Reasons for Frequent Emergency Department Use by Medicaid Enrollees: A Qualitative Study

Medicaid Expansion and Preventable Emergency Department Use by Race/Ethnicity

INTRODUCTION

This study aimed to examine changes in emergency department (ED) visits for ambulatory care sensitive conditions (ACSCs) among uninsured or Medicaid-covered Black, Hispanic, and White adults aged 26-64 in the first 5 years of the Affordable Care Act Medicaid expansion.

METHODS

Using 2010-2018 inpatient and ED discharge data from nine expansion and five nonexpansion states, an event study difference-in-differences regression model was used to estimate changes in number of annual ACSC ED visits per 100 adults ("ACSC ED rate") associated with the 2014 Medicaid expansion, overall and by race/ethnicity. A secondary outcome was the proportion of ACSC ED visits out of all ED visits ("ACSC ED share"). Analyses were conducted in 2022-2023.

RESULTS

Medicaid expansion was associated with no change in ACSC ED rates among all, Black, Hispanic, or White adults. When excluding California, where most counties expanded Medicaid before 2014, expansion was associated with a decrease in ACSC ED rate among all, Black, Hispanic, and White adults. Expansion was also associated with a decrease in ACSC ED share among all, Black, and White adults. White adults experienced the largest reductions in ACSC ED rate and share.

CONCLUSIONS

Medicaid expansion was associated with reductions in ACSC ED rates in some expansion states and reductions in ACSC ED share in all expansion states combined, with some heterogeneity by race/ethnicity. Expansion should be coupled with policy efforts to better link newly insured Black and Hispanic patients to non-ED outpatient care, alongside targeted outreach and expanded primary care capacity, which may reduce disparities in ACSC ED visits.

Frontline perspectives on barriers to care for patients with California Medicaid: a qualitative study

BACKGROUND

While insurance is integral for accessing healthcare in the US, coverage alone may not ensure access, especially for those publicly insured. Access barriers for Medicaid-insured patients are rooted in social drivers of health, insurance complexities in the setting of managed care plans, and federal- and state-level policies. Elucidating barriers at the health system level may reveal opportunities for sustainable solutions.

METHODS

To understand barriers to ambulatory care access for patients with Medi-Cal (California's Medicaid program) and identify improvement opportunities, we performed a qualitative study using semi-structured interviews of a referred sample of clinicians and administrative staff members experienced with clinical patient encounters and/or completion of referral processes for patients with Medi-Cal (n = 19) at a large academic medical center. The interview guide covered the four process steps to accessing care within the health system: (1) scheduling, (2) referral and authorization, (3) contracting, and (4) the clinical encounter. We transcribed and inductively coded the interviews, then organized themes across the four steps to identify perceptions of barriers to access and improvement opportunities for ambulatory care for patients with Medi-Cal.

RESULTS

Clinicians and administrative staff members at a large academic medical center revealed barriers to ambulatory care access for Medi-Cal insured patients, including lack of awareness of system-level policy, complexities surrounding insurance contracting, limited resources for social support, and poor dissemination of information to patients. Particularly, interviews revealed how managed Medi-Cal impacts academic health systems through additional time and effort by frontline staff to facilitate patient access compared to fee-for-service Medi-Cal. Interviewees reported that this resulted in patient care delays, suboptimal care coordination, and care fragmentation.

CONCLUSIONS

Our findings highlight gaps in system-level policy, inconsistencies in pursuing insurance authorizations, limited resources for scheduling and social work support, and poor dissemination of information to and between providers and patients, which limit access to care at an academic medical center for Medi-Cal insured patients. Many interviewees additionally shared the moral injury that they experienced as they witnessed patient care delays in the absence of system-level structures to address these barriers. Reform at the state, insurance organization, and institutional levels is necessary to form solutions within Medi-Cal innovation efforts.

