016 and 2017, representing a 50.6% increase, with the greatest increase in rates occurring between 2014 and 2016,” researchers wrote.

Additional analyses revealed:

• All-cause diabetes ED visits increased more for urban (58.3%; 95% CI, 52.5%-64.1%) and uninsured subgroups (75.3% [95% CI, 59.8%-90.8%]) than for their counterparts
• Diabetes-specific ED visits (weighted number of 1,911,795) nationally increased slightly among all subgroups
• State-specific ED use rates show wide state-to-state variations in ED use by race and ethnicity, rural or urban location, and insurance
• On average across states, diabetes-specific ED use among Black patients was approximately 3 times (rate ratio [RR], 3.09; 95% CI, 2.91-3.30) greater than among non-Hispanic White patients, and among Hispanic patients, it was 29% greater (RR, 1.29; 95% CI, 1.19-1.40) than among non-Hispanic White patients
• Mean rate of ED use among rural patients was 34% greater (RR, 1.34; 95% CI, 1.26-1.44) than among urban patients
• Mean rates of ED use among patients with Medicaid (RR, 6.65; 95% CI, 6.49-6.82) and Medicare (RR, 4.37; 95% CI, 4.23-4.51) were greater than among privately insured adults

State by state analyses showed:

• Except for Kentucky (rate in 2017, 37.7 [95% CI, 37.0-38.4]), White adults in each state in our sample across all years had lower rates of diabetes-specific ED visits compared with the national average for all races and ethnicities (rate in 2016, 25.9 [95% CI, 25.1-26.8])
• A low rate of ED use among Black adults was seen in Maryland (rate in 2008, 30.5 [95% CI, 29.5-31.6]; rate in 2017, 52.9 [95% CI, 51.6-54.1])
• The highest rate of ED use among Black adults was in Iowa (rate in 2011, 69.2 [95% CI, 60.7-77.7]; rate in 2017, 111.5 [95% CI, 102.9-120.1])

Overall, the increase in all-cause diabetes-related ED use from 2008 to 2017 outpaced rates of treat-and-release ED use among those without diabetes, after controlling for increased prevalence. Recent initiatives to better capture comorbid conditions among those admitted to inpatient facilitates could have played a role in the findings.

The racial and ethnic disparities seen in the study remained after controlling for ACA coverage gains and efforts to lower ED use by payer and health systems. More than 20 million Americans became eligible for health insurance after the passage of the ACA in 2010.

Geographically, findings may also “reflect a state-specific lack of access to primary care in rural communities despite coverage gains,” authors hypothesized.

Currently, Medicaid covers 18% of the US population and 24% of individuals with diabetes; because this program is taxpayer funded, “costly ED use that is potentially preventable through improved outpatient and community interventions for diabetes should be a focus for future health reform.”

The reliance on administrative hospital discharge data and the potential for changes in coding practices throughout the study window mark limitations. Researchers also only assessed treat-and-release trends and did not include diabetes complications that resulted in admission to the ED.

“Future policy research and implementation to reduce the burden of diabetes should go beyond coverage gains and delve more into the social determinants of health and equity specific to state-level and substate-level regions,” authors concluded.

Reference

Uppal TS, Chehal PK, Fernandes G, et al. Trends and variations in emergency department use associated with diabetes in the US by sociodemographic factors, 2008-2017. JAMA Netw Open. Published online May 25, 2022. doi: 10.1001/jamanetworkopen.2022.13867