ORIGINAL ARTICLE
The Relationship Between a Worksite Wellness Clinic and Hospital Emergency Department Visits Xuguang (Grant) Tao, MD, PhD, Peter J. Fagan, PhD, MDiv, Elizabeth LeNoach, BA, Michelle Hawkins, DNP, MBA, Michelle Ross-Gavin, RN, BSN, CCM, and Edward J. Bernacki, MD, MPH Objective: To assess the relationship between the provision of episodic medical care at the worksite and nonadmission emergency department (ED) visits. Methods: A historical cohort design was used to study the differences of nonadmission ED visits among insurance plan participants employed at two acute care hospitals, one with a worksite wellness clinic and one without over an 8-year period. Results: A significant reduction in the risk of an insurance plan member visiting the ED in the time period after the clinic was opened among plan members with access to a worksite wellness clinic was observed. No significant reduction was noted in ED visits for insurance plan members without access to a worksite clinic. Conclusions: A wellness clinic rendering episodic medical care is associated with significant reductions in ED visits and insured employees who use an ED.
T
he frequency of emergency department (ED) visits in the United States has been steadily increasing, driven by a number of factors.1–3 There were approximately 128.9 million visits to US EDs in 2010, or 42.8 visits per 100 individuals and 13.3% of these visits resulted in an admission.4 It is estimated that 56%, or roughly 67 million visits, could have been handled in a non-ED setting.4 The average cost of an ED visit is approximately four times higher than comparable visits of similar acuity to non-ED community providers of health care.3 Therefore, programs aimed at reducing the use of hospital EDs for illnesses or injuries that could be safely assessed and treated in urgent care facilities or physician’s offices present an opportunity for considerable health care cost reductions.4,5 A number of strategies have been suggested as interventions to reduce the number of visits to EDs as follows:4,6–8 1. Increasing the supply of non–ED-based primary care services (community health clinics, retail clinics, worksite wellness centers, expansion of physician practice hours, etc). 2. Patient education and 24/7 nurse help lines. 3. Financial incentives to avoid ED use (increasing co-payments for ED visits). 4. Fostering relationships between individuals and their primary care physician or patient-centered medical homes. Among all of the interventions suggested previously to reduce ED visits, this study investigated one of them, an occupational health and wellness center providing episodic acute care to employees. This strategy has been suggested as a viable mechanism to reduce ED visits but not formally studied. The objective of this paper was to study nonadmission employee ED visits before and after the opening of From the Division of Occupational and Environmental Medicine (Drs Tao and Bernacki), Department of Medicine; Department of Psychiatry and Behavioral Sciences (Dr Fagan), Johns Hopkins University School of Medicine; and Johns Hopkins Health Care (Ms LeNoach, Dr Hawkins, and Ms Ross-Gavin), Johns Hopkins Health Systems, Baltimore, Md. No authors received funding for this work. There are no conflicts of interest. Address correspondence to: Edward J. Bernacki, MD, MPH, Division of Occupational and Environmental Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287 ([email protected]). C 2014 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0000000000000259
the Employee Health and Wellness Center (EHWC) at the Johns Hopkins Hospital (JHH). The rate of nonadmission ED visits in this population will be compared with nonadmission ED visits of individuals employed by another hospital owned by the Johns Hopkins Health System, the Johns Hopkins Bayview Medical Center (BMC). The employees of both institutions have similar benefits and access to the same plan administrative personnel and educational materials, but the BMC employees do not have access to a worksite employee health and wellness center to receive acute or episodic primary health care during work hours.
METHOD Study Population and Location The study population included all the employees of the JHH and the BMC enrolled in Johns Hopkins Employer Health Programs (EHP) at some point between January 1, 2005, and December 31, 2012. The JHH and the BMC are two separate hospitals located in Baltimore, Maryland, in the Johns Hopkins Health System. The JHH has approximately 10,600 employees, and the BMC has 3400 employees. The proportionate enrollment in EHP was approximately 85% at the JHH and 82% at the BMC. Both institutions employ primarily nurses, administrators, paraprofessionals, and support staff.
