Appropriate standards for "appropriateness" research

Effectiveness of hospital emergency department regionalization and categorization policy on appropriate patient emergency care use: a nationwide observational study in Taiwan

BACKGROUND

Emergency department (ED) overcrowding is a health services issue worldwide. Modern health policy emphasizes appropriate health services utilization. However, the relationship between accessibility, capability, and appropriateness of ED use is unknown. Thus, this study aimed to examine the effect of hospital ED regionalization policy and categorization of hospital emergency capability policy (categorization policy) on patient-appropriate ED use.

METHODS

Taiwan implemented a nationwide three-tiered hospital ED regionalization and categorization of hospital emergency capability policies in 2007 and 2009, respectively. We conducted a retrospective observational study on the effect of emergency care policy intervention on patient visit. Between 2005 and 2011, the Taiwan National Health Insurance Research Database recorded 1,835,860 ED visits from 1 million random samples. ED visits were categorized using the Yang-Ming modified New York University-ED algorithm. A time series analysis was performed to examine the change in appropriate ED use rate after policy implementation.

RESULTS

From 2005 to 2011, total ED visits increased by 10.7%. After policy implementation, the average appropriate ED visit rate was 66.9%. The intervention had no significant effect on the trend of appropriate ED visit rate.

CONCLUSIONS

Although regionalization and categorization policies did increase emergency care accessibility, it had no significant effect on patient-appropriate ED use. Further research is required to improve data-driven policymaking.

[Not Available]

Zusammenfassung. Es lässt sich in den westlichen Industrienationen eine deutliche Zunahme der Inanspruchnahme von Zentralen Notaufnahmen (ZNA) der Krankenhäuser beobachten. Aufgrund der Flüchtlingswelle erhält dieses Thema zusätzliche Brisanz. In Städten machen Migranten einen relevanten Teil des Patientengutes der ZNAs aus, trotzdem sind sie in der Versorgungsforschung bisher nicht angemessen repräsentiert. Die retrospektive Studie beleuchtet die Entwicklung der Inanspruchnahme einer Universitären Notaufnahme durch Migranten bezüglich Patientenzahlen differenziert nach Soziodemografie, Wochentag und Zuweisungsart über zehn Jahre. Bei der jährlich steigenden Behandlungszahl in Notaufnahmen kommt es zu einem überproportionalen Anstieg von ausländischen Patientenkontakten. Der aufgezeigte Trend wird zunehmen und es sollte bei der Planung von notfallmedizinischen Vorhalteleistungen die soziodemografische Struktur berücksichtigt werden, insbesondere sollte sich die Notfallmedizin auf zusätzlich migrationsspezifisch veränderte Anforderungen einstellen.

The proportion of potentially preventable emergency department visits by patients with sickle cell disease

BACKGROUND

Emergency department (ED) visits by children with sickle cell disease (SCD) are often classified as urgent based on resource utilization. This classification may not accurately reflect the potentially preventable nature of SCD visits. We sought to determine the proportion of SCD crisis-related pediatric ED visits that are possibly preventable.

PROCEDURE

We reviewed 2 years of ED visits with a diagnosis of SCD with crisis at a hospital with an established sickle cell program. Criteria for preventable visits were predefined by pediatric hematologists. Non-pain-related chief complaints requiring emergent evaluation or painful episodes preceded by 2 opioid doses were considered not preventable; others were potentially preventable.

RESULTS

The study included 603 visits by 187 patients; 33% were potentially preventable. Overall, 29% of visits were emergent based on non-pain-related emergent complaints. Of the remaining pain-related visits, 26% were preceded by 2 or more doses of opioids at home. Visits by children with asthma were 0.58 times as likely to be preventable, due to more non-pain-related emergent chief complaints (32%) and more children (36%) taking 2 or more opioid doses.

CONCLUSIONS

Approximately two thirds of SCD crisis-related pediatric ED visits are not immediately preventable; that percentage is higher in children with asthma.

Comparison of presenting complaint vs discharge diagnosis for identifying " nonemergency" emergency department visits

IMPORTANCE

Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patient's diagnosis upon ED discharge appears to reflect a "nonemergency" condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care.

OBJECTIVE

To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use.

DESIGN, SETTING, AND PARTICIPANTS

The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all "primary care-treatable" visits. The 2009 NHAMCS data set contains 34,942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses.

MAIN OUTCOMES AND MEASURES

Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits.

RESULTS

Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care-treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care-treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room.

