Connecting the Dots Among Poverty, Chronic Diseases, ER Visits

Lilo H. Stainton | February 6, 2019 | Health Care
Analyzing data from more than 3 million emergency room visits, group confirms most troubling concerns about New Jersey healthcare

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emergency room
Common wisdom has it that New Jersey residents with chronic health conditions who live in poor communities where jobs are scarce are more likely to visit the hospital emergency room than better-heeled residents with similar medical challenges.

In this case, common wisdom — in the form of the first major study from the New Jersey Hospital Association’s Center for Health Analytics, Research & Transformation (CHART) — is on the money.

That’s an apt phrase, given that the report, released late last week, also found emergency room visits for those with chronic conditions like diabetes and hypertension cost on average 50 percent more than for patients without those problems.

CHART examined 2017 hospital data from more than 3 million emergency department visits statewide to better understand the full impact of chronic conditions on the state’s healthcare system. The study also found that these long-lasting conditions can be hard to control and have a significant impact on the quality of life of patients and their families.

The results suggest that many residents still face significant barriers when it comes to accessing preventive care, including through primary-care physicians, who can help treat chronic conditions before they become critical, at a lower cost than in the hospital.

Your ZIP code, your life

The situation was particularly concerning in a handful of ZIP codes that make up parts of three urban communities — Atlantic City, Trenton, and Jersey City — that also have relatively high poverty and unemployment rates, issues that are considered important social determinants of health.

“We really found that your geographic location or your ZIP code could be just as important to your health as your genetic code,” said Sean Hopkins, CHART’s senior vice president. Other studies, including one funded by the Robert Wood Johnson Foundation that compared the average life expectancy of Princeton residents (87 years) to those in Trenton (73 years), have shown similar results.

“Where we see that some of these areas are lacking (in healthcare and support services), we see a heightened level of poor health status, and it kind of bears itself out in the number of chronic health conditions” reported at the ER, Hopkins added.

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Statewide, the data showed that roughly two out of five patients admitted to a hospital emergency room in New Jersey suffer from at least one chronic health condition. But these visits — which tend to involve more complex care and therefore more resources — absorb more than half the cost of all outpatient emergency care. In concrete terms, this meant more than $1 billion in 2017 for these cases alone.

Chronic conditions common

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Nearly one in five patients seen in the emergency room that year suffered from hypertension, or high blood pressure, CHART’s analysis showed, and 12 percent were battling drug addictions. Diabetes, high cholesterol, and asthma were also common chronic conditions reported. Nationwide, 60 percent of adults have at least one chronic condition and 40 percent have two or more, the report noted.

“You can live well with a chronic condition, but that requires access to primary care, a medical home, and care management,” said Cathy Bennett, president and CEO of NJHA, which represents the state’s 71 acute-care hospitals. “CHART’s study zeroes in on hotspot ZIP codes where there are clear gaps in that level of care. These communities demand greater attention to make sure all individuals have access to the services they need,” she added.

Hopkins said he has already discussed the data with hospitals in some of these hotspots. The goal is to use the findings to help NJHA members identify and target local needs, possibly through initiatives like mobile clinics, health fairs, or expanded prevention programs.

Expanding the conversation

But the study was also designed to spark a larger conversation among broader stakeholders, like social service agencies and government officials, about how to address some of the wider social determinants of health, Hopkins added. In some communities this could involve adding capacity at local clinics, but it could also mean contracting with ride-sharing companies to ensure patients have transportation to medical appointments or working to improve access to fresh foods.

“These are the types of things as a society we need to start thinking about,” Hopkins said. “We need to come together to bridge some of these chasms.”

CHART’s review focused on the 3.1 million patients who were treated and released by emergency departments at all but three hospitals in 2017. In an effort to create a more accurate comparison, researchers did not consider data from patients who were admitted to these acute-care facilities for treatment. Of these emergency outpatients, 2.1 million had one or more chronic conditions, although in some cases their ER visit was unrelated to those issues.

Costly complications

Regardless of what brought them to the emergency room, patients with chronic conditions cost the system more than those without those complications, CHART found. Individuals who were in good health resulted in charges that averaged $480 per emergency visit, versus $738 for those with chronic issues.

Statewide, in 2017 there were an average of nearly 130 emergency room visits by individuals with chronic conditions per 1,000 people. But when researchers broke this down by county — and overlaid employment and economic data — they noticed higher rates of ER visits by those with health issues in regions with greater social challenges.

In Cumberland County, which has the highest unemployment (6.6 percent) and lowest median household income (less than $50,000), the rate of emergency room visits by those with chronic conditions is nearly double the state average (237/1,000). Atlantic and Camden counties showed the second- and third-highest rates, respectively, and both have some of the lowest income and employment rates statewide.

What the report did not measure was the toll — economic and otherwise — these chronic conditions have on individuals, family members, and their communities overall. Nationwide, medical care for these issues consumes nearly one-third of all healthcare spending, the report noted, but long-term illnesses also increase absenteeism at work, lower productivity, and add emotional and physical burdens on caregivers, which further stress the system.

“Chronic conditions create a family and societal burden in New Jersey,” Hopkins said, “like tentacles that reach out into the community.”