The Johns Hopkins Employee Health and Wellness Center The EHWC opened on the campus of the JHH in East Baltimore, Maryland, on October 1, 2008. The EHWC delivers acute or episodic health care. The EHWC does not provide any traditional occupational health services (tuberculosis screening, preplacement examinations, etc) or occupational injury care. Services are provided to employees from 7 AM to 4 PM, Monday to Friday. The clinic assesses and treats various medical conditions, the most common of which are ear, nose, and throat (30%); respiratory (22%); ophthalmologic (14%); skin (8%); and urinary tract (6%) conditions. The services are provided free of charge to the employees, but employees are required to pay for laboratory, x-ray film, and pharmaceutical expenses associated with the visit. The average number of visits for assessment and treatment is 2600 per year. The vast majority of assessments and treatments are for new patients or established patients with an expanded problemfocused history, examination, and medical decision making with low to medium complexity. Approximately 2% of the visits resulted in a referral to the ED. During the study period, the median age of the EHP participants utilizing the EHWC was 40.2 years. Females utilized the EHWC in a higher proportion than males, 87.0% versus 13%. This participation rate is higher than the female composition of the JHH workforce (76%) during the study period.
Study Design and Data Collection A historical cohort study design was used for the study. The JHH and BMC employees insured with EHP were followed for 8 years from January 1, 2005, to December 31, 2012. Emergency Department visits prior to October 1, 2008, were classified as the “preclinic period,” meaning before the EHWC began operations, and the “postclinic period,” meaning after the EHWC became
JOEM r Volume 56, Number 12, December 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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operational on that date. Only ED visits without a hospital admission were utilized in the analysis to confine the study to nonadmission episodes of care. The EHP member data were obtained from the Johns Hopkins Health Care LLC, third-party administrator for Johns Hopkins Medicine. The data contained information on the insurance status of employees and the number of ED visits made each month by insured employees during the study period. In addition to the ED visit data, the other contextual information that was obtained included co-payment increases, age, sex, and the number of chronic conditions by employee plan participant.
Johns Hopkins Employer Health Programs Johns Hopkins EHP is a health care benefit plan that was established in 1996. It is a self-funded program that currently serves 55,000 plan members. The EHP member benefit structure for services at both hospitals is similar. In 2013, the co-insurance out of pocket maximum includes a $2000 deductible for an individual and $3500 for a family for care provided outside the network. There were no co-payments. In 2012, the ED co-payment was increased from $100 to $125 at the BMC and from $75 to $125 at the JHH. For both institutions, if an individual is admitted to an acute care hospital from the ED, 100% of the co-payment for the ED visit is waived. Johns Hopkins EHP, along with other health care benefits plans, is offered to the Johns Hopkins employees on hiring, but employees must formally apply for this health benefit to receive coverage. In 2013, 84.9% of the JHH employees and 82.3% of the BMC employees selected EHP as their health care benefits plan.
Data Analysis The analysis was stratified by population (JHH and BMC). Analysis was also performed on a subset of high EHWC utilizers. These high utilizers worked in the following departments: Environmental Services, Building and Grounds, Clinical Engineering Services, Electrical Services, Mechanical Services, Power Plant, and Nutrition. This group of employees is composed mostly of hourly workers. We termed this population the maintenance, dietary, and transport personnel (MDT) subgroup. The outcome indicators included the percentage of EHP members having any ED visit by month and average ED visits per 100 members per month. The expected ED visits after period were calculated on the basis of the ED visit rates in the preclinic period. The rates in postclinic period were compared with preclinic period by population and the observed ED visits. Expected ED visits for both study populations were also compared. The number of months that an employee participated in EHP or member months was used as the denominator when rates were calculated. A multivariate logistic regression method was used to examine the association of having an ED visit with the postclinic period, controlling for co-payment increases, sex, age, and the number of chronic conditions. Odds ratios (OR) and 95% confidence interval (CI) were used as risk measures. SAS 9.3 (SAS Institute, Inc., Cary, NC) was used for the analysis. We received Johns Hopkins Medicine Institutional Review Board approval (NA_00093626) and the approval of the Johns Hopkins Health Care Data Sharing for Research Review Committee for this study (available at http://www.hopkinsmedicine.org/ institutional review board/about/eIRB/).