CONCLUSIONS AND RELEVANCE

Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.

Does Access to Comprehensive Outpatient Care Alter Patterns of Emergency Department Utilization Among Uninsured Patients in East Baltimore?

Background: The annual number of emergency department (ED) visits in the United States increased 23% between 1997 and 2007. The uninsured and those with chronic medical conditions are high users of emergency care. Objective: We sought to determine whether access to comprehensive outpatient primary and specialty care and care coordination provided by The Access Partnership (TAP) reduced ED utilization among uninsured patients relative to patients who chose not to enroll. Methods: Multiple time series analysis was performed to examine rates of ED utilization and inpatient admission among TAP patients and a comparison group of eligible patients who did not join (non-TAP patients). Monthly ED utilization and inpatient admission rates for both groups were examined prior to and subsequent to referral to TAP, within a study period 2007-2011. Results: During the study period, 623 patients were eligible to enroll, and 374 joined the program. Rates of ED visits per month increased in both groups. Compared with non-TAP patients, TAP patients had 2.0 fewer ED visits not leading to admission per 100 patient-months post-TAP ( P = .03, 95% confidence interval = 0.2-3.9). TAP status was a moderate predictor of ED visits not leading to admission, after controlling for age, gender, and zip code ( P = .04, 95% confidence interval = 0.1-3.9). Conclusions: Although overall ED utilization did not change significantly between program participants and nonparticipants, TAP patients had a lower rate of ED visits not resulting in inpatient admission relative to the comparison group.

Impact of policy changes on emergency department use by Medicaid enrollees in Oregon

OBJECTIVE

In 2003, Oregon's Medicaid expansion program, the Oregon Health Plan (OHP), implemented premiums and copayments and eliminated outpatient behavioral health services. We ascertained whether these changes, including $50 copayments for emergency department (ED) visits, affected ED use.

METHODS

This study used statewide administrative data on 414,009 adult OHP enrollees to compare ED utilization rates (adjusted for patient characteristics) in 3 time periods: (1) before the cutbacks, (2) after the cutbacks, and (3) after partial restoration of benefits. We examined overall ED visits and several subsets of ED visits: visits requiring hospital admission, injury-related, drug-related, alcohol-related, and other psychiatric visits. Because the policy changes affected only the expansion program (OHP Standard), we ascertained the impact of these changes compared with a control group of categorically eligible Medicaid enrollees (OHP Plus).

RESULTS

Compared with the control group, case-mix-adjusted ED utilization rates fell 18% among OHP Standard enrollees after the cutbacks. The rate of ED visits leading to hospitalization fell 24%. Injury-related visits and psychiatric visits excluding chemical dependency exhibited a similar pattern to overall ED visits. Drug-related ED visits increased 32% in the control group, perhaps reflecting the closure of drug treatment programs after the cutbacks reduced their revenue.

CONCLUSION

The policy changes were followed by a substantial reduction in ED use. That ED visits requiring hospital admission fell to about the same extent as overall ED use suggests that OHP enrollees may have been discouraged from using EDs for emergencies as well as less-serious problems.

Derivation and reliability of an instrument to estimate medical benefit of emergency treatment

OBJECTIVES

For many patients, it is difficult to define the benefit derived from a visit to the emergency department (ED). No criterion standard exists that defines benefit from emergency treatment compared to routine outpatient care, and our limited ability to estimate benefit from emergency treatment has significant implications for emergency care-related health services research. The objectives of this study were to develop a decision algorithm to be used in estimating benefit of emergency treatment (EBET) and to assess its reliability when applied to patients making unscheduled ED visits.

METHODS

The EBET instrument defines benefit as a 3-level outcome, namely, significant, possible, or unlikely, and its content validity was assessed through expert review. The instrument was independently applied by multiple investigators to 3 different ED patient cohorts. A consensus-based process was used to determine the final EBET for each patient visit. Weighted kappas and their 95% confidence intervals were calculated to assess the reliability of the EBET Instrument applied individually, and the Spearman-Brown formula was used to assess the overall reliability of the EBET instrument when applied using multiple raters and a standardized consensus process.

RESULTS

A total of 875 visits (300 from a general ED population, 300 from a homeless ED population, and 275 from an HIV-infected ED population) were scored using the EBET instrument. The consensus process included independently scoring groups ranging from approximately 50 to 100 patient visits, determining the level of agreement, discussing the discordant results among the investigators, and assigning a final EBET category to each visit. This process was repeated sequentially until all visits within each cohort were scored. The overall weighted kappas ranged from 0.66 to 0.76, and the Spearman-Brown correlation ranged from 0.83 to 0.87.

