Emergency department usage by uninsured patients in Galveston County, Texas

Emergency Department Utilization among Underserved African American Older Adults in South Los Angeles

Objectives: Using the Andersen’s Behavioral Model of Health Services Use, we explored social, behavioral, and health factors that are associated with emergency department (ED) utilization among underserved African American (AA) older adults in one of the most economically disadvantaged urban areas in South Los Angeles, California. Methods: This cross-sectional study recruited a convenience sample of 609 non-institutionalized AA older adults (age ≥ 65 years) from South Los Angeles, California. Participants were interviewed for demographic factors, self-rated health, chronic medication conditions (CMCs), pain, depressive symptoms, access to care, and continuity of care. Outcomes included 1 or 2+ ED visits in the last 12 months. Polynomial regression was used for data analysis. Results: Almost 41% of participants were treated at an ED during the last 12 months. In all, 27% of participants attended an ED once and 14% two or more times. Half of those with 6+ chronic conditions reported being treated at an ED once; one quarter at least twice. Factors that predicted no ED visit were male gender (OR = 0.50, 95% CI = 0.29–0.85), higher continuity of medical care (OR = 1.55, 95% CI = 1.04–2.31), individuals with two CMCs or less (OR = 2.61 (1.03–6.59), second tertile of pain severity (OR = 2.80, 95% CI = 1.36–5.73). Factors that predicted only one ED visit were male gender (OR = 0.45, 95% CI = 0.25–0.82), higher continuity of medical care (OR = 1.39, 95% CI = 1.01–2.15) and second tertile of pain severity (OR = 2.42, 95% CI = 1.13–5.19). Conclusions: This study documented that a lack of continuity of care for individuals with multiple chronic conditions leads to a higher rate of ED presentations. The results are significant given that ED visits may contribute to health disparities among AA older adults. Future research should examine whether case management decreases ED utilization among underserved AA older adults with multiple chronic conditions and/or severe pain. To explore the generalizability of these findings, the study should be repeated in other settings.

Patient Presentations in Outpatient Settings: Epidemiology of Adult Head Trauma Treated Outside of Hospital Emergency Departments

BACKGROUND

While deaths, hospitalizations, and emergency department visits for head trauma are well understood, little is known about presentations in outpatient settings. Our objective was to examine the epidemiology and extent of healthcare-seeking adult (18-64 years) head trauma patients presenting in outpatient settings compared with patients receiving nonhospitalized emergency department care.

METHODS

We used 2004-2013 MarketScan Medicaid/commercial claims to identify head trauma patients managed in outpatient settings (primary care provider, urgent care) and the emergency department. We examined differences in demographic and injury-specific factors, Centers for Disease Control and Prevention-defined head trauma diagnoses, and extent of and reasons for postindex visit ambulatory care use within 30/90/180 days by index visit location, as well as annual and monthly variations in head trauma trends. We used outpatient incidence rates to estimate the US nationwide outpatient burden.

RESULTS

A total of 1.19 million index outpatient visits were included (emergency department: 348,659). Nationwide, they represented a weighted annual burden of 1.16 million index outpatient cases. These encompassed 46% of all known healthcare-seeking head trauma in 2013 (outpatient/emergency department/inpatient/fatalities) and increased in magnitude (+31%) from 2004 to 2013. One fourth (27%) of office/clinic visits led to diagnosis with concussion on index presentation (urgent care: 32%). Distributions of demographic factors varied with index visit location while injury-specific factors were largely comparable. Subsequent visits reflected high demand for follow-up treatment, increased concussive diagnoses, and sequelae-associated care.

CONCLUSIONS

Adult outpatient presentations of head trauma remain poorly understood. The results of this study demonstrate the extensive magnitude of their occurrence and close association with need for follow-up care.