RESULTS There were a total of 772,811 member months during the 8 years or 96-month period between January 1, 2005, and December 31, 2012 (580,517 member months for the JHH and 192,294 for the BMC). Of this number, 39% of the member months were in the preclinic period, and 61% of the member months were in the postclinic 1314
period. As shown in Table 1, the percentage of EHP members with any ED visits during a month decreased from 2.5% to 2.1% or a 16.3% relative reduction among the JHH EHP members. The JHH MDT subset had a more dramatic reduction in monthly ED visits decreasing from 5.1% to 4.0%, a 21.8% relative reduction. The average ED visit per 100 member months decreased from 6.22 to 5.61 for the entire JHH population and from 12.86 to 10.71 for the JHH MDT subset. Reductions in ED visits per 100 member months were also noted in the BMC population with a 3.6% relative reduction observed for all BMC EHP members and a 7.7% reduction for the MDT EHP member subset. Changes in ED utilization for the JHH and the BMC was also measured by differences between the observed and expected EHP participants with an ED visit and the number of ED visits per 100 member months. The JHH had 1463 less EHP members with any ED visit in the postclinic period than expected and 2020 less ED visits than expected. The differences were much smaller among the BMC EHP participants. The corresponding numbers were 176 less than expected member visits to an ED and 224 less than expected ED visits per 100 member months (Table 1). Controlling for co-payment increases, sex, age, and the number of chronic conditions, multivariate logistic regression indicated a significant reduction in the risk of a member visiting the ED in the time period after the EHWC was opened (OR = 0.775; 95% CI: 0.722 to 0.833; P < 0.0001). No significant reduction was noted among the BMC EHP plan members seeking ED care over the same time period (OR = 0.970; 95% CI: 0.904 to 1.041; P = 0.2730) (Table 2). We also found that women and individuals younger than 40 years of age were more likely to visit the ED than males and older EHP members. At the JHH, ED visits per 100 member months was 6.1 for females and 5.1 for males, whereas at the BMC ED visits per 100 member months was 5.4 for females and 4.0 for males. In addition, as the number of chronic diseases prevalent among EHP member population increased, the OR of having an ED visit increased substantially from an OR of 1.703 for one chronic condition to 5.31 for six chronic conditions. We were interested in assessing the differences in ED utilization for primarily hourly workers (the MDT subset) versus primarily salaried workers (a non-MDT subset) related to worksite wellness clinic use. Further logistic regressions were performed for MDT and non-MDT subsets controlling for co-payment increases, sex, age, and the number of chronic conditions. The results for this group of plan participants are presented in Fig. 1. The ORs and 95% CIs for MDT and non-MDT subsets among the JHH and the BMC indicated that both the JHH MDT and non-MDT had a significant negative association of having an ED visit in the postclinic period. The adjusted ORs were 0.72 (95% CI: 0.61 to 0.84) for the JHH MDT and 0.79 (95% CI: 0.73 to 0.86) for the JHH non-MDT. The adjusted ORs for the BMC MDT (1.00; CI: 0.83 to 1.21) and non-MDT (0.97; CI: 0.90 to 1.04) subsets were not statistically significant over the corresponding time period. Figure 2 indicates that the adjusted reduction rates were −28.40% (95% CI: −39.20% to −15.06%) for the JHH MDT and −20.60% (95% CI: −26.7% to −14.0%) for the JHH non-MDT subsets. These differences were statistically significant. The adjusted reduction rates at the BMC were 0.30% (95% CI: −16.08% to 21.0%) for MDT and −3.4% (95% CI: −10.5 to 4.3%) for non-MDT subsets. No statistical significant association was observed for both the BMC, MDT and non-MDT subsets. Table 3 estimates the changes in EHP payments for ED care for the JHH and BMC employee plan participants after the opening of the worksite wellness clinic. The average payment to hospital providers by EHP to cover ED services during the 8-year period was $866 for a visit without an admission. This expense was used to estimate the avoided cost of an ED visit. The estimated avoided
