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Racial and Ethnic Differences in the Utilization of Emergency Departments for Transition Age Young Adults with ASD Only and ASD with ID
Racial and ethnic differences in emergency department (ED) utilization are well known in the literature for typical young adults. Less is known about differences among those with autism (ASD) with or without intellectual disability (ID). In particular, little is known about ASD and ID young adults covered by Medicare. Persons less than 65 covered by Medicare have met criteria for a disability designation by the Social Security Administration. This may indicate a greater severity of disability. Furthermore, adults with ASD/ID often encounter difficulty finding appropriate providers and are more likely to have injuries and comorbidities that necessitate visits to the ED.
Objectives: This presentation will describe racial/ethnic differences in ED utilization among young adult Medicare beneficiaries aged 18-25 years with ASD and no intellectual disability (ASD-only) as compared to beneficiaries with ASD and ID (ASD+ID).
Methods:
We conducted a retrospective analysis of existing national Centers for Medicare and Medicaid (CMS) claims Limited Data Sets (LDS) for 2008-2010. ASD and ID cases were identified by searching all claims types (Inpatient “IP”, Outpatient “OUT”, Hospice, Carrier, Skilled Nursing and Home Health) for ASD beneficiaries (ICD-9 diagnosis codes 299.xx) and diagnosis codes 317.xx, 318.xx or 319.xx as ID. Claims associated with ED utilization for treat and release (T&R) ED events were identified in the Outpatient File using Revenue Center Codes "0450", "0451", "0452", "0456", and "0459" and the Patient Discharge Status Code. ED events admitted to the same hospital were identified using the Admit Source Code in the IP file. This study combined the two types of ED visits for analysis. Zero inflated negative binomial (ZINB) regression models were conducted separately for 2008, 2009 & 2010 and included binary indicators for ASD+ID versus ASD-only, sex, age group (23-25 vs. 18-22), ACG Concurrent Risk Score and Medicaid buy-in months. Minority status was identified as any Hispanic or racial minorities not listed as white: black, Asian, north American native, & Hispanic. The relationship between group status and minority status for ED visits is examined with an interaction term in the ZINB model.
Results:
Only results for 2008 are presented here due to space limitations. All 3 years will be presented at the conference. The ASD-only group was composed of 25.6% racial/ethnic minorities and the ASD+ID group was 33.9% minority.
Table 1 Demographic characteristics.
Table 2 displays the ZINB model for number of ED visits during 2008. The ASD+ID group had 17% more ED encounters. Minorities as a group appear to use 28% fewer ED visits. Examining Minority Status by ASD+ID and ASD-only separately reveals that the ASD+ID-Minority subjects used 30% more ED visits per year than the ASD-only-white group.
Conclusions:
Minorities appear to use fewer ED service when examined as a group. ASD+ID-Minorities use 30% more ED services as compared with ASD-only-white subjects. Additional research is needed to determine whether choice is the primary driver of ED utilization in this population or whether other factors like case severity, comorbidities and provider availability are driving the increased ED utilization.