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Rotily M, Persico N, Lamouroux A, Rojas-Vergara AC, Loundou A, Boucekine M, Apostolidis T, Odena S, Chischportich C, Auquier P. Health mediation does not reduce the readmission rate of frequent users of emergency departments living in precarious conditions: what lessons can be learned from this randomised controlled trial? BMC Emerg Med 2024; 24:83. [PMID: 38750416 PMCID: PMC11094847 DOI: 10.1186/s12873-024-01000-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2024] [Accepted: 05/06/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND Severe overcrowding of emergency departments (EDs) affects the quality of healthcare. One factor of overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. The primary aim was to determine whether HM intervention for frequent users of EDs (FUED) living in precarious conditions could reduce the readmission rate at 90 days. METHODS Between February 2019 and May 2022, we enrolled and interviewed 726 FUED in four EDs of southeastern France in this randomised controlled trial. The HM intervention started in the ED and lasted 90 days. In addition to the primary endpoint (first readmission at 90 days), secondary endpoints (readmission at 30 and 180 days, number of hospitalisations at 30, 90, 180 days, admissions for the same reasons as the first admission) were also studied. The outcomes were measured in the ED information systems. Statistical methods included an intention-to-treat analysis and a per-protocol analysis. Comparisons were adjusted for gender, age, ED, and health mediator. RESULTS 46% of patients reported attending the ED because they felt their life was in danger, and 42% had been referred to the ED by the emergency medical dispatch centre or their GP; 40% of patients were considered to be in a serious condition by ED physicians. The proportion of patients who were readmitted at 90 days was high but did not differ between the control and the HM intervention groups (31.7% vs. 36.3%, p = 0.23). There was no significant difference in any of the secondary outcome measures between the control and HM intervention groups. Per-protocol analysis also showed no significant difference for the primary and secondary endpoints. CONCLUSIONS This randomised controlled trial did not show that our health mediation intervention was effective in reducing the use of emergency services by FUED living in precarious conditions. Some limitations are discussed: the duration of the intervention (90 days), the long-term effects (> 6 months), the involvement of the ED staff. TRIAL REGISTRATION Registered on clinicaltrials.gov as NCT03660215 on 4th September 2018.
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Affiliation(s)
- Michel Rotily
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France.
| | - Nicolas Persico
- Service des Urgences, Hôpital Nord, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Aurore Lamouroux
- Centre de santé hospitalo-universitaire des Aygalades, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Ana Cristina Rojas-Vergara
- Centre de santé hospitalo-universitaire des Aygalades, Assistance Publique Hôpitaux de Marseille, Marseille, France
| | - Anderson Loundou
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France
| | - Mohamed Boucekine
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France
| | - Themistoklis Apostolidis
- Laboratoire de Psychologie Sociale (LPS), Aix Marseille Université, Aix en Provence, Marseille, France
| | - Sophie Odena
- Laboratoire d'Economie et de Sociologie du Travail, Aix Marseille Université, Centre National de la Recherche Scientifique, Aix en Provence, Marseille, France
| | | | - Pascal Auquier
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France
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Naït Salem R, Rotily M, Apostolidis T, Odena S, Lamouroux A, Chischportich C, Persico N, Auquier P. Health mediation: an intervention mode for improving emergency department care and support for patients living in precarious conditions. BMC Health Serv Res 2023; 23:495. [PMID: 37194100 PMCID: PMC10186303 DOI: 10.1186/s12913-023-09522-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 05/09/2023] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Severe overcrowding of emergency departments (EDs) impacts the quality of healthcare. One factor of this overcrowding is precariousness, but it has rarely been considered a key factor in designing interventions to improve ED care. Health mediation (HM) aims to facilitate access to rights, prevention, and care for the most vulnerable persons and to raise awareness among healthcare providers about obstacles in accessing healthcare. We here present the results of an ancillary qualitative study to explore the prospects regarding a health mediation intervention implemented in EDs for deprived persons who are frequent ED users, from professionals' and patients' perspectives. METHODS Design, data collection, and data analysis were done according to a psychosocial approach, based on thematic content analysis and semi-structured interviews of 16 frequent ED users and deprived patients exposed to HM and of 14 professionals in 4 EDs of South-eastern France. RESULTS All patients reported multifactorial distress. Most of them expressed experiencing isolation and powerlessness, and lacking personal resources to cope with healthcare. They mentioned the use of ED as a way of quickly meeting a professional to respond to their suffering, and recognized the trustworthy alliance with health mediators (HMrs) as a means to put them back in a healthcare pathway. The presence of HMrs in EDs was appreciated by ED professionals because HMrs responded to requests they were not able to access and were perceived as an efficient support for caring for deprived persons in emergency contexts. CONCLUSIONS Our results are in favour of health mediation in EDs as a promising solution, requested by patients and ED professionals, to cope with frequent ED users and deprived patients. Our results could also be used to adapt other strategies for the most vulnerable populations to reduce the frequency of ED readmissions. At the interface of the patients' health experience and the medico-social sector, HM could complete the immediate responses to medical needs given in EDs and contribute in alleviating the social inequalities of health.