C 2014 American College of Occupational and Environmental Medicine
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Before Period
8,958 22,029 2.5% 6.18
1,762 4,414 5.1% 12.86
7,196 17,615 2.2% 5.47
20,009 2.1% 5.61
34,327 1,378 3,675 4.0% 10.71
322,083 6,117 16,334 1.9% 5.07
Expected After Period
356,410 7,495
Observed After Period
−15.0% −7.3% −15.0% −7.3%
−1,281 −0.3% −0.40
−16.7% −21.8% −16.7%
−739 −1.1% −2.15
−1.079
−21.8%
−9.2% −16.3% −9.2
−2,020 −0.4% −0.57
−384
−16.3%
Reduction (%)
−1,463
O-E
3,296 1.9% 4.94
66,665 1,277
546 3.3% 8.36
6,533 218
3,842 2.0% 5.25
73,198 1,495
Before Period
5,144 1.8% 4.75
108,350 1,927
887 3.1% 8.25
10,746 331
6,031 1.9% 5.06
119,096 2,258
Observed After Period
5,357 1.9% 4.94
2,075
898 3.3% 8.36
359
6,255 2.0% 5.25
2,434
Expected After Period
BMC
−7.2% −4.0% −7.2% −4.0%
−213 −0.1% −0.20
−1.2% −7.7% −1.2%
−7.7%
−3.6% −7.2% −3.6%
−7.2%
Reduction (%)
−148
−11 −0.3% −0.10
−28
−224 −0.1% −0.19
−176
O-E
BMC, Johns Hopkins Bayview Medical Center; E, expected ED visits; ED, emergency department; EHP, Johns Hopkins Employer Health Programs; JHH, Johns Hopkins Hospital; MDT, maintenance, dietary, and transport personnel; O, observed ED visits
Total EHP members 224,105 EHP members with any ED visit 5,671 by month Total number of ED visits 13,949 % of EHP member with any ED 2.5% Average ED visit per 100 member 6.22 month Maintenance, dietary, transport personnel (MDT) EHP members 22,905 EHP members with any ED visit 1,176 by month Total number of ED visits 2,945 % of EHP member with any ED 5.1% Average ED visit per 100 member 12.86 month Non-MDT EHP members 201,202 EHP members with any ED visit 4,495 by month Total number of ED visits 11,004 % of EHP member with any ED 2.2% Average ED visit per 100 member 5.47 month
Variables
JHH
TABLE 1. Expected and Observed ED Visits in Postclinic Opening Period and Percentage of Reduction by Population
JOEM r Volume 56, Number 12, December 2014 A Worksite Wellness Clinic and Hospital Emergency Department Visits
C 2014 American College of Occupational and Environmental Medicine
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
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TABLE 2. Adjusted Odds Ratios and 95% Confidence Intervals for Having Any ED Visit Associated With Postclinic Opening Period by the JHH and the BMC JHH Variables Sex: Male vs Female Age 40–49 yrs vs
The Relationship Between a Worksite Wellness Clinic and Hospital Emergency Department Visits Xuguang (Grant) Tao, MD, PhD, Peter J. Fagan, PhD, MDiv, Elizabeth LeNoach, BA, Michelle Hawkins, DNP, MBA, Michelle Ross-Gavin, RN, BSN, CCM, and Edward J. Bernacki, MD, MPH Objective: To assess the relationship between the provision of episodic medical care at the worksite and nonadmission emergency department (ED) visits. Methods: A historical cohort design was used to study the differences of nonadmission ED visits among insurance plan participants employed at two acute care hospitals, one with a worksite wellness clinic and one without over an 8-year period. Results: A significant reduction in the risk of an insurance plan member visiting the ED in the time period after the clinic was opened among plan members with access to a worksite wellness clinic was observed. No significant reduction was noted in ED visits for insurance plan members without access to a worksite clinic. Conclusions: A wellness clinic rendering episodic medical care is associated with significant reductions in ED visits and insured employees who use an ED.
