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Research Article
Emergency Department Utilization by HIV-Infected South Carolina Residents, 1996-2015
Elise M Gruber, Abigail G Stock, Alyssa A Gitter and Kent J Stock*
Lowcountry Infectious Diseases & Infusion Center, Charleston, South Carolina, USA

ABSTRACT
Introduction
Emergency Department (ED) utilization by HIV-infected patients in the United States (US) exceeds that of the general population. The demographic characteristics of HIV-infected South Carolina (SC) residents who make ED visits in this state are important to delineate because ED visits are costly and potentially avoidable. Identifying high utilizer groups will allow for the better allocation of limited resources and prevent the costly and unnecessary use of EDs in SC.

Materials/Methods
A retrospective, twenty-year cohort study was conducted to examine the demographic characteristics of ED utilization on behalf of HIV-infected SC residents. The SC Uniform Billing database (UB-40 All Payer Hospital data) maintained by the SC Revenue and Fiscal Affairs Office was used for the study.

Results
A total of 29,909 ED visits were made by HIV-infected SC residents between 1996 and 2015. The total number of annual ED visits made by HIV-infected residents increased 246.5%, whereas ED visits made on behalf of all SC residents increased only 100.7% over the same period of time. HIV-infected males comprised 60.0% of the total ED visits. The annual ED visits made by HIV-infected males increased 211.8% compared to 309.1% for HIV-infected females in this state. The majority (73.3%) of HIV-infected SC residents making ED visits were African-American. African-Americans experienced a 250.8% increase in annual ED visits over time compared to a 238.2% increase in whites and a 1,300% increase among other minorities. The majority (58.92%) of ED visits occurred in the 18-44 year old age group. This age group realized a 96.8% increase in annual ED visits over time. Annual ED visits made by the 45-64 year old age group and the 65 and older age group increased 883.7% and 2,850.0%, respectively. The 0-17 year old age group was the only age group to experience a decrease (600%) during this period of time. The majority of SC counties with the highest total annual ED visit rates were rural.

Conclusion
Despite the introduction of cART HIV-infected SC residents make ED visits at a higher rate than the general population. Certain demographic groups appear to be disproportionately represented in the ED setting. By targeting these high utilizer groups, the state may better allocate resources and prevent the unnecessary and costly use of EDs in South Carolina.

Introduction
Emergency Department (ED) visits have increased nationally over the past two decades [1,2]. The increase in visits surpasses the rate of population growth alone [2]. The increase in ED visits does not appear to be reversing since the Affordable Care Act (ACA) was fully implemented in 2015 [3]. ED utilization by HIV-infected patients in the United States (US) exceeds that of the general population [4]. The ACA intended to reduce ED visits on behalf of HIV-infected individuals through the expansion of Medicaid coverage, mandated inclusion of preventative care services and by establishing “‘minimum essential benefits’ e.g., physician visits, hospital stays and prescription drugs...” by insurance companies [5]. ED utilization on behalf of HIV-infected South Carolina (SC) residents has not been characterized since Combination Antiretroviral therapy (cART) was widely introduced in 1996. The demographic characteristics are important to delineate because ED visits on behalf of HIV-infected patients can be costly and potentially avoidable [4,6,7]. Identifying high utilizer groups will allow for the better allocation of limited resources and prevent costly and unnecessary use of EDs in SC.
Materials and Methods
This retrospective, twenty-year cohort study was conducted to examine the demographic characteristics of ED utilization on behalf of HIV-infected SC residents. The SC Uniform Billing database (UB-04 All Payer Hospital Data) maintained by the SC Revenue and Fiscal Affairs Office was used for the study. Acute care facilities in SC (N=70) collected the data. Specialty rehabilitation centers were excluded. Both HIV-infected and non-infected SC residents were included in the study. The data set was limited to HIV-infected and non-infected SC residents who made ED visits between the years 1996-2015. Inclusion criteria stipulated HIV or AIDS be listed as a top ten ED visit diagnosis. HIV-infected SC residents who made ED visits in neighboring states were excluded. The data inquiry was performed on June 7, 2017.

The data included white and African-American residents. Alternative racial/ethnic groups are included in the designation “Other” due to small representation in the data set. Age was organized into groups consistent with those traditionally reported by the Center for Disease Control in Atlanta, Georgia. Additional variables included in the study were County of Origin and Gender. County of Origin is indicative of a patient’s county of residence rather than ED visit location.