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Affiliation(s)
- Riwan Naït Salem
- Laboratoire de Psychologie Sociale (LPS), Aix Marseille Université, Aix-en-Provence, France
| | - Michel Rotily
- Centre de Santé Universitaire - Espace Santé Aygalades - Assistance Publique Hopitaux de Marseille, Marseille, France.
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France.
| | | | - Sophie Odena
- Aix Marseille Univ, CNRS, LEST, Aix-en-Provence, France
| | - Aurore Lamouroux
- Centre de Santé Universitaire - Espace Santé Aygalades - Assistance Publique Hopitaux de Marseille, Marseille, France
| | | | - Nicolas Persico
- Service d'Accueil des Urgences Adultes, Hopital Nord, Assistance Publique Hopitaux de Marseille, Marseille, France
| | - Pascal Auquier
- Centre d'Etudes et de Recherche sur les services de santé et la qualité de vie (CEReSS), Aix Marseille Université, Marseille, France
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Ordonez E, Dowdell K, Navejar N, Dongarwar D, Itani A, Salihu H. An Assessment of the Social Determinants of Health in an Urban Emergency Department. West J Emerg Med 2021; 22:890-897. [PMID: 35354001 PMCID: PMC8328163 DOI: 10.5811/westjem.2021.4.50476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 04/03/2021] [Indexed: 11/11/2022] Open
Abstract
Introduction: Social determinants of health (SDOH) have significant impacts on patients who seek care in the emergency department (ED). We administered a social needs screening tool and needs assessment survey to assess SDOH and evaluate for trends in the population of patients visiting our ED.
Methods: A survey was distributed via convenience sampling to adult ED patients to capture self-reported demographic information and data about social needs. We categorized the questions related to SDOH based on the International Classification of Diseases, Tenth Revision, Clinical Modification coding format and created a composite variable called “SDOH Strata” based on the SDOH Index scores (0-5-low, 6-10-middle, or ≥11-high). We conducted bivariate analyses using the sociodemographic characteristics of the patients and their SDOH Strata using Fisher’s exact test. We then conducted multinomial logistic regression to examine the association between the patients’ sociodemographic characteristics and the SDOH Strata.
Results: A total of 269 surveys were collected. We observed that Hispanic/Latino patients were more than two times as likely (odds ratio: 2.04, 95% confidence interval [CI], 1.12,-6.51) to be in the higher impact stratum than in the lower impact stratum. Those who were undocumented had 3.43 times increased adjusted odds (95% CI, 1.98, 9.53) of being in the higher than the lower impact stratum compared to US citizens. Additionally, people speaking Spanish as their primary language were 5.16 times as likely to be in the higher impact stratum compared to the reference (English-speaking and lower impact stratum).
Conclusion: In our patient population, patients noted to have the highest impact burden of the SDOH were those who identified as Hispanic/Latino, Spanish-speaking, and undocumented immigrant status.