CONCLUSIONS

The EBET instrument demonstrated good to excellent reliability when applied independently by raters to both unselected and selected ED patients. Its reliability, however, was excellent to outstanding when multiple raters applied it using a consensus process. The EBET instrument may serve as a useful tool for defining benefit from emergency treatment.

Paramedic determinations of medical necessity: a meta-analysis

INTRODUCTION

Reducing unnecessary ambulance transports may have operational and economic benefits for emergency medical services (EMS) agencies and receiving emergency departments. However, no consensus exists on the ability of paramedics to accurately and safely identify patients who do not require ambulance transport. Objective. This systematic review and meta-analysis evaluated studies reporting U.S. paramedics' ability to determine medical necessity of ambulance transport.

METHODS

PubMed, Cumulative Index to Nursing and Allied Health Literature (CINAHL), and Cochrane Library databases were searched using Cochrane Prehospital and Emergency Care Field search terms combined with the Medical Subject Headings (MeSH) terms "triage"; "utilization review"; "health services misuse"; "severity of illness index," and "trauma severity indices." Two reviewers independently evaluated each title to identify relevant studies; each abstract then underwent independent review to identify studies requiring full appraisal. Inclusion criteria were original research; emergency responses; determinations of medical necessity by U.S. paramedics; and a reference standard comparison. The primary outcome measure of interest was the negative predictive value (NPV) of paramedic determinations. For studies reporting sufficient data, agreement between paramedic and reference standard determinations was measured using kappa; sensitivity, specificity, and positive predictive value (PPV) were also calculated.

RESULTS

From 9,752 identified titles, 214 abstracts were evaluated, with 61 studies selected for full review. Five studies met the inclusion criteria (interrater reliability, kappa = 0.75). Reference standards included physician opinion (n = 3), hospital admission (n = 1), and a composite of physician opinion and patient clinical circumstances (n = 1). The NPV ranged from 0.610 to 0.997. Results lacked homogeneity across studies; meta-analysis using a random-effects model produced an aggregate NPV of 0.912 (95% confidence interval: 0.707-0.978). Only two studies reported complete 2 x 2 data: kappa was 0.105 and 0.427; sensitivity was 0.992 and 0.841; specificity was 0.356 and 0.581; and PPV was 0.158 and 0.823.

CONCLUSION

The results of the few studies evaluating U.S. paramedic determinations of medical necessity for ambulance transport vary considerably, and only two studies report complete data. The aggregate NPV of the paramedic determinations is 0.91, with a lower confidence limit of 0.71. These data do not support the practice of paramedics' determining whether patients require ambulance transport. These findings have implications for EMS systems, emergency departments, and third-party payers.

An evaluation of the appropriateness of advice and healthcare contacts made following calls to NHS Direct Wales

Background

An evaluation of NHS Direct Wales (NHSDW), a national telephone-based healthcare advice and information service, was undertaken. A key objective was to describe the actions of callers and assess the appropriateness of advice and healthcare contacts made following calls, results of which are reported here.

Methods

Postal questionnaires were sent to consecutive callers to NHSDW in May 2002 and February 2004 to determine 1) callers' actions following calls and 2) their views about the appropriateness of: advice given; and when to seek further care. An independent clinical panel agreed and applied a set of rules about healthcare sites where examinations, investigations, treatments and referrals could be obtained. The rules were then applied to the subsequent contacts to healthcare services reported by respondents and actions were classified in terms of whether they had been necessary and sufficient for the care received.

Results

Response rates were similar in each survey: 1033/1897 (54.5%); 606/1204 (50.3%), with 75% reporting contacting NHSDW. In both surveys, nearly half of all callers reported making no further healthcare contact after their call to NHSDW. The most frequent subsequent contacts made were with GPs.

More than four fifths of callers rated the advice given - concerning any further care needed and when to seek it - as appropriate (further care needed: survey 1: 673/729, 82.3%; survey 2: 389/421, 92.4%; when to seek further care - survey 1: 462/555, 83.2%; survey 2: n = 295/346, 85.3%). A similar proportion of cases was also rated through the rule set and backed up by the clinical panel as having taken necessary and sufficient actions following their calls to NHSDW (survey 1: 624/729, 80.6%; survey 2: 362/421, 84.4%), with more unnecessary than insufficient actions identified at each survey (survey 1: unnecessary 132/729, 17.1% versus insufficient 11/729, 1.4%; survey 2: unnecessary 47/421, 11.0% versus insufficient 14/421, 3.3%).