The annual ED visit rate for HIV-infected SC residents was calculated by dividing the total number of ED visits made annually on behalf of HIV-infected residents by the total number of HIV-infected residents documented that year. The annual ED visit rate for all SC residents was calculated by using the number of ED visits made annually divided by the total state population documented that year. Annual ED visit rates for HIV-infected SC residents were calculated by County of Origin using similar, region-specific calculations in order to account for population disparities between counties. The total number of HIV-infected SC residents was obtained from the HIV surveillance report monitored by the STD/HIV Division, SC Department of Health and Environmental Control. Only SC residents were included. In 1981, the state of SC mandated that all AIDS cases be reported. A mandate was instituted in 1986 that all HIV cases be reported. The data inquiry used in the study was performed on September 27, 2017.

The total number of SC residents was obtained from data published by the US Census Bureau. For years that the total state or county population was unknown projections were formulated from data sets based on acceptable estimated rates of growth. The data inquiry used in the study was performed on September 27, 2017. Counties were designated as rural based on criteria established by the Office of Rural Health Policy, Health Resources and Service Administration in Rockville, Maryland. The information was based on US Census data from 2010. The data inquiry was made on October, 5, 2017.
Results
General trends
The total number of ED visits made from 1996-2015 by HIV-infected SC residents was 29,909. The lowest number of annual ED visits made by HIV-infected SC residents occurred in 1998 (N=780) while the highest number occurred in 2014 (N=2,703). The total number of annual ED visits for HIV-infected SC residents increased 246.54% over time (Figure 1). The total number of ED visits on behalf of all SC residents from 1996-2015 was 31,652,809. The lowest number of annual ED visits occurred in 1996 (N=1,055,510) while the highest number occurred in 2015 (N=2,118,602). This represents a 100.72% increase in ED visits on behalf of all SC residents during this period of time. The annual ED visit rate increased 55.67% for all SC residents and 88.03% for HIV-infected SC residents (Figure 2).
Gender
Males constituted 60.00% (N=17,947) of the total ED visits made by HIV-infected residents from 1996-2015 while 40.00% (N=11,962) of ED visits were made by females. The lowest number of annual ED visits on behalf of HIV-infected males occurred in 1998 (N=493) and the highest number occurred in 2014 (N=1,537), reflecting a 211.76% increase over time (Figure 3). The lowest number of annual ED visits on behalf of HIV-infected females occurred in 1999 (N=285) and the highest number of visits occurred in 2014 (N=1,166), reflecting a 309.12% increase over time. Male HIV-infected SC residents comprised 68.61% of ED visits in 1996 and 59.31% of ED visits in 2015. Females comprised 31.39% of ED visits in 1996 and 40.68% of ED visits in 2015.
Race/Ethnicity
The majority (73.26%) of HIV-infected SC residents who made ED visits between 1996 and 2015 were African-American (N=21,912). White HIV-infected SC residents comprised 25.27% of ED visits during this period of time (N=7,557). Minority groups not otherwise characterized comprised 1.47% of total ED visits (N=440). The total number of ED visits made annually on behalf of African-American HIV-infected SC residents peaked in 2014 (N=1,947) and was at its lowest in 1998 (N=555). This reflects a 250.81% increase in ED visits over the two decades studied (Figure 4). The total number of ED visits made annually on behalf of white HIV-infected SC residents peaked in 2014 (N=700) and was at its lowest in 1999 (N=207). This reflects a 238.16% increase in ED visits over the two decades studied. The total number of ED visits made annually on behalf of other minority groups peaked in 2014 and 2015 (N=56) and was at its lowest in 1997 and 1998 (N=4 for each year). This reflects a 1,300.00% increase in ED visits over the two decades studied.

The racial/ethnic composition of HIV-infected SC residents making ED visits has changed over time. In 1996, African-Americans comprised 73.50% of total ED visits, whites 26.03% and other racial/ethnic groups 0.47%. In 2015, African-Americans comprised 74.47% of total ED visits, whites 23.34% and other racial/ethnic groups 2.19%.
Age groups
The majority (58.92%) of HIV-infected SC residents who made ED visits between 1996 and 2015 were in the 18-44 year old age group (N=17,623). The 45-64 year old age group compromised 38.94% of total ED visits during this time (N=12,793). The 65 and older age group compromised 2.75% (N=260) of total ED visits and the 0-17 year old age group represented 0.79% (N=253) of the total ED visits. The total number of ED visits made annually on behalf of the 18-44 year old age group peaked in 2014 (N=1,210) and was at its lowest in 1998 (N=615). The percent increase in annual ED visits for this age group was 96.75% (Figure 5). The total number of ED visits made annually on behalf of the 45-64 year old age group peaked in 2014 (N=1,377) and was at its lowest in 1998 (N=140), indicating a 883.57% increase over time. The total number of ED visits made annually on behalf of the 65 and older age group peaked in 2015 (N=118) and was at its lowest in 1996 and 1998 (N=4 for each year). This represents a 2,850.00% increase in annual ED visits over time. The 0-17 year old age group recorded the highest number of annual ED visits in 1998 (N=21) and the lowest in 2010 (N=3), indicating a 600.00% decrease in annual ED visits over time.

