Wide disparities exist in diabetes-related emergency department (ED) use between racial and ethnic groups, rural and urban patients, and Medicare and Medicaid-insured adults versus those who were privately insured between 2008 and 2017, a serial cross-sectional study indicates.
All-cause ED visits increased by over 50% during the same period even though substantial health reforms were made during the same study interval, a serial cross-sectional study indicates.
“We found persistently higher rates of diabetes-specific treat-and-release ED use among rural, Black, and Medicare and Medicaid-insured adults with large state-to-state variations within each group that were not reflected in national trends,” Tegveer Uppal, MPH, Rollins School of Public Health, Atlanta, Georgia, and colleagues report.
“The persistence of these disparities calls for focused local and federal efforts to understand and address the underlying reasons for differential ED use,” they suggest.
The study was published online May 25 in JAMA Network Open.
Diabetes-Related ED Visits Increase Over 50%
Data from the Healthcare Cost and Utilization Project Nationwide Emergency Department Sample (NEDS) was used to estimate national diabetes-related ED visits. A subset of data from the State Emergency Department Databases was also used to estimate state-specific diabetes-related ED visits. The authors identified 32,433,015 all-cause ED visits nationally for 2008, 2011, 2014, and 2016.
At 56.8%, females were more likely to visit the ED. The mean age of patients who visited the ED was 58.4 years.
A total of 1,911,795 diabetes-specific ED visits were identified among adults with diabetes. The national rate of all-cause diabetes ED visits increased from 257.6 (95% CI, 249.9 – 263.3) per 10,000 adults in 2008 to 400.8 (95% CI, 387.6 – 414.0) in 2016 and 2017 — a 55.6% increase (95% CI, 50.6%-60.6%), outpacing the percentage increase in the annual rate of total ED visits, the authors report.
The rate of diabetes-specific ED visits also increased from 17.2 (95% CI, 16.7 – 17.7) per 10,000 adults in 2008 to 25.9 (95% CI, 25.1 – 26.8) per 10,000 adults in 2016 and 2017, representing a 50.6% increase (95% CI, 46.3% – 54.9%) over the study interval, with the greatest increase in rates occurring between 2014 and 2016, the authors add.
Largest Increase Seen in Blacks, Hispanics, Rural Populations
On average, across states, diabetes-specific ED use among Black patients was roughly three times higher at a rate ratio of 3.09 (95% CI, 2.91 – 3.30) than among non-Hispanic White patients.
ED use was also 29% higher among Hispanic patients than it was among non-Hispanic White patients at a rate ratio of 1.29 (95% CI, 1.19 – 1.40), investigators note.
The mean rate of ED use among rural patients was 34% greater than among urban patients at a rate ratio of 1.34 (95% CI, 1.26 – 1.44), the authors observe. The mean rate of ED use among patients with Medicaid coverage was over six times greater at a rate ratio of 6.65 (95% CI, 6.49 – 6.82) and over four times greater among those with Medicare coverage at a rate ratio of 4.37 (95% CI, 4.23 – 4.51) compared with privately insured adults.
As the authors point out, the percentage of uninsured patients needing a diabetes-specific ED visit represented the greatest increase in percentage change at 123.4% (95% CI, 103.9% – 142.9%) between 2008 and 2016 and 2017.
“This study offers new empirical evidence of marked disparities, both nationally and within states, in age-adjusted, all-cause, and diabetes-specific ‘treat-and-release’ ED use by race and ethnicity, region, rural vs urban location, and insurance type from 2008 to 2017,” the authors affirm — even though major health reforms including the Affordable Care Act were put in place during the study interval.
The study was funded by MSD, a subsidiary of Merck. Uppal reports receiving research funding from Merck.
JAMA Netw Open. Published online May 25, 2022. Full text
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