T
he frequency of emergency department (ED) visits in the United States has been steadily increasing, driven by a number of factors.1–3 There were approximately 128.9 million visits to US EDs in 2010, or 42.8 visits per 100 individuals and 13.3% of these visits resulted in an admission.4 It is estimated that 56%, or roughly 67 million visits, could have been handled in a non-ED setting.4 The average cost of an ED visit is approximately four times higher than comparable visits of similar acuity to non-ED community providers of health care.3 Therefore, programs aimed at reducing the use of hospital EDs for illnesses or injuries that could be safely assessed and treated in urgent care facilities or physician’s offices present an opportunity for considerable health care cost reductions.4,5 A number of strategies have been suggested as interventions to reduce the number of visits to EDs as follows:4,6–8 1. Increasing the supply of non–ED-based primary care services (community health clinics, retail clinics, worksite wellness centers, expansion of physician practice hours, etc). 2. Patient education and 24/7 nurse help lines. 3. Financial incentives to avoid ED use (increasing co-payments for ED visits). 4. Fostering relationships between individuals and their primary care physician or patient-centered medical homes. Among all of the interventions suggested previously to reduce ED visits, this study investigated one of them, an occupational health and wellness center providing episodic acute care to employees. This strategy has been suggested as a viable mechanism to reduce ED visits but not formally studied. The objective of this paper was to study nonadmission employee ED visits before and after the opening of From the Division of Occupational and Environmental Medicine (Drs Tao and Bernacki), Department of Medicine; Department of Psychiatry and Behavioral Sciences (Dr Fagan), Johns Hopkins University School of Medicine; and Johns Hopkins Health Care (Ms LeNoach, Dr Hawkins, and Ms Ross-Gavin), Johns Hopkins Health Systems, Baltimore, Md. No authors received funding for this work. There are no conflicts of interest. Address correspondence to: Edward J. Bernacki, MD, MPH, Division of Occupational and Environmental Medicine, Johns Hopkins School of Medicine, Baltimore, MD 21287 ([email protected]). C 2014 by American College of Occupational and Environmental Copyright Medicine DOI: 10.1097/JOM.0000000000000259
the Employee Health and Wellness Center (EHWC) at the Johns Hopkins Hospital (JHH). The rate of nonadmission ED visits in this population will be compared with nonadmission ED visits of individuals employed by another hospital owned by the Johns Hopkins Health System, the Johns Hopkins Bayview Medical Center (BMC). The employees of both institutions have similar benefits and access to the same plan administrative personnel and educational materials, but the BMC employees do not have access to a worksite employee health and wellness center to receive acute or episodic primary health care during work hours.
METHOD Study Population and Location The study population included all the employees of the JHH and the BMC enrolled in Johns Hopkins Employer Health Programs (EHP) at some point between January 1, 2005, and December 31, 2012. The JHH and the BMC are two separate hospitals located in Baltimore, Maryland, in the Johns Hopkins Health System. The JHH has approximately 10,600 employees, and the BMC has 3400 employees. The proportionate enrollment in EHP was approximately 85% at the JHH and 82% at the BMC. Both institutions employ primarily nurses, administrators, paraprofessionals, and support staff.
The Johns Hopkins Employee Health and Wellness Center The EHWC opened on the campus of the JHH in East Baltimore, Maryland, on October 1, 2008. The EHWC delivers acute or episodic health care. The EHWC does not provide any traditional occupational health services (tuberculosis screening, preplacement examinations, etc) or occupational injury care. Services are provided to employees from 7 AM to 4 PM, Monday to Friday. The clinic assesses and treats various medical conditions, the most common of which are ear, nose, and throat (30%); respiratory (22%); ophthalmologic (14%); skin (8%); and urinary tract (6%) conditions. The services are provided free of charge to the employees, but employees are required to pay for laboratory, x-ray film, and pharmaceutical expenses associated with the visit. The average number of visits for assessment and treatment is 2600 per year. The vast majority of assessments and treatments are for new patients or established patients with an expanded problemfocused history, examination, and medical decision making with low to medium complexity. Approximately 2% of the visits resulted in a referral to the ED. During the study period, the median age of the EHP participants utilizing the EHWC was 40.2 years. Females utilized the EHWC in a higher proportion than males, 87.0% versus 13%. This participation rate is higher than the female composition of the JHH workforce (76%) during the study period.
Study Design and Data Collection A historical cohort study design was used for the study. The JHH and BMC employees insured with EHP were followed for 8 years from January 1, 2005, to December 31, 2012. Emergency Department visits prior to October 1, 2008, were classified as the “preclinic period,” meaning before the EHWC began operations, and the “postclinic period,” meaning after the EHWC became
JOEM r Volume 56, Number 12, December 2014 Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
1313
JOEM r Volume 56, Number 12, December 2014
Tao et al
operational on that date. Only ED visits without a hospital admission were utilized in the analysis to confine the study to nonadmission episodes of care. The EHP member data were obtained from the Johns Hopkins Health Care LLC, third-party administrator for Johns Hopkins Medicine. The data contained information on the insurance status of employees and the number of ED visits made each month by insured employees during the study period. In addition to the ED visit data, the other contextual information that was obtained included co-payment increases, age, sex, and the number of chronic conditions by employee plan participant.