The distribution of HIV-infected SC residents who made annual ED visits within specific age groups has changed over time. In 1996, the 18-44 year old age group comprised 83.27% of annual ED visits, the 45-64 year old age group, 14.94%, the 65 and older age group, 0.38% and the 0-17 year old age group, 1.41%. In 2015, the 18-44 year old age group comprised 45.38% of annual ED visits, the 45-64 year old age group, 49.84%, the 65+ year old age group, 4.62%, and the 0-17 year old age group, 0.16%.
County of origin
Charleston County had the largest number of ED visits on behalf of HIV-infected SC residents between 1996 and 2015 (N=3,967, 12.19%). McCormick County had the lowest number of ED visits during this period (N=57, 0.17%). The highest average annual ED visit rate occurred in Newberry County. The lowest average annual ED visit rate occurred in Edgefield County (Table 1).

The sixteen counties with the highest total annual ED visit rates made by HIV-infected county residents were Allendale, Bamberg, Chesterfield, Dillon, Fairfield, Florence, Georgetown, Greenwood, Laurens, Lexington, Marlboro, Newberry, Oconee, Saluda, Union and Williamsburg. Ten of these sixteen counties are considered rural (Figure 6). Several counties realized a decrease in their annual ED visit rate from 1996 to 2015. These counties were Aiken, Allendale, Anderson, Bamberg, Barnwell, Beaufort, Calhoun, Clarendon, Darlington, Dillon, Dorchester, Edgefield, Fairfield, Florence, Greenville, Greenwood, Jasper, Laurens, Lexington, Marion, Marlboro, Oconee, and Richland.
Discussion
This study aimed to define the demographic characteristics of HIV-infected SC residents who made ED visits since cART was widely introduced in 1996. This population-based study examined a twenty-year period from 1996-2015. Our investigation revealed many significant findings. The number of ED visits made annually by HIV-infected SC residents has increased over time. The rate of increase is greater than that of the general population and therefore cannot be attributed to population growth alone. Previously published studies have suggested similar trends nationwide [4,8,9]. The reasons for this finding are not known. Prior studies have suggested that HIV-infected patients that visit EDs’ have a higher admission rate and therefore may present in worse condition than their uninfected counterparts [4,7]. They are also more likely to use the ED for low urgency visits [6]. Poor access to preventative services, greater incidence of comorbidities, substance abuse, low socioeconomic status and lack of insurance may preferentially direct HIV-infected patients to use ED services more commonly than uninfected patients [6,10-12].

Males represent 49% of the total state population but comprise the majority (71%) of HIV infected residents [13]. Males also consistently make the majority of ED visits in this state, however, women have been shown to comprise a growing percentage of annual ED visits over time. This is contrasted by a 34% decrease in newly diagnosed HIV cases in women over the past ten years [13]. Prior authors have suggested HIV-infected women demonstrate increased health care utilization and are more likely to use the ED than their male counterparts [9,14-16]. This, paired with inadequate primary care engagement, may be contributing factors to this discrepancy [17,18].

African-Americans are disproportionately affected by HIV in the state of SC. They comprise 28% of the total state population but represent 69% of the total HIV cases in this state [19,13]. The majority of ED visits were made by African-Americans, reflecting high disease prevalence in this group. Unfortunately, an increasing percentage of annual ED visits are made by African-Americans or other minority groups. Racial disparities in care exist which may increase the need for minorities to utilize EDs to meet their health care needs [20,21]. Other variables that have been associated with higher ED utilization that are found commonly in minority groups include poverty, lack of insurance, cost barriers, poor access to medical care and inadequate testing [19,22-24].

The HIV population in SC is aging. HIV-infected residents age 50 and older represent 46.7% of the total infected patients compared to 37% of the total state population [13]. While the majority of ED visits from 1996-2015 were made by the 18-44 year old age group, the greatest increase in ED visits occurred in the 45-64 year old and 65 years and older age groups. This trend likely reflects the changing demographic characteristics of our state’s HIV population. In addition, the aging HIV population in our state is realizing an increase in age-related conditions that require additional medical care and services which likely contributes to ED utilization [25]. The only age group to realize a decrease in ED utilization over time was the 0-17 year old age group. This reflects the continued decrease in HIV incidence documented in this age group.

Finally, the majority (62.5%) of counties that were listed in the top third percentile for total annual ED visits rates from 1996-2015 are considered rural. Rural residents in the US face many health issues including physician or provider work shortages, a widening gap in life expectancy and a wave of hospital closures [26]. Rural residents tend to be less healthy than their urban counterparts in part because of poor lifestyle choices [27]. Medicaid covers a larger percentage of rural residents compared to urban dwellers and therefore inadequate insurance coverage and the lack of Medicaid expansion in SC may also be adversely affecting rural-based, HIV-infected residents’ access to preventative care [28]. Rural residents are more likely to have a low socioeconomic status and this has been shown to be associated with greater ED use for conditions that can be managed in the outpatient setting [12]. Rural counties are also less likely to receive HIV preventative services which are likely to unfavorably influence ED utilization [29].

Our study has several limitations. The uniform billing database does not contain ED visits made on behalf of HIV-infected South Carolina residents in other states. In addition the database does not include clinical information i.e., CD4 counts, use of cART, or whether they are currently in care. Despite the introduction of cART, SC HIV-infected residents make ED visits at a higher rate than the general population. Certain demographic groups appear to be disproportionately represented in the ED setting. By targeting these high utilizer groups, the state may begin to better allocate resources and prevent the unnecessary and costly use of EDs in South Carolina.

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Figures


Figure 1: Total annual ED visits made by all South Carolina residents (left axis) and HIV-infected SC residents (right axis), South Carolina hospitals, 1996-2015.




Figure 2: Annual ED visit rates among all South Carolina residents and HIV-infected South Carolina residents, South Carolina hospitals, 1996-2015.



Figure 3: Total number of annual ED visits on behalf of HIV-infected South Carolina residents by gender, South Carolina hospitals, 1996-2015.



Figure 4: Total annual ED visits on behalf of HIV-infected South Carolina residents by Race/Ethnicity, South Carolina hospitals, 1996-2015.



Figure 5: Total annual ED visits on behalf of HIV-infected South Carolina residents by age group, South Carolina hospitals, 1996-2015.

Tables

 

Total ED Visits 1996

Total ED Visits 2015

Total ED Visits 1996-2015

Annual ED Visit Rate 1996 (per 1,000 Residents)

Annual ED Visit Rate 2015 (per 1,000 Residents)

Average Annual ED Visit Rate 1996-2015 (per 1,000 Residents)

Abbeville

1

9

76

53

196

112

Aiken

12

19

233

65

46

38

Allendale

8

14

224

364

286

272

Anderson

27

30

397

162

83

75

Bamberg

13

10

282

217

99

174

Barnwell

10

5

215

161

40

115

Beaufort

20

41

519

121

97

78

Berkeley

2

66

969

10

134

133

Calhoun

3

3

81

143

60

100

Charleston

62

288

3652

61

144

118

Cherokee

7

36

224

156

387

143

Chester

6

26

79

150

277

54

Chesterfield

1

12

218

21

108

143

Clarendon

17

15

214

165

84

69

Colleton

13

42

271

137

228

85

Darlington

40

37

460

328

136

121

Dillon

27

18

358

474

122

191

Dorchester

21

50

674

156

127

118

Edgefield

1

2

35

16

14

18

Fairfield

1

1

303

23

10

178

Florence

119

97

1657

363

120

144

Georgetown

15

49

713

124

187

175

Greenville

124

200

1843

209

140

127

Greenwood

21

17

548

183

70

157

Hampton

1

27

321

22

185

140

Horry

54

243

1769

144

245

126

Jasper

6

9

89

130

88

54

Kershaw

20

53

406

206

272

130

Lancaster

4

128

427

58

472

94

Laurens

30

29

574

330

155

205

Lee

7

46

266

140

279

107

Lexington

68

28

1762

209

36

149

McCormick

0

0

56

0

0

132

Marion

26

36

254

289

211

103

Marlboro

19

15

437

229

112

199

Newberry

3

79

716

65

681

351

Oconee

20

7

179

500

81

152

Orangeburg

18

101

909

61

201

105

Pickens

5

21

179

79

135

80

Richland

124

127

2984

85

38

58

Saluda

0

1

83

0

26

143

Spartanburg

36

220

1716

105

285

141

Sumter

40

233

1417

113

345

119

Union

1

10

164

37

182

198

Williamsburg

5

26

642

57

103

180

York

6

39

356

28

71

40

Table 1: Counties in South Carolina with the highest and lowest total sum of ED visit rates on behalf of HIV-infected residents from 1996 to 2015, South Carolina Hospitals 1996-2015.

Citation: Gruber EM, Stock AG, Gitter AA, Stock KJ (2019) Emergency Department Utilization by HIV-Infected South Carolina Residents, 1996-2015. J AIDS Clin Res Sex Transm Dis 6: 022.
Copyright: © 2019 Gruber EM, et al., This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.