Administration of Emergency Medicine THE 2013 DIP: FACTORS INFLUENCING FALLING EMERGENCY DEPARTMENT VISITS AND INPATIENT ADMISSIONS IN DISTRICT OF COLUMBIA AND MARYLAND Khaled Alghamdi, MD,*†‡ Mark Zocchi, MPH,† William J. Frohna, MD,§ and Jesse M. Pines, MD, MBA, MSCE*† *Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, †Office for Clinical Practice Innovation, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia, ‡King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia, and §Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, District of Columbia Reprint Address: Jesse M. Pines, MD, MBA, MSCE, Department of Emergency Medicine, The George Washington University School of Medicine and Health Sciences, 2100 Pennsylvania Avenue NW, Room 314, Washington, DC 20037 , Abstract—Background: Earlier reports have docu- mented growth of United States emergency department (ED) visits since the early 1990s. Objective: In this report, we describe recent trends in ED utilization and inpatient ad- missions in Maryland and District of Columbia hospitals from 2011 to 2013. Methods: We analyzed monthly ED visit and inpatient admission volumes from 53 acute care hospi- tals in Maryland and the District of Columbia from 2011 to 2013. Fixed-effect regression was used to assess the rela- tionship between community-level demographics, hospital insurance mix, urgent care/retail clinic density, and hospi- tals participating in Maryland’s Total Patient Revenue (TPR) pilot—a global payment program—and changes in ED visit and hospital admission volume from 2012 to 2013. Results: Across 53 Maryland and District of Columbia hos- pitals, ED visits grew 2.8% between 2011 and 2012. From 2012 to 2013, ED visits declined by 3.5%. Admissions declined by 3.3% from 2011 to 2012, then declined again 3.6% from 2012 to 2013. Community demographic or hospi- tal insurance-mix variable and density of urgent care cen- ters were not associated with lower ED visits. Inpatient admissions fell significantly more in hospitals participating in Maryland’s TPR global payment pilot program. Conclu- sions: In 2013, ED visits in fell in Maryland and District of Columbia hospitals, and inpatient admission volumes fell from 2011 to 2013. This is a reversal of decades-long trends in higher health care utilization. These trends were not ex- plained by demographics, insurance, or ED alternatives, however, falling admission rates were more pronounced in Maryland hospitals participating in global payment programs. Ó 2016 Elsevier Inc. All rights reserved. , Keywords—ED visits; admission; utilization; trend; decline INTRODUCTION Since 1992 when the Centers for Disease Control and Prevention started reporting data on the use of United States (US) hospital-based emergency departments (ED), reported utilization has consistently outpaced pop- ulation growth. The most recent data available from the National Ambulatory Medical Care Survey estimated 2010 US ED visits at 129.8 million, compared to 94.7 million in 1997 (1,2). At the population level, there were 42.8 ED visits per 100 people in 2010 compared to 35.6 in 1997 (3). Higher utilization rates in EDs and other settings and rising health care costs have sparked concerns that these increases are unsustainable in the long term for the US economy. The Affordable Care Act (ACA) of 2010 was passed to address many of the systematic issues with the health care system, and it is expected that there will be a transformation of care delivery in the next decade. In acute care delivery, there has been a major focus on RECEIVED: 9 December 2014; FINAL SUBMISSION RECEIVED: 7 January 2016; ACCEPTED: 17 February 2016 1 The Journal of Emergency Medicine, Vol. -, No. -, pp. 1–5, 2016 Ó 2016 Elsevier Inc. All rights reserved. 0736-4679/$ - see front matter http://dx.doi.org/10.1016/j.jemermed.2016.02.028