See Related Article on p.64
[1]
]. When compared with other populations, adolescents and young adults (AYAs) have higher utilization of emergency services. Prior studies have identified that older AYAs [[2]
] and those who are publicly insured [[3]
,[4]
] or have medical complexity [[5]
,[6]
] have the highest rates of ED utilization. The higher rates of ED utilization among AYAs are juxtaposed against lower utilization of primary care services, particularly well-care visits (WCVs) [[7]
]. Policymakers have long focused on increasing rates of WCVs, in part to reduce avoidable costs, such as those incurred in expensive ED visits [8
, 9
, 10
]. To date, limited evidence has quantified the relationship between WCVs and ED visits for AYAs.Holland et al. explore the relationship between WCVs and ED visits for 49,089 AYAs (aged 12–21 years) who sought care in 2018 using Vermont's all-payer claims data [
[11]
]. Overall, approximately half (49%) of AYAs had a WCV, and 25% of AYAs had at least one ED visit during the year. AYAs who did not attend a WCV had 24% greater odds of going to the ED at least once during the year. Between the two groups, there was an absolute increase of 7.6% in AYAs who experienced the ED visit: 21.4% of patients who attended a WCV received care in the ED, whereas 29.0% of individuals who did not have a WCV received care in the ED. AYAs with the greatest odds of ED utilization in the adjusted model were older, female, Medicaid-insured, and with medical complexity. The authors propose that policies focused on increasing WCVs may help to decrease ED utilization among AYAs.As Holland et al. acknowledge, the analyses identified an association between WCVs and ED visits for AYAs, but conclusions regarding causality or potential mechanisms cannot be made without additional data. ED visits for communicable diseases versus exacerbations of chronic disease versus accidents or injuries would suggest different mechanisms by which WCVs might decrease utilization. A strong link to a medical home through regular WCVs, for example, could lead to earlier identification and treatment for common conditions that can escalate to emergency care if left unmanaged, such as asthma, sexually transmitted infections, or depression. Preventive counseling in WCVs could decrease risky behaviors that can lead AYAs to requiring ED-level care, such as car accidents associated with substance use or texting while driving.
Although WCVs may play an important role in reducing ED utilization, other strategies will be needed to complement yearly WCVs to facilitate high-value use of different health care settings among AYAs. One study of ED utilization among AYAs illustrated that just simply increasing WCVs is likely insufficient to reduce ED visits [
[4]
]. In the study, the primary reason for presentation was the perception of being sick and needing to see a doctor immediately; however, 40% of the patients were triaged as nonurgent, representing a potential knowledge deficit regarding the appropriate use of the ED. In addition, 90% of AYAs in the study had been seen by their primary care provider within the past year. Studies have shown varying levels of success in addressing this knowledge deficit through targeted interventions designed to help patients understand what conditions are appropriate to treat at different levels of care [[12]
]. In addition, the feasibility and acceptability of addressing this knowledge gap during WCVs are uncertain, as providers already struggle to cover the recommended list of preventive topics [[13]
]. Alternate acute care settings, such as retail-based clinics, urgent care clinics, and school-based health centers, can also play a role in reducing ED utilization among AYAs [[14]
].The urgency to identify strategies to reduce avoidable ED utilization has never been greater than during the COVID-19 pandemic and the resulting concurrent youth mental health crisis. During each COVID-19 surge, ED capacity has been significantly strained—with AYAs making up larger proportions of COVID-19 cases, ED visits, and hospitalizations in later waves [
[15]
]. The youth mental health crisis that the pandemic has exacerbated layers on yet more stress to EDs [Demographic Trends of COVID-19 cases and deaths in the US reported to CDC.
https://covid.cdc.gov/covid-data-tracker/#demographics
Date accessed: September 6, 2021
[16]
], particularly when usual behavioral health supports in schools and clinics were unavailable [[17]
]. With the proportion of AYA ED visits related to behavioral health increasing by 31% in 2020 compared with 2019, strategies to increase access to community-based and crisis support systems are needed [[18]
].Beyond the pandemic, the focus on high-value health care utilization will remain important as value-based models that prioritize both outcomes and costs are adopted by payers and health care systems [
[19]
]. Within value-based models, inappropriate ED utilization can both increase the total cost of care for AYAs and result in penalties if the rate of ED visits is monitored as a performance measure. On the other hand, WCVs are commonly included as core performance measures in these payment models [[20]
]. Evidence, such as that presented by Holland et al., can be leveraged to inform performance improvement plans by health systems, particularly in value-based contracts where total cost of care and rates of ED visits or WCVs are tracked. Decreasing ED utilization by AYAs will require a multiprolonged approach that may include improving rates of WCVs and should also consider opportunities to more effectively educate AYAs about appropriate use of different levels of care and increase access to the continuum of community-based mental health services.2021 core Set of Children’s health care Quality measures for Medicaid and CHIP (child core Set).
https://www.medicaid.gov/medicaid/quality-of-care/downloads/2021-child-core-set.pdf
Date accessed: September 6, 2021
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- Status complexicus? The emergence of pediatric complex care.Pediatrics. 2018; 141: S202-S211
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- Vermont all-payer ACO model Annual health outcomes and Quality of care Report performance Year Vermont all-payer ACO model Annual health outcomes and Quality of care Report Perform Year 1 (2018). 2020
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- The Use and Out-of-Pocket cost of urgent care clinics and retail-based clinics by adolescents and young adults compared with children.J Adolesc Health. 2017; 60: 107-112
- Demographic Trends of COVID-19 cases and deaths in the US reported to CDC.(Available at:)https://covid.cdc.gov/covid-data-tracker/#demographicsDate accessed: September 6, 2021
- A dangerous pandemic pair: Covid19 and adolescent mental health emergencies.Am J Emerg Med. 2021; 46: 776-777
- Coronavirus disease 2019 (COVID-19) and mental health for children and adolescents.JAMA Pediatr. 2020; 174: 819-820
- Mental health–related emergency department visits among children aged <18 Years during the COVID-19 pandemic — United States, January 1–October 17, 2020.MMWR Morb Mortal Wkly Rep. 2020; 69: 1675-1680
- Measuring Progress: Adoption of Alternative payment models in Commercial, Medicaid, Medicare Advantage, and Traditional Medicare Programs. 2019
- 2021 core Set of Children’s health care Quality measures for Medicaid and CHIP (child core Set).(Available at:)https://www.medicaid.gov/medicaid/quality-of-care/downloads/2021-child-core-set.pdfDate accessed: September 6, 2021
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- Assessing the Relationship Between Well-Care Visit and Emergency Department Utilization Among Adolescents and Young AdultsJournal of Adolescent HealthVol. 70Issue 1