Johns Hopkins Employer Health Programs Johns Hopkins EHP is a health care benefit plan that was established in 1996. It is a self-funded program that currently serves 55,000 plan members. The EHP member benefit structure for services at both hospitals is similar. In 2013, the co-insurance out of pocket maximum includes a $2000 deductible for an individual and $3500 for a family for care provided outside the network. There were no co-payments. In 2012, the ED co-payment was increased from $100 to $125 at the BMC and from $75 to $125 at the JHH. For both institutions, if an individual is admitted to an acute care hospital from the ED, 100% of the co-payment for the ED visit is waived. Johns Hopkins EHP, along with other health care benefits plans, is offered to the Johns Hopkins employees on hiring, but employees must formally apply for this health benefit to receive coverage. In 2013, 84.9% of the JHH employees and 82.3% of the BMC employees selected EHP as their health care benefits plan.
Data Analysis The analysis was stratified by population (JHH and BMC). Analysis was also performed on a subset of high EHWC utilizers. These high utilizers worked in the following departments: Environmental Services, Building and Grounds, Clinical Engineering Services, Electrical Services, Mechanical Services, Power Plant, and Nutrition. This group of employees is composed mostly of hourly workers. We termed this population the maintenance, dietary, and transport personnel (MDT) subgroup. The outcome indicators included the percentage of EHP members having any ED visit by month and average ED visits per 100 members per month. The expected ED visits after period were calculated on the basis of the ED visit rates in the preclinic period. The rates in postclinic period were compared with preclinic period by population and the observed ED visits. Expected ED visits for both study populations were also compared. The number of months that an employee participated in EHP or member months was used as the denominator when rates were calculated. A multivariate logistic regression method was used to examine the association of having an ED visit with the postclinic period, controlling for co-payment increases, sex, age, and the number of chronic conditions. Odds ratios (OR) and 95% confidence interval (CI) were used as risk measures. SAS 9.3 (SAS Institute, Inc., Cary, NC) was used for the analysis. We received Johns Hopkins Medicine Institutional Review Board approval (NA_00093626) and the approval of the Johns Hopkins Health Care Data Sharing for Research Review Committee for this study (available at http://www.hopkinsmedicine.org/ institutional review board/about/eIRB/).
RESULTS There were a total of 772,811 member months during the 8 years or 96-month period between January 1, 2005, and December 31, 2012 (580,517 member months for the JHH and 192,294 for the BMC). Of this number, 39% of the member months were in the preclinic period, and 61% of the member months were in the postclinic 1314
period. As shown in Table 1, the percentage of EHP members with any ED visits during a month decreased from 2.5% to 2.1% or a 16.3% relative reduction among the JHH EHP members. The JHH MDT subset had a more dramatic reduction in monthly ED visits decreasing from 5.1% to 4.0%, a 21.8% relative reduction. The average ED visit per 100 member months decreased from 6.22 to 5.61 for the entire JHH population and from 12.86 to 10.71 for the JHH MDT subset. Reductions in ED visits per 100 member months were also noted in the BMC population with a 3.6% relative reduction observed for all BMC EHP members and a 7.7% reduction for the MDT EHP member subset. Changes in ED utilization for the JHH and the BMC was also measured by differences between the observed and expected EHP participants with an ED visit and the number of ED visits per 100 member months. The JHH had 1463 less EHP members with any ED visit in the postclinic period than expected and 2020 less ED visits than expected. The differences were much smaller among the BMC EHP participants. The corresponding numbers were 176 less than expected member visits to an ED and 224 less than expected ED visits per 100 member months (Table 1). Controlling for co-payment increases, sex, age, and the number of chronic conditions, multivariate logistic regression indicated a significant reduction in the risk of a member visiting the ED in the time period after the EHWC was opened (OR = 0.775; 95% CI: 0.722 to 0.833; P < 0.0001). No significant reduction was noted among the BMC EHP plan members seeking ED care over the same time period (OR = 0.970; 95% CI: 0.904 to 1.041; P = 0.2730) (Table 