Comparing two strategies for emergency department chest pain patients: immediate computed tomography coronary angiography versus delayed outpatient treadmill testing

Chest pain (CP) is a common emergency department (ED) complaint and return visits (recidivism) are common. Recidivism may be related to incomplete evaluation of a patient's complaint. Computed tomography coronary angiography (CTCA) is accurate for diagnosing coronary artery disease (CAD) in patients with CP. We will compare a strategy of immediate CTCA with a strategy of delayed outpatient stress testing and hypothesize that CTCA will reduce recidivism in patients with CP. We conducted a retrospective cohort study comparing strategies for ED patients with CP: immediate CTCA (CT cohort) versus delayed outpatient stress testing (control cohort). Two hundred eighty subjects were included, 140 in each of the strategies. Recidivism within 6 months of the index ED evaluation occurred in 12 subjects from the CT cohort and 18 subjects from the control cohort (9% vs. 13%, P = 0.41). Duration of stay was increased in the CT cohort (456 vs. 417 min, P = 0.031). Immediate CTCA was associated with improved detection of obstructive CAD (8% vs. 1%, P = 0.005). In conclusion, immediate CTCA, when compared with delayed outpatient stress testing, did not reduce ED recidivism for CP. Length of stay was increased in the immediate CTCA cohort. The use of CTCA improved detection of obstructive CAD.

Challenging assumptions about uninsured children in the pediatric emergency department

OBJECTIVE

Emergency departments (EDs) are experiencing increased volumes and crowding problems. Although crowding is often blamed on uninsured patients, the role of uninsured children is unclear. We compared ED use by insured and uninsured children.

METHODS

Parents of children presenting at a tertiary care pediatric hospital ED were surveyed to determine health insurance coverage and frequency of ED use. Hospital billing records were reviewed separately to validate our survey results. Results were compared with Census Bureau data on the prevalence of uninsured children.

RESULTS

We enrolled 2024 participants in the survey arm. Of all children 48.4% (n = 972) were privately insured, 42.1% (n = 846) have government insurance, and 9.5% (n = 191) were uninsured. Billing records showed that 10.2% (n = 3825) of pediatric ED patients during the previous year were uninsured. Census data showed that 13% of children statewide were uninsured. Among survey subjects, uninsured children were more likely than privately insured children (53% vs 42%), but less likely than children with government insurance (67%), to have moderate ED use (≥1 additional ED visit in 12 months; P < 0.001) or frequent ED use (≥5 visits in 12 months; 4% vs 2% vs 8%; P < 0.001). When private and government insurance categories were combined, uninsured children showed no greater likelihood of moderate ED use (53% vs 53%, P = 0.89) or frequent ED use (4% vs 5%, P = 0.71) than insured children did.

CONCLUSIONS

Uninsured pediatric patients were not disproportionately represented in the ED population. Moreover, uninsured children were not more likely than insured children to be moderate or frequent ED users.

Medication use across transition points from the emergency department: identifying factors associated with medication discrepancies

BACKGROUND

As patients move across transition points of care, medication discrepancies are likely to occur. In the emergency department (ED), patients are vulnerable to medication discrepancies because they are in an environment in which rapid decisions need to be made under high levels of stress.

OBJECTIVE

To identify the patient-, environment-, and medication-related factors involving unexplained medication discrepancies across transition points after ED presentation.

METHODS

Using a retrospective chart review design, a stratified, random sampling of data was undertaken over a 12-month period. Information was obtained from an electronic administrative database and medical records as patients moved from the ED to another transition point of care. Medication discrepancies were classified into 2 outcome groups: (1) no discrepancies and situations in which discrepancies were adequately explained and (2) discrepancies that had no adequate explanation.

RESULTS

For the 12-month period, 210 randomly selected patients were included; 73 (34.8%) had at least one unexplained medication discrepancy. Binary logistic regression modeling showed 4 factors that were statistically significant in determining the incidence of at least one unexplained medication discrepancy. Benefit card holders (individuals who receive benefits from government insurance programs comparable to the US-based Medicare and Medicaid initiatives, which include the elderly, the disabled, low income earners, and unemployed persons) had 3.73 greater odds of experiencing an unexplained medication discrepancy (95% CI 1.72 to 8.07; p = 0.001). Patients prescribed 5 or more drugs at discharge from the ED had 12.22 greater odds of having at least one unexplained medication discrepancy (95% CI 5.52 to 27.08; p < 0.001). Patients who were first seen by a physician within 1 hour of a change in working shift had 3.70 greater odds of having an unexplained medication discrepancy (95% CI 1.67 to 8.18; p = 0.001). For each additional minute of wait time for a physician, the odds of having an unexplained medication discrepancy increased by a factor of 1.01 (95% CI 1.00 to 1.01; p = 0.042).

CONCLUSIONS

Patient-, environment-, and drug-related factors contribute to the risk of medication discrepancies across transition points from the ED.