A qualitative system model to describe the causes and drivers of frequent potentially avoidable presentations to the emergency department

Frequent potentially avoidable presentations to Emergency Departments (EDs) represent a complex problem, driven by multiple interdependent and interacting factors that change over time and influence one another. We sought to describe and map the drivers of frequent potentially avoidable presentations to a regional ED, servicing regional and rural areas, and identify possible solutions from the perspectives of key stakeholders. This study used a qualitative, community-based systems dynamics approach utilising Group Model Building (GMB). Data were collected from two 3-h online workshops embedded with small-group discussions and conducted with stakeholder groups operating within a regional health system. Stakeholders were guided through a series of participatory tasks to develop a causal loop diagram (CLD) using Systems Thinking in Community Knowledge Exchange software (n=29, workshop one), identify potential action points and generate a prioritised action list to intervene in the system (n=21, workshop two). Data were collected through note taking, real-time system mapping, and recording the workshops. Each action was considered against the Public Health 12 framework describing twelve leverage points to intervene in a system. A CLD illustrating the complex and interrelated factors that drive frequent potentially avoidable ED presentations was developed and classified into four categories: (1) access to services; (2) coordination; (3) patient needs; and (4) knowledge and skills. Nine action areas were identified, with many relating to care and service coordination. Most actions aligned with lower-level system impact actions. This study provides an in-depth understanding of influencing factors and potential solutions for frequent potentially avoidable ED presentations across a regional health system. The CLD demonstrates frequent potentially avoidable ED presentations are a complex problem and identified that a prevention response should engage with system- and individual-level solutions. Further work is needed to prioritise actions to support the implementation of higher-level system impacts.

Association of open globe injury characteristics with outcome measures in the emergency department

PURPOSE

To evaluate the association of demographic and clinical features of emergency department (ED) patients presenting with open globe injuries (OG) with outcomes such as inpatient admission rate, length of stay (LOS), and total cost.

METHODS

The Nationwide Emergency Department Sample database 2018 and 2019 was used to analyze the association of demographic and clinical features of OG patients with outcome measures.

RESULTS

8404 OG patients were identified. Medicaid patients were associated with higher ED costs and a higher frequency of extended LOS. The 70+ age group was associated with higher inpatient admission. Frail patients were associated with significantly increased likelihood of inpatient admission, higher likelihood of extended LOS and higher total combined ED cost. Falls and being struck were associated with shorter LOS.

CONCLUSION

This study describes the most common demographic and clinical characteristics of OGIs that present to the ED, as well as the association of these characteristics with outcome measures such as inpatient admission rates, LOS, and total cost. The study further identified potential high-risk patients for prolonged length of stay. The findings will better optimize patient care protocols to improve outcomes.

Factors associated with frequent emergency department visits among health centre patients receiving primary care

RATIONALE, AIMS AND OBJECTIVES

We sought to examine specific care-seeking behaviours and experiences, access indicators, and patient care management approaches associated with frequency of emergency department (ED) visits among patients of Health Resources and Services Administration-funded health centres that provide comprehensive primary care to low-income and uninsured patients.

METHOD

We used cross-sectional data of a most recent nationally representative sample of health centre adult patients aged 18-64 (n = 4577) conducted between October 2014 and April 2015. These data were merged with the 2014 Uniform Data System to incorporate health centre characteristics. We measured care-seeking behaviours by whether the patient called the health centre afterhours, for an urgent appointment, or talked to a provider about a concern. Access to care indicators included health centre continuity of care and receipt of transportation or translation services. We included receipt of care coordination and specialist referral as care management indicators. We used a multilevel multinomial logistic regression model to identify the association of independent variables with number of ED visits (4 or more visits, 2-3 visits, 1 visit, vs. 0 visits), controlling for predisposing, enabling, and need characteristics.

RESULTS

Calling the health centre after-hours (OR = 2.41) or for urgent care (OR = 2.53), and being referred to specialists (OR = 2.36) were associated with higher odds of four or more ED visits versus none. Three or more years of continuity with the health centre (OR = 0.32) was also associated with lower odds of four or more ED visits versus none.