2). We also found that women and individuals younger than 40 years of age were more likely to visit the ED than males and older EHP members. At the JHH, ED visits per 100 member months was 6.1 for females and 5.1 for males, whereas at the BMC ED visits per 100 member months was 5.4 for females and 4.0 for males. In addition, as the number of chronic diseases prevalent among EHP member population increased, the OR of having an ED visit increased substantially from an OR of 1.703 for one chronic condition to 5.31 for six chronic conditions. We were interested in assessing the differences in ED utilization for primarily hourly workers (the MDT subset) versus primarily salaried workers (a non-MDT subset) related to worksite wellness clinic use. Further logistic regressions were performed for MDT and non-MDT subsets controlling for co-payment increases, sex, age, and the number of chronic conditions. The results for this group of plan participants are presented in Fig. 1. The ORs and 95% CIs for MDT and non-MDT subsets among the JHH and the BMC indicated that both the JHH MDT and non-MDT had a significant negative association of having an ED visit in the postclinic period. The adjusted ORs were 0.72 (95% CI: 0.61 to 0.84) for the JHH MDT and 0.79 (95% CI: 0.73 to 0.86) for the JHH non-MDT. The adjusted ORs for the BMC MDT (1.00; CI: 0.83 to 1.21) and non-MDT (0.97; CI: 0.90 to 1.04) subsets were not statistically significant over the corresponding time period. Figure 2 indicates that the adjusted reduction rates were −28.40% (95% CI: −39.20% to −15.06%) for the JHH MDT and −20.60% (95% CI: −26.7% to −14.0%) for the JHH non-MDT subsets. These differences were statistically significant. The adjusted reduction rates at the BMC were 0.30% (95% CI: −16.08% to 21.0%) for MDT and −3.4% (95% CI: −10.5 to 4.3%) for non-MDT subsets. No statistical significant association was observed for both the BMC, MDT and non-MDT subsets. Table 3 estimates the changes in EHP payments for ED care for the JHH and BMC employee plan participants after the opening of the worksite wellness clinic. The average payment to hospital providers by EHP to cover ED services during the 8-year period was $866 for a visit without an admission. This expense was used to estimate the avoided cost of an ED visit. The estimated avoided
C 2014 American College of Occupational and Environmental Medicine
Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
Before Period
8,958 22,029 2.5% 6.18
1,762 4,414 5.1% 12.86
7,196 17,615 2.2% 5.47
20,009 2.1% 5.61
34,327 1,378 3,675 4.0% 10.71
322,083 6,117 16,334 1.9% 5.07
Expected After Period
356,410 7,495
Observed After Period
−15.0% −7.3% −15.0% −7.3%
−1,281 −0.3% −0.40
−16.7% −21.8% −16.7%
−739 −1.1% −2.15
−1.079
−21.8%
−9.2% −16.3% −9.2
−2,020 −0.4% −0.57
−384
−16.3%
Reduction (%)
−1,463
O-E
3,296 1.9% 4.94
66,665 1,277
546 3.3% 8.36
6,533 218
3,842 2.0% 5.25
73,198 1,495
Before Period
5,144 1.8% 4.75
108,350 1,927
887 3.1% 8.25
10,746 331
6,031 1.9% 5.06
119,096 2,258
Observed After Period
5,357 1.9% 4.94
2,075
898 3.3% 8.36
359
6,255 2.0% 5.25
2,434
Expected After Period
BMC
−7.2% −4.0% −7.2% −4.0%
−213 −0.1% −0.20
−1.2% −7.7% −1.2%
−7.7%
−3.6% −7.2% −3.6%
−7.2%
Reduction (%)
−148
−11 −0.3% −0.10
−28
−224 −0.1% −0.19
−176
O-E
BMC, Johns Hopkins Bayview Medical Center; E, expected ED visits; ED, emergency department; EHP, Johns Hopkins Employer Health Programs; JHH, Johns Hopkins Hospital; MDT, maintenance, dietary, and transport personnel; O, observed ED visits
Total EHP members 224,105 EHP members with any ED visit 5,671 by month Total number of ED visits 13,949 % of EHP member with any ED 2.5% Average ED visit per 100 member 6.22 month Maintenance, dietary, transport personnel (MDT) EHP members 22,905 EHP members with any ED visit 1,176 by month Total number of ED visits 2,945 % of EHP member with any ED 5.1% Average ED visit per 100 member 12.86 month Non-MDT EHP members 201,202 EHP members with any ED visit 4,495 by month Total number of ED visits 11,004 % of EHP member with any ED 2.2% Average ED visit per 100 member 5.47 month
Variables
JHH
TABLE 1. Expected and Observed ED Visits in Postclinic Opening Period and Percentage of Reduction by Population
JOEM r Volume 56, Number 12, December 2014 A Worksite Wellness Clinic and Hospital Emergency Department Visits
C 2014 American College of Occupational and Environmental Medicine
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Tao et al
TABLE 2. Adjusted Odds Ratios and 95% Confidence Intervals for Having Any ED Visit Associated With Postclinic Opening Period by the JHH and the BMC JHH Variables Sex: Male vs Female Age 40–49 yrs vs