Conclusion

Based on NHSDW caller surveys responses and applying a transparent rule set to caller actions a large majority of subsequent actions were assessed as appropriate, with insufficient contacts particularly infrequent. The challenge for NHSDW is to reduce the number of unnecessary contacts made following calls to the service, whilst maintaining safety.

Urgency classification methods for emergency department visits: do they measure up?

Across the United States, emergency departments (EDs) are plagued by overcrowding and its deleterious effects. Consequently, investigators have attempted to identify a subset of nonurgent patients who could potentially be managed in alternative settings to help alleviate the burden of overcrowding. Previous authors have used several methods to define ED visit urgency; however, the lack of a single valid method has resulted in widely variable estimates of nonurgent ED use. Accurate identification of nonurgent ED visits is necessary to compare nonurgent populations across health care settings and design safe, effective interventions aimed at reducing ED overcrowding. In this paper, we review the currently used methods for the classification of ED visit urgency, discuss the implications of measurement of ED urgency for health care stakeholders, and suggest future directions for the feasible, practical measurement of ED urgency.

Why non-urgent patients choose emergency over primary care services? Empirical evidence and managerial implications

OBJECTIVE

To investigate structural and psychological factors that lead non-urgent patients to choose the Accidents & Emergency Department (A&ED) rather than primary care services.

DATA SOURCES

Data were collected through interviews by means of a structured questionnaire. Data regarding the A&ED sample were also drawn from the database of the department.

STUDY DESIGN

Hypotheses were tested in a survey comparing A&ED non-urgent patients and patients using GP surgeries. Different perceptions of the characteristics of A&ED and primary care services were measured and a perceptual map was created using the linear discriminant analysis (LDA).

DATA COLLECTION

Emergency services users were interviewed in the A&ED of the General Hospital of the Province of Macerata (Italy). Primary care users were interviewed in four GP surgeries. 527 patients were interviewed between December 2006 and February 2007.

PRINCIPAL FINDINGS

A&ED and primary care patients look for different characteristics as diagnostic and therapeutic potentialities, empathy and competence, quick access or long-lasting relationship. Information asymmetry explains part of the behaviour.

CONCLUSIONS

Use of A&ED services for non-urgent care can be reduced. The understanding of reasons underlying the choice and a change in access, timing and contents of care/services provided by general practitioners (GPs) might provide incentives for shifting from A&ED to GPs surgeries.

Impact of Medicaid cutbacks on emergency department use: the Oregon experience

STUDY OBJECTIVE

Federal policy changes and tightened state budgets may reduce Medicaid enrollment in many states. In March 2003, the Oregon Health Plan (Oregon's Medicaid expansion program) made substantial changes in its benefit package that resulted in the disenrollment of more than 50,000 beneficiaries. We sought to study the impact of these Oregon Health Plan policy changes on statewide emergency department (ED) use.

METHODS

In this observational study, hospital billing data on 2,680,954 visits to 26 Oregon EDs were obtained, sampled up to 24 months before and 24 months after the cutbacks. These visits represent approximately 62% of all visits to Oregon's 58 EDs. We ascertained counts of ED visits by payer group before and after the Oregon Health Plan cutback date, plus hospital admissions from the ED as a measure of acuity.

RESULTS

After the Oregon Health Plan policy changes, ED visits by the uninsured underwent an abrupt and sustained increase, from 6,682 per month in 2002 to 9,058 per month in 2004. Oregon Health Plan-sponsored and commercially insured visits decreased, resulting in a slight decrease in overall ED visits. Multivariable models adjusting for secular trends and seasonality showed a 20% (95% confidence interval 13% to 28%) increase in uninsured ED visits, whereas the adjusted number of Oregon Health Plan-sponsored visits decreased. The proportion of uninsured ED visits resulting in hospital admission increased (odds ratio 1.50; 95% confidence interval 1.39 to 1.62).

CONCLUSION

Oregon's Medicaid cutbacks were followed by increases in ED use and hospitalizations by the uninsured. Recent federal legislation facilitating similar Medicaid changes in other states may lead to replication of these events elsewhere.

Characteristics of non-urgent patients. Cross-sectional study of emergency department and primary care patients

OBJECTIVE

To describe characteristics of patients seeking medical attention for non-urgent conditions at an emergency department (ED) and patients who use non-scheduled services in primary healthcare.