CONCLUSIONS

Findings underscore opportunities to reduce higher frequency of ED visits in health centres, which are primary care providers to many low-income populations. Our findings highlight the potential importance of improving patient retention, better access to providers afterhours or for urgent visits, and access to specialist as areas of care in need of improvement.

National Analysis of Sternal Wound Complications and Readmissions After Coronary Bypass Surgery

BACKGROUND

Wound complications are a cause for readmission after cardiac surgery. Health insurance status has been associated with poor postoperative outcomes. We investigate the association between health insurance status and post-CABG wound dehiscence or infection along with 30-day wound-related readmission using a national database.

METHODS

We queried the National Readmissions Database for the year 2018 for patients aged 18 years or more undergoing multivessel coronary artery bypass graft surgery (CABG). Patients were subcategorized by health insurance status (private, Medicaid, Medicare, uninsured). Our primary outcomes were wound dehiscence or infection during the index admission and 30-day readmission after discharge for wound-related complications.

RESULTS

In all, 131,976 patients met inclusion criteria: 32.7% private, 7.6% Medicaid, 59.3% Medicare, and 0.4% uninsured. Compared with patients having private insurance, Medicaid patients had greater odds of readmission for superficial wound dehiscence (odds ratio [OR] 2.11; 1.11-4.00; P = .022) and deep wound dehiscence (OR 2.11; 95% CI, 1.09-4.10; P = .026), as did Medicare patients (OR 2.34; 95% CI, 1.29-3.88; P = .004; and OR 3.23; 95% CI, 1.76-5.90; P = .001, respectively). Medicaid patients additionally had higher odds of readmission for superficial wound infection (OR 1.59; 95% CI, 1.11-4.00; P = .014). Compared with patients with private insurance, Medicaid patients had higher odds of deep wound dehiscence on index admission (OR 1.97; 95% CI, 1.02-3.83; P = .044), and Medicare patients had higher odds of superficial wound dehiscence (OR 2.55; 95% CI, 1.28-5.06; P = .001).

CONCLUSIONS

Patients with Medicaid and Medicare had greater odds of readmission for wound complications and higher rates of wound dehiscence in their index admission. Further research is warranted to characterize factors driving readmission due to postsurgical wound complications in low socioeconomic status populations.

Parental Childhood Adversity and Pediatric Emergency Department Utilization: A Pilot Study

OBJECTIVES

Adverse childhood experiences (ACEs) including physical, emotional, or sexual abuse; neglect; and/or exposure to household instability have been associated with adult emergency department utilization, but the impact of parental ACEs on pediatric emergency department (PED) utilization has not been studied. The primary aim was to determine if parental ACEs impact resource utilization as measured by (1) frequency of PED utilization, (2) acuity of PED visits, and (3) 72-hour PED return rates. The secondary aim was to determine if resilience interacts with the impact of parental ACEs on PED utilization.

METHODS

This study is a cross-sectional survey using previously validated measures of ACEs, resiliency, and social determinants of health screening. Surveys were administered from October 17, 2019, to November 27, 2019, via iPad by research assistants in our institution's PEDs. Survey responses were linked to data abstracted from the electronic health record. Descriptive statistics were used to characterize our study population. Pearson correlation was used to identify correlation between ACEs, social determinants of health, and PED utilization measures.

RESULTS

A total of 251 parents had complete data. Parental ACEs were positively associated with frequency of PED visits (incidence rate ratio, 1.013). In addition, high levels of parental resilience attenuated the association between parental ACEs and the number of severe acuity visits and were associated with fewer 72-hour return visits (incidence rate ratio, 0.49).

CONCLUSIONS

Parental ACEs appear to be positively associated with frequency of PED utilization and inversely associated with higher-acuity PED visits and parental resiliency.