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Affiliation(s)
- Edgardo Ordonez
- Baylor College of Medicine, Henry J.N. Taub Department of Emergency Medicine, Houston, Texas; Baylor College of Medicine Center of Excellence in Health Equity, Training and Research, Houston, Texas
| | - Katherine Dowdell
- Baylor College of Medicine, Henry J.N. Taub Department of Emergency Medicine, Houston, Texas
| | - Natasha Navejar
- Baylor College of Medicine Center of Excellence in Health Equity, Training and Research, Houston, Texas
| | - Deepa Dongarwar
- Baylor College of Medicine Center of Excellence in Health Equity, Training and Research, Houston, Texas
| | - Aya Itani
- Baylor College of Medicine, Henry J.N. Taub Department of Emergency Medicine, Houston, Texas
| | - Hamisu Salihu
- Baylor College of Medicine Center of Excellence in Health Equity, Training and Research, Houston, Texas
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Miller J, McNaughton C, Joyce K, Binz S, Levy P. Hypertension Management in Emergency Departments. Am J Hypertens 2020; 33:927-934. [PMID: 32307541 PMCID: PMC7577644 DOI: 10.1093/ajh/hpaa068] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2019] [Revised: 02/25/2020] [Accepted: 04/15/2020] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND Elevated blood pressure (BP) is pervasive among patients that visit emergency departments (EDs) for their care. METHODS In this review article, we outline the current approach to the management of these individuals and highlight the crucial role emergency medicine clinicians play in reducing the morbidity associated with elevated BP. RESULTS We highlight the critical importance of immediate treatment when elevated BP contributes to new or worsening end-organ injury but emphasize that such hypertensive emergencies are rare. For the vast majority of patients with elevated BP in the ED who do not have new or worsening end-organ injury from elevated BP, immediate BP reduction within the ED is not recommended or safe. Nonetheless, within weeks after an ED visit, there is a pressing need to improve the care of patients with elevated or previously undiagnosed hypertension. For many, it may be their only regular point of engagement with the healthcare system. To address this, we present novel perspectives that envision a new role for emergency medicine in chronic hypertension management-one that acknowledges the significant population-level gaps in BP control that contribute to disparities in cardiovascular disease and sets the stage for future changes in systems-based practice. CONCLUSIONS Emergency medicine plays a key and evolving role in reducing morbidity associated with elevated BP.
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Affiliation(s)
- Joseph Miller
- Henry Ford Hospital, Detroit, Michigan, USA
- Wayne State University, Detroit, Michigan, USA
| | - Candace McNaughton
- Vanderbilt University Medical Center and Tennessee Valley Healthcare System VA, Nashville, Tennessee, USA
| | - Katherine Joyce
- Henry Ford Hospital, Detroit, Michigan, USA
- Wayne State University, Detroit, Michigan, USA
| | - Sophia Binz
- Henry Ford Hospital, Detroit, Michigan, USA
- Wayne State University, Detroit, Michigan, USA
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Poon SJ, Roumie CL, O'Shea CJ, Fabbri D, R Coco J, Collins SP, D Levy P, McNaughton CD. Association of Elevated Blood Pressure in the Emergency Department With Chronically Elevated Blood Pressure. J Am Heart Assoc 2020; 9:e015985. [PMID: 32508176 PMCID: PMC7429032 DOI: 10.1161/jaha.119.015985] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Emergency department (ED) visits for hypertension are rising, but the importance of elevated blood pressure (BP) measured during the ED visit is controversial. We evaluated the relationship between ED BP and mean BP over the subsequent year. Methods and Results We performed a retrospective cohort study from January 1, 2010 to December 31, 2013 of 8105 adult patients who made 1 visit to an academic medical center ED with ≥2 ED BPs and ≥2 BPs measured in the subsequent year. The primary exposure was lowest ED systolic BP. The primary outcome was mean systolic BP ≥140 mm Hg over the year following the index ED visit. Diastolic BP was examined as a secondary exposure and outcome. Multiple logistic regression was performed adjusting for several covariates, with interaction terms for hypertension diagnosis, ED disposition, pain-related ED chief complaint, and sex. Patients whose lowest ED systolic BP was 140 to 159 mm Hg had an adjusted odds ratio of having a mean SBP ≥140 mm Hg in the subsequent year of 10.9 (95% CI, 7.6-15.6). Patients without diagnosed hypertension and ED BP 140/90 to 159/99 mm Hg were more likely to have elevated BP in the following year. Hospitalization increased the likelihood of persistently elevated systolic BP but not diastolic BP. There was no effect modification by pain-related ED complaint. Conclusions When ED BP is consistently elevated, BP is highly likely to remain elevated in the subsequent year, regardless of pain, and particularly among patients without diagnosed hypertension. Further research is needed to determine the optimal management of elevated ED BP.
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Affiliation(s)
- Sabrina J Poon
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
| | - Christianne L Roumie
- Department of Medicine Vanderbilt University Medical Center Nashville TN.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center HSR&D Center Nashville TN
| | - Colin J O'Shea
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN
| | - Daniel Fabbri
- Department of Biomedical Informatics Vanderbilt University Medical Center Nashville TN.,Department of Electrical Engineering and Computer Science Vanderbilt University Nashville TN
| | - Joseph R Coco
- Department of Biomedical Informatics Vanderbilt University Medical Center Nashville TN
| | - Sean P Collins
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center HSR&D Center Nashville TN
| | - Phillip D Levy
- Department of Emergency Medicine and Integrative Biosciences Center Wayne State University Detroit MI
| | - Candace D McNaughton
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN.,Veterans Health Administration-Tennessee Valley Healthcare System Geriatric Research Education Clinical Center HSR&D Center Nashville TN
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