DESIGN

Descriptive cross-sectional study.

SETTING

Primary healthcare centres and an ED with the same catchment area in Stockholm, Sweden.

PATIENTS

Non-scheduled primary care patients and non-referred non-urgent ED patients within a defined catchment area investigated by structured face-to-face interviews in office hours during a nine-week period.

MAIN OUTCOME MEASURES

Sociodemographic characteristics, chief complaints, previous healthcare use, perception of symptoms, and duration of symptoms before seeking care.

RESULTS

Of 924 eligible patients, 736 (80%) agreed to participate, 194 at the ED and 542 at nine corresponding primary care centres. The two groups shared demographic characteristics except gender. A majority (47%) of the patients at the primary care centres had respiratory symptoms, whereas most ED patients (52%) had digestive, musculoskeletal, or traumatic symptoms. Compared with primary care patients, a higher proportion (35%) of the ED patients had been hospitalized previously. ED patients were also more anxious about and disturbed by their symptoms and had had a shorter duration of symptoms. Both groups had previously used healthcare frequently.

CONCLUSIONS

Symptoms, previous hospitalization and current perception of symptoms seemed to be the main factors discriminating between patients studied at the different sites. There were no substantial sociodemographic differences between the primary care centre patients and the ED patients.

Categorizing urgency of infant emergency department visits: agreement between criteria

BACKGROUND

The lack of valid classification methods for emergency department (ED) visit urgency has resulted in large variation in reported rates of nonurgent ED utilization.

OBJECTIVES

To compare four methods of defining ED visit urgency with the criterion standard, implicit criteria, for infant ED visits.

METHODS

This was a secondary data analysis of a prospective birth cohort of Medicaid-enrolled infants who made at least one ED visit in the first six months of life. Complete ED visit data were reviewed to assess urgency via implicit criteria. The explicit criteria (adherence to prespecified criteria via complete ED charts), ED triage, diagnosis, and resources methods were also used to categorize visit urgency. Concordance and agreement (kappa) between the implicit criteria and alternative methods were measured.

RESULTS

A total of 1,213 ED visits were assessed. Mean age was 2.8 (SD +/- 1.78) months, and the most common diagnosis was upper respiratory infection (21.0%). Using implicit criteria, 52.3% of ED visits were deemed urgent. Urgent visits using other methods were as follows: explicit criteria, 51.8%; ED triage, 60.6%; diagnosis, 70.3%; and resources, 52.7%. Explicit criteria had the highest concordance (78.3%) and agreement (kappa = 0.57) with implicit criteria. Of limited data methods, resources demonstrated the best concordance (78.1%) and agreement (kappa = 0.56), while ED triage (67.9%) and diagnosis (71.6%) exhibited lower concordance and agreement (kappa = 0.35 and kappa = 0.42, respectively). Explicit criteria and resources equally misclassified urgency for 11.1% of visits; ED triage and diagnosis tended to overclassify visits as urgent.

CONCLUSIONS

The explicit criteria and resources methods best approximate implicit criteria in classifying ED visit urgency in infants younger than six months of age. If confirmed in further studies, resources utilized has the potential to be an inexpensive, easily applicable method for urgency classification of infant ED visits when limited data are available.

Emergency outpatient services in the city of Berlin: factors for appropriate use and predictors for hospital admission

OBJECTIVES

To determine the proportion of patients making inappropriate use of medical care at hospital emergency rooms. To identify the factors that influence appropriateness of use and the probability of subsequent hospital admission.

METHODS

Data were collected from 815 patients at three gynaecological/internal medicine emergency clinics in Berlin, Germany using multiple data sources: (i) standardized interviews covered service use history, psychosocial variables, migration history and sociodemographics; (ii) medical data were retrieved from patients' medical records, including case histories, diagnoses and therapies; (iii) emergency room physicians were asked to evaluate patients' language comprehension, physician-patient relationship and treatment urgency. Statistical analyses included chi tests, correlational and logistic regression analyses.

RESULTS

According to a self-constructed index measuring appropriateness of emergency service use, about half of the patients' visits would have to be classified as inappropriate. Age, chronic illness and the time of day of the emergency service attendance were significantly associated with appropriateness of use. The probability of a hospital admission following the emergency treatment increased with patients' age and the physician's evaluation of treatment urgency. Remarkably, and contrary to the results of international studies, the patient's ethnicity played no significant role with respect to the appropriateness of use of emergency outpatient services or the likelihood of subsequent hospital admission.

Methods of categorizing emergency department visit urgency: a survey of pediatric emergency medicine physicians

OBJECTIVE

Between 20% and 80% of emergency department (ED) visits are nonurgent. This variability in estimates is partially due to the multiple classification methods used, none of which has undergone validity or reliability testing. Our objectives were to determine the methods thought to be most valid and to understand expert perceptions of nonurgent ED utilization.

METHODS

A survey of the Pediatric Emergency Medicine (PEM) Special Interest Group at the 2005 Pediatric Academic Societies meeting was conducted. An education session with case-based discussion for categorizing ED visit urgency was presented. Six methods were reviewed: implicit criteria, explicit criteria, resource utilization, diagnoses, Current Procedural Terminology Codes, and nurse triage category. The primary outcome was the percentage of respondents ranking each method first or second best for categorizing urgency. Respondents also identified ED resources and presenting symptoms constituting an urgent visit.

RESULTS

Seventy-four percent of attendees completed the survey, most were Pediatric Emergency Medicine physicians. Implicit criteria were rated highest, with 65.1% ranking it first or second, followed by explicit criteria (53.8%). With limited data available, resource utilization ranked highest (68.6%), followed by nurse triage (61.2%). There was an agreement that certain presenting symptoms and resources were adequate for determining ED visit urgency; however, there was no agreement on whether x-rays, urinalyses, or fever in a child older than 3 months was sufficient to identify urgency.

CONCLUSIONS

Methods using complete medical record information are favored to determine ED visit urgency. Resource utilization and nurse triage are preferred when limited data are available. This survey will serve as the basis for endorsement of methodologically sound criteria for ED visit urgency.

The characteristics of self-referrals to ER for non-urgent conditions and comparison of urgency evaluation between patients and nurses

The aim of the study was to identify the characteristics of self-referrals for non-urgent conditions to the ER, and compare urgency evaluation between patients and nurses. The participants were 73 Israeli clients who arrived at ER without referral from a physician, during the morning shift, and were discharged home after treatment. Their average age was 39.4 years. Most of the visits resulted from orthopedic problems. Over 60% indicated that they had chosen the ER because the treatment there was better, and a third reported that they usually turn to ER when they feel sick. In most cases, the visits were within 3 h of the symptoms emerging, and about a third of the participants indicated that lately they had been under situations of stress and anxiety. Significant differences (p=0.000) were found between nurses and patients, in the urgency evaluation of the visit. While most of the clients (77%), evaluated their condition as urgent to most urgent, most of the nurses (78%) evaluated it as non-urgent. Identifying the characteristics of the non-urgent use of the ER and the differences between caregivers and patients regarding the urgency evaluation of the visit, will provide insights into the population perceived as a burden on the work of the ER as well as benefiting and improving services.

Association between primary care practice characteristics and emergency department use in a medicaid managed care organization

BACKGROUND

Many patients use emergency departments (EDs) for primary care. Previous studies have found that patient characteristics affect ED utilization. However, such studies have led to few policy changes.

OBJECTIVES

We sought to determine whether Medicaid patients' ED use is associated with characteristics of their primary care practices.

RESEARCH DESIGN

This was a cohort study.

SUBJECTS

A total of 57,850 patients, assigned to 353 primary care practices affiliated with a Medicaid HMO, were included.

MEASURES

Predictor variables were characteristics of primary care practices, which were measured by visiting each practice. The outcome variable was ED use adjusted for patient characteristics.

RESULTS

On average, patients made 0.80 ED visits/person/yr. Patients from practices with more than 12 evening hours/wk used the ED 20% less than patients from practices without evening hours. A higher ratio of the number of active patients per clinician-hour of practice time was associated with more ED use. When more Medicaid patients were in a practice, these patients used the ED more frequently. Other factors associated with ED use included equipment for the care of asthma and presence of nurse practitioners and physician assistants.

DISCUSSION

Modifiable characteristics of primary care practices were associated with ED use. Because the observational design of this study does not allow definitive conclusions about causality, future studies should include intervention trials to determine whether changing practice characteristics can reduce ED use.

CONCLUSIONS

Improving primary care access and scope of services may reduce ED use. Focusing on systems issues rather than patient characteristics may be a more productive strategy to improve appropriate use of emergency medical care.

Impact of physician training level on emergency readmission within internal medicine

Objectives: The research question was whether training level of admitting physicians and referrals from practitioners in primary health care (PHC) are risk factors for emergency readmission within 30 days to internal medicine.

Methods: This report is a prospective multicenter study carried out during 1 month in 1997 in seven departments of internal medicine in the County of Stockholm, Sweden. Two of the units were at university hospitals, three at county hospitals and two in district hospitals. The study area is metropolitan–suburban with 1,762,924 residents. Data were analyzed by multiple logistic regression.

Results: A total of 5,131 admissions, thereby 408 unplanned readmissions (8 percent) were registered (69.8 percent of 7,348 true inpatient episodes). The risk of emergency readmission increased with patient's age and independently 1.40 times (95 percent confidence interval [CI], 1.13–1.74) when residents decided on hospitalization. Congestive heart failure as primary or comorbid condition was the main reason for unplanned readmission. Referrals from PHC were associated with risk decrease (odds ratio, 0.53; 95 percent CI, 0.38–0.73).

Conclusion: The causes of unplanned hospital readmissions are mixed. Patient contact with primary health care appears to reduce the recurrence. In addition to the diagnoses of cardiac failure, training level of admitting physicians in emergency departments was an independent risk factor for early readmission. Our conclusion is that it is cost-effective to have all decisions on admission to hospital care confirmed by senior doctors. Inappropriate selection of patients to inpatient care contributes to poor patient outcomes and reduces cost-effectiveness and quality of care.

Disputes over coverage of emergency department services: a study of two health maintenance organizations

STUDY OBJECTIVE

We describe the characteristics and outcomes of enrollee-health plan disputes over insurance coverage for emergency department (ED) services at 2 large health maintenance organizations (HMOs) that apply the prudent layperson standard.

METHODS

We abstracted information from a stratified random sample of approximately 3,500 appeals of coverage denials lodged by privately insured enrollees between 1998 and 2000 at 2 of the nation's largest HMOs (hereafter referred to as Plan 1 and Plan 2). We describe appeals involving ED services in terms of the timing of visits, patient age, costs of services, primary reason the patient sought care, and appeal outcome.

RESULTS

Disputes over ED services accounted for approximately one half (52%) of postservice appeals at Plan 1 and one third (34%) at Plan 2. Nearly one half (46%) of ED appeals involved weekend, nighttime, or holiday visits to the ED; 22% were children's visits. The average cost of services in dispute was US$1,107. The most common general reasons for the ED visits in dispute were symptoms of illness (64%), injuries (22%), and services related to disease (8%). The most common presenting symptoms were abdominal pain, cramps, or spasms (7.6%); earaches or ear infections (3.4%); and lacerations/cuts (2.9%). Enrollees won more than 90% of appeals.

CONCLUSION

The prevalence of ED cases among all appeals reflects disagreement between lay and expert judgments about what constitutes emergency care under the prudent layperson standard. The high rate at which enrollees win these appeals highlights significant disagreement in interpretation of the standard among different adjudicators within managed care organizations (medical groups and health plans). When enrollees fail to challenge denials that would be reversed on appeal, they bear the financial brunt of ambiguities in interpretation of the prudent layperson standard.

Workload and case-mix in a Greek emergency department

The objective of the present study was to evaluate the workload and case-mix of the Emergency Department of a referral hospital, with the aim of determining the causes of overcrowding. The study was of a descriptive prospective design and was carried out in a 700-bed university hospital covering a population of approximately 200,000 inhabitants. The total number of patient visits to the Emergency Department and hospital admissions were recorded during one year, whereas the case-mix of patients visiting the department was evaluated during 11 consecutive on-call days using a triage scale with four categories of patient severity. During the year of the study 81,110 patients (a mean of 443 visits per on-call day) visited the department, with a hospital admission rate of 14.5%. The case-mix analysis of 3389 patients who visited the department during the 11 consecutive on-call days studied revealed that 5.7% were critically ill patients, 53.8% were patients with urgent but non-critical health problems, 30% were patients with non-urgent problems and 10.5% were miscellaneous cases, probably inappropriately visiting the department. In conclusion, the Emergency Department studied is severely overcrowded in relation to the population that it covers. A great part of this overload was directly related to non-urgent cases and inappropriate visits.

Health literacy and use of outpatient physician services by Medicare managed care enrollees

OBJECTIVE

To determine whether inadequate functional health literacy adversely affects use of physician outpatient services.

DESIGN

Cohort study.

SETTING

Community.

PARTICIPANTS

New Medicare managed care enrollees age 65 or older in 4 U.S. cities (N = 3,260).

MEASUREMENTS AND MAIN RESULTS

We measured functional health literacy using the Short Test of Functional Health Literacy in Adults. Administrative data were used to determine the time to first physician visit and the total number of visits during the 12 months after enrollment. The time until first visit, the proportion without any visit, and adjusted mean visits during the year after enrollment were unrelated to health literacy in crude and multivariate analyses. Participants with inadequate and marginal health literacy were more likely to have an emergency department (ED) visit than those with adequate health literacy (30.4%, 27.6%, and 21.8%, respectively; P =.01 and P <.001, respectively). In multivariate analysis, the adjusted relative risk of having 2 or more ED visits was 1.44 (95% confidence interval, 1.01 to 2.02) for enrollees with marginal health literacy and 1.34 (1.00 to 1.79) for those with inadequate health literacy compared to participants with adequate health literacy.

CONCLUSIONS

Inadequate health literacy was not independently associated with the mean number of visits or the time to a first visit. This suggests that inadequate literacy is not a major barrier to accessing outpatient health care. Nevertheless, the higher rates of ED use by persons with low literacy may be caused by real or perceived barriers to using their usual source of outpatient care.

Propuesta y validación del Protocolo de Adecuación de Urgencias Hospitalarias modificado

BACKGROUND AND OBJECTIVE

Hospital Emergency inappropriate attendances need to be evaluated, including emergencies that can be solved in primary care. The study aim was to validate a Hospital Emergency Appropriateness Evaluation Protocol (HEAEP) having into account patient health care setting.

MATERIAL AND METHOD

An HEAEP with explicit criteria was developed. We randomly chose 100 emergency medical records among all patients attended at the Granada Hospital Ruiz de Alda in the first quarter of 2000. Records were evaluated by six emergency specialists to compare results provided by the HEAEP.

RESULTS

The HEAEP identified as appropriate all attendances so classified by experts. As inappropriate, HEAEP only pointed out 69% of the emergency visits considered as inappropriate by experts.

CONCLUSIONS

The modified HEAEP shown a good internal validity and high reproducibility. The main advantage is to point out as inappropriate emergency attendances that can be solved in primary care.

Inappropriate Emergency Department Visits and Use of the Health Care for the Homeless Program Services by Homeless Adults in the Northeastern United States

This study tested whether the use of the Health Care for the Homeless Program (HCHP) by homeless adults was associated with reduced risk of inappropriate emergency department (ED) use. Researchers interviewed 941 homeless adults at 52 soup kitchens. Of those interviewed, 508 reported having at least 1 ED visit during the last 6 months. Then, 243 subjects' 688 ED records were retrieved. Inappropriateness of each ED use was evaluated based on clinical criteria. Logistic regressions were applied. Having two or more HCHP visits [odds ratio (OR) = 0.43, 95% confidence interval (CI) 0.19, 0.90] by homeless adults was associated with decreased odds of having inappropriate ED visits.

An emergency medical services program of alternate destination of patient care

OBJECTIVE

The emergency department (ED) is ideally reserved for urgent health needs. The ED, however, is often the site of care for nonurgent conditions. The authors investigated whether emergency medical technicians could decrease ED use by patients with nonurgent concerns who use 911 by appropriately identifying and triaging them to alternate care destinations.

METHODS

From August 2000 through January 2001, two King County fire-based emergency medical services (EMS) agencies participated in an alternate care destination program for patients with specific low-acuity diagnosis codes (intervention group). Eligible patients were offered care at a clinic-based destination as an alternate to the ED (n = 1,016). The frequency of the destination of care (ED, clinic, or home) for the intervention group was compared with a matched control group that was comprised of a preintervention historical cohort of EMS encounters from the same two fire-based agencies and with the same acuity and diagnosis criteria and seasonal interval (n = 2,617).

RESULTS

Compared with the preintervention group, a smaller proportion of patients in the intervention group received care in the ED (44.6% vs. 51.8%, p = 0.001), while a greater proportion of patients in the intervention group received clinic care (8.0% vs. 4.5%, p = 0.001) or home care (no transport) (47.4 vs. 43.7%, p = 0.043). Results were comparable when adjusted for other patient characteristics. Similar relationships were not evident among nonparticipating King County EMS agencies. Based on physician review and patient interview, the alternate care intervention appeared to be safe and satisfactory.

CONCLUSION

An EMS-based program may represent one approach to limiting nonurgent ED use.