Examining delays in diagnosis for slipped capital femoral epiphysis from a health disparities perspective

Slipped Capital Femoral Epiphysis (SCFE) is a skeletal pathology affecting adolescents which requires timely surgery to prevent progression. Delays in diagnosis and treatment of SCFE can negatively affect patient prognosis, and few studies have examined how health disparities and barriers to care may influence these delays. In particular, only a handful of studies have included a Hispanic patient sample, despite this ethnic group’s increased risk for the disease and unique barriers to care. A retrospective chart review was conducted for 124 patients surgically treated for idiopathic SCFE from January 2010 to September 2017. Patient data included age, facility and date of diagnosis, sex, BMI, race and ethnicity, Southwick slip angle, and insurance type. Results indicated that patients with private insurance were more likely to present with a mild slip than patients who were insured by Medicaid or uninsured, while patients without insurance were more likely to have severe slips. Patients without insurance also had a significantly higher mean slip than patients with insurance. The relationship between insurance status and slip angle degree was significant independent of race, even though Hispanic individuals were significantly more likely to have Medicaid or be uninsured. All patients without insurance, and a majority of those with Medicaid, were diagnosed in the emergency department. Time to diagnosis and slip angle were positively correlated, which suggests that longer delays led to increase of the slip angle, consistent with previous findings. Time to diagnosis and BMI were also correlated, which may be tied to socioeconomic factors, but the possibility of weight bias should not be dismissed. These results suggest that socioeconomic status and other factors may have contributed to barriers to care which led to delays in diagnosis and thus more severe slips. Future SCFE research should include health disparities variables to better inform treatment and prognosis.

Educational Intervention in the Emergency Department to Address Disparities in Stroke Knowledge

OBJECTIVES

In the United States, Black individuals have higher stroke incidence and mortality when compared to white individuals and are also at risk of having lower stroke knowledge and awareness. With the need to implement focused interventions to decrease stroke disparities, the objective of this study is to evaluate the feasibility and efficacy of an emergency department-based educational intervention aimed at increasing stroke awareness and preparedness among a disproportionately high-risk group.

MATERIALS AND METHODS

Over a three-month timeframe, an emergency department-based, prospective educational intervention was implemented for Black patients in an urban, academic emergency department. All participants received stroke education in the forms of a video, written brochure and verbal counseling.  Stroke knowledge was assessed pre-intervention, immediately post-intervention, and at one-month post-intervention.

RESULTS

One hundred eighty-five patients were approached for enrollment, of whom 100 participants completed the educational intervention as well as the pre- and immediate post- intervention knowledge assessments. Participants demonstrated increased stroke knowledge from baseline knowledge assessment (5.35 ± 1.97) at both immediate post-intervention (7.66 ± 2.42, p < .0001) and one-month post-intervention assessment (7.21 ± 2.21, p < .0001).

CONCLUSIONS

Emergency department-based stroke education can result in improved knowledge among this focused demographic. The emergency department represents a potential site for educational interventions to address disparities in stroke knowledge.

Executive summary of the 2021 SAEM consensus conference: From bedside to policy: Advancing social emergency medicine and population health through research, collaboration, and education

BACKGROUND

Social emergency medicine (social EM) examines the intersection of emergency care and the social factors that influence health outcomes. In 2021, the SAEM consensus conference focused on social EM and population health, with the goal of prioritizing research topics, creating collaborations, and advancing the field of social EM.

METHODS

Organization of the conference began in 2019 within SAEM. Cochairs were identified and a planning committee created the framework for the conference. Leaders for subgroups were identified, and subgroups performed literature reviews and identified additional stakeholders within EM and community organizations. As a result of the COVID-19 pandemic, the conference format was modified.

RESULTS

A total of 246 participants registered for the conference and participated in some capacity at three distinct online sessions. Research prioritization subgroups were as follows-group 1: ED screening and referral for social and access needs; group 2: structural competency; and group 3: race, racism, and antiracism. Thirty-two "projects in progress" were presented within five domains-identity and health: people and places; health care systems; training and education; material needs; and individual and structural violence.

CONCLUSIONS

Despite ongoing challenges posed by the COVID-19 pandemic, the 2021 SAEM consensus conference brought together hundreds of stakeholders to define research priorities and create collaborations to push the field forward.

Multimorbidity clustering of the emergency department patient flow: Impact analysis of new unscheduled care clinics

Background

In France, the number of emergency department (ED) admissions doubled between 1996 and 2016. To cope with the resulting crowding situation, redirecting patients to new healthcare services was considered a viable solution which would spread demand more evenly across available healthcare delivery points and render care more efficient. The objective of this study was to analyze the impact of opening new on-demand care services based on variations in patient flow at a large hospital emergency department.

Methods

We performed a before-and-after study investigating the use of unscheduled care services in the Aube region in eastern France, that focused on ED attendance at Troyes Hospital. A hierarchical clustering based on co-occurrence of diagnoses was applied which divided the population into different multimorbidity profiles. Temporal trends of the resultant clusters were also studied empirically and using regression models. A multivariate logistic regression model was constructed to adjust the periodic effect for appropriate confounders and therefore confirm its presence.

Results

In total, 120,722 visits to the ED were recorded over a 24-month period (2018–2019) and 16 clusters were identified, accounting for 94.76% of all visits. There was a decrease of 56.77 visits per week in seven specific clusters and an increase of use of unscheduled health care services by 328.12 visits per week.

Conclusions

Using an innovative and reliable methodology to evaluate changes in patient flow through the ED, these findings may help inform public health policy experts on the implementation of unscheduled care services to ease pressure on hospital EDs.

Conceptual Model of Emergency Department Utilization among Deaf and Hard-of-Hearing Patients: A Critical Review

Deaf and hard-of-hearing (DHH) populations are understudied in health services research and underserved in healthcare systems. Existing data indicate that adult DHH patients are more likely to use the emergency department (ED) for less emergent conditions than non-DHH patients. However, the lack of research focused on this population’s ED utilization impedes the development of health promotion and quality improvement interventions to improve patient health and quality outcomes. The purpose of this study was to develop a conceptual model describing patient and non-patient (e.g., community, health system, provider) factors influencing ED utilization and ED care processes among DHH people. We conducted a critical review and used Andersen’s Behavioral Model of Health Services Use and the PRECEDE-PROCEED Model to classify factors based on their theoretical and/or empirically described role. The resulting Conceptual Model of Emergency Department Utilization Among Deaf and Hard-of-Hearing Patients provides predisposing, enabling, and reinforcing factors influencing DHH patient ED care seeking and ED care processes. The model highlights the abundance of DHH patient and non-DHH patient enabling factors. This model may be used in quality improvement interventions, health services research, or in organizational planning and policymaking to improve health outcomes for DHH patients.

Care transitions and social needs: A Geriatric Emergency care Applied Research (GEAR) Network scoping review and consensus statement

OBJECTIVES

Individual-level social needs have been shown to substantially impact emergency department (ED) care transitions of older adults. The Geriatric Emergency care Applied Research (GEAR) Network aimed to identify care transition interventions, particularly addressing social needs, and prioritize future research questions.

METHODS

GEAR engaged 49 interdisciplinary stakeholders, derived clinical questions, and conducted searches of electronic databases to identify ED discharge care transition interventions in older adult populations. Informed by the Protocol for Responding to and Assessing Patients' Assets, Risks, and Experiences (PRAPARE) framework, data extraction and synthesis of included studies included the degree that intervention components addressed social needs and their association with patient outcomes. GEAR convened a consensus conference to identify topics of highest priority for future care transitions research.

RESULTS

Our search identified 248 unique articles addressing care transition interventions in older adult populations. Of these, 17 individual care transition intervention studies were included in the current literature synthesis. Overall, common care transition interventions included coordination efforts, comprehensive geriatric assessments, discharge planning, and telephone or in-person follow-up. Fourteen of the 17 care transition intervention studies in older adults specifically addressed at least one social need within the PRAPARE framework, most commonly related to access to food, medicine, or health care. No care transition intervention addressing social needs in older adult populations consistently reduced subsequent health care utilization or other patient-centered outcomes. GEAR stakeholders identified that determining optimal outcome measures for ED-home transition interventions was the highest priority area for future care transitions research.

CONCLUSIONS

ED care transition intervention studies in older adults frequently address at least one social need component and exhibit variation in the degree of success on a wide array of health care utilization outcomes.

Emergency Department Presentation of Retinal Artery Occlusion

PURPOSE

To determine how often patients who present to the Emergency Department (ED) for retinal artery occlusions (RAOs) undergo brain imaging, cardiovascular testing, and are hospitalized.

DESIGN

Retrospective cross-sectional study.

PARTICIPANTS

Patients who presented to the ED with a RAO in the National Emergency Department Sample (NEDS), a nationally representative US database.

METHODS

The NEDS was queried from 2006-2014 to identify patients who presented to the ED with the primary diagnosis of RAO. Patient and hospital characteristics were evaluated, and a multivariable regression was performed to determine predictors of hospitalization. Testing was categorized into three groups: 1) brain imaging - computed tomography and/or magnetic resonance; 2) carotid imaging - ultrasound, computed tomography, and/or magnetic resonance; 3) cardiac testing - electrocardiogram and/or echocardiogram. The number of tests performed for each category was recorded.

MAIN OUTCOME MEASURES

Proportions of patients undergoing brain imaging, carotid imaging, and/or cardiac testing. Rate and predictors for hospitalization.

RESULTS

Among 259,343,582 ED visits, 2, 802 had a primary diagnosis of RAO. Patients were mostly ≥ 65 years old (59%) and male (54%). Hypertension (59%), dyslipidemia (36%), and diabetes (20%) were the most common pre-existing cardiovascular diseases. Brain imaging, carotid imaging, and cardiac testing were performed in 20.3%, 7.1%, and 23.8% of patients, respectively; at least one test from each of these three categories was performed in 4.1% of patients. Half of the patients were hospitalized. Factors that increased the chances of hospitalization included (P < 0.05): age < 45 years old; female sex; being a smoker; presenting to a metropolitan hospital; having giant cell arteritis, carotid artery disease, atrial fibrillation, cardiac valve disease, obesity, dyslipidemia, hypertension, diabetes, and chronic ischemic heart disease.

CONCLUSIONS

Most patients who presented to the ED with a RAO did not receive emergent brain imaging, carotid imaging, or basic cardiac testing. A multidisciplinary approach is needed to raise awareness that RAOs should be treated as a precursor of stroke or a stroke equivalent.

Concordance and Patient-Centered Care in Medicaid Enrollees' Care Experience With Providers

Patient-centered care is at the nexus of several overlapping institutional reforms to improve health care system performance. However, we know little regarding Medicaid patients' experience with their doctors along several key dimensions of patient-centered care, and how their experience compares with Medicare and privately insured patients. We studied 4 outcomes using the 2017 National Health Interview Survey: patient-provider concordance on racial/sexual/cultural identity, respectful provider attitude, solicitation of patient opinion/beliefs during the care encounter, and patient-centered communication (PCC). The primary independent variable was Medicaid enrollee status. We dichotomized responses and ran multivariate logistic regressions for each type of care experience outcome, controlling for sociodemographic factors, health care access, and health care utilization of respondents. Compared to Medicare and privately insured enrollees, Medicaid enrollees reported much lower odds of seeing providers who treated them with respect (OR = 1.91, P < .001; OR = 1.62, P < .01) and who offered PCC (OR = 1.35, P < .05; OR = 1.35, P < .01), but similar odds of seeing concordant providers (OR = 0.78, P = .96; OR = 0.96, P = .72). Importantly, Medicaid enrollees reported higher odds of seeing providers who solicited their opinion/beliefs/preferences than their Medicare or privately insured counterparts (OR = 0.82, P < .05; OR = 0.87 P < .10). Medicaid enrollees report less patient-centered experiences in some important facets of their provider interaction than their Medicare or privately insured counterparts. Federal, state, and local policies and practices directed at improving these facets of patient-provider interaction are needed and should be aimed squarely at Medicaid providers, especially those working in geographic areas and settings with a disproportionate number of racial, gender, cultural, and linguistic minorities.

The Tasmanian Conception to Community (C2C) Study Database 2008-09 to 2013-14: Using linked health administrative data to address each piece in the puzzle

BACKGROUND

Tasmania, Australia has a small widely dispersed regional and rural population. The Conception to Community (C2C) Study Database was established as a research platform to inform service planning and policy development and improve health outcomes for Tasmanian mothers and children. The aims of this study were to establish by maternal socio-demographic characteristics: 1) the distribution of births in Tasmania; 2) hospital utilisation for children from birth to 5-years; and 3) the association between child and maternal emergency department (ED) presentation rates.

METHODS

Perinatal and public hospital ED and admitted patient data were linked for every child born in Tasmania between 2008-09 to 2013-14, and their mothers. Individualised rates of ED presentations and hospital admissions were calculated from birth to 5-years. Frequent presenters to ED were defined as having at least four presentations per annum. Ratios of ED presentation and hospital admission rates by sociodemographic characteristics (region (north, north-west, south), rurality, maternal age, and area socioeconomic disadvantage) were estimated using mixed-effects negative binomial models, with random intercepts for each child and family.

RESULTS

The C2C Database is comprised of records for 37,041 children and 27,532 mothers. One-in-ten Tasmanian babies lived in a remote area. The mean yearly rate of ED presentations per child varied by sex, age, region and rurality. Frequent presenters were more likely to reside in the north-west or north, in urban areas, have mothers under 20- years, be male, and live in more disadvantaged areas, with 2.3% of children frequent presenters in their first year of life. The odds of a child being a frequent presenter during their first-year was 6.1- times higher if the mother was a frequent presenter during this period.

CONCLUSION

Associations between maternal and child health service use and combined effects of regionality and rurality highlight opportunities for targeted intervention and service innovations.

Association between Chlamydia and routine place for healthcare in the United States: NHANES 1999-2016

BACKGROUND

The United States is experiencing a surge in Chlamydia trachomatis (CT) infections representing a critical need to improve sexually transmitted infection (STI) screening and treatment programs. To understand where patients with STIs seek healthcare, we evaluated the relationship between CT infections and the place where individuals report usually receiving healthcare.

METHODS

Our study used a nationally representative sample from the National Health and Nutrition Examination Survey (NHANES) from 1999 to 2016. The study population is adult patients, aged 18 to 39 years in whom a urine CT screen was obtained. Logistic regression models were used to determine if location of usual healthcare was predictive of a positive urine CT screen result. Models were adjusted for known confounders including age, gender, race/ethnicity, education, and insurance status.

RESULTS

In this nationally representative sample (n = 19,275; weighted n = 85.8 million), 1.9% of individuals had a positive urine CT result. Participants reported usually going to the doctor's office (70.3%), "no place" (24.8%), Emergency Department (ED) (3.3%), or "other" place (1.7%) for healthcare. In adjusted models, the predicted probability of having a positive urine CT result is higher (4.9% vs 3.2%, p = 0.022; OR = 1.58) among those that reported the ED as their usual place for healthcare compared to those that reported going to a doctor's office or clinic.

CONCLUSIONS

Individuals having a positive urine CT screen are associated with using the ED as a usual source for healthcare. Understanding this association has the potential to improve STI clinical and policy interventions as the ED may be a critical site in combatting the record high rates of STIs.

Patient-Reported Outcomes Predict Future Emergency Department Visits and Hospital Admissions in Patients With Stroke

Background

Identification of stroke patients at increased risk of emergency department (ED) visits or hospital admissions allows implementation of mitigation strategies. We evaluated the ability of the Patient‐Reported Outcomes Information Measurement System (PROMIS) patient‐reported outcomes (PROs) collected as part of routine care to predict 1‐year emergency department (ED) visits and admissions when added to other readily available clinical variables.

Methods and Results

This was a cohort study of 1696 patients with ischemic stroke, intracerebral hemorrhage, subarachnoid hemorrhage, or transient ischemic attack seen in a cerebrovascular clinic from February 17, 2015, to June 11, 2018, who completed the following PROs at the visit: Patient Health Questionnaire‐9, Quality of Life in Neurological Disorders cognitive function, PROMIS Global Health, sleep disturbance, fatigue, anxiety, social role satisfaction, physical function, and pain interference. A series of logistic regression models was constructed to determine the ability of models that include PRO scores to predict 1‐year ED visits and all‐cause and unplanned admissions. In the 1 year following the PRO encounter date, 1046 ED visits occurred in 548 patients; 751 admissions occurred in 453 patients. All PROs were significantly associated with future ED visits and admissions except PROMIS sleep. Models predicting unplanned admissions had highest optimism‐corrected area under the curve (range, 0.684–0.724), followed by ED visits (range, 0.674–0.691) and then all‐cause admissions (range, 0.628–0.671). PROs measuring domains of mental health had stronger associations with ED visits; PROs measuring domains of physical health had stronger associations with admissions.

Conclusions

PROMIS scales improve the ability to predict ED visits and admissions in patients with stroke. The differences in model performance and the most influential PROs in the prediction models suggest differences in factors influencing future hospital admissions and ED visits.

Top 10 presenting diagnoses of homeless veterans seeking care at emergency departments

BACKGROUND

The health concerns that spur care-seeking in emergency departments (EDs) among homeless populations are not well described. The Veterans Affairs (VA) comprehensive healthcare system does not require health insurance and thus offers a unique window into ED service use by homeless veterans.

OBJECTIVE

This study examined the top 10 diagnostic categories for ED use among homeless and non-homeless veterans classified by age, gender, and race/ethnicity.

DESIGN

An observational study was conducted using national VA administrative data from 2016 to 2019.

PARTICIPANTS

Data on 260,783 homeless veterans and 2,295,704 non-homeless veterans were analyzed.

MAIN MEASURES

Homelessness was defined as a documented diagnostic code or use of any VA homeless program. Presenting diagnoses to the ED were grouped based on Clinical Classifications Software Refined (CCSR) categories endorsed by the Agency for Healthcare Research and Quality (AHRQ).

KEY RESULTS

The most common diagnostic categories for ED use among homeless veterans were, in order, musculoskeletal pain, alcohol-related disorders, suicidal behaviors, low back pain, and non-specified conditions, which together accounted for 22-24% of all ED visits. Among non-homeless veterans, alcohol-related disorders, suicidal behaviors, and depressive disorders did not number in the top 10 diagnostic categories for ED use. Some differences between homeless and non-homeless veterans presenting for ED care, such as age, gender, and race/ethnicity largely mirrored known epidemiological differences between these groups in general. But respiratory infections and symptoms were only in the top 10 for black veterans and depressive disorder was only in the top 10 for Hispanic veterans.

CONCLUSIONS

These data suggest that addressing psychosocial factors and optimizing healthcare for behavioral health and pain conditions among veterans experiencing homelessness has the potential to reduce emergency care-seeking.

"I wanted to participate in my own care": Evaluation of a Patient Navigation Program

Introduction

Patient navigation programs can help people overcome barriers to outpatient care. Patient experiences with these programs are not well understood. The goal of this study was to understand patient experiences and satisfaction with an emergency department (ED)-initiated patient navigation (ED-PN) intervention for US Medicaid-enrolled frequent ED users.

Methods

We conducted a mixed-methods evaluation of patient experiences and satisfaction with an ED-PN program for patients who visited the ED more than four times in the prior year. Participants were Medicaid-enrolled, English- or Spanish-speaking, New Haven-CT residents over the age of 18. Pre-post ED-PN intervention surveys and post-ED-PN individual interviews were conducted. We analyzed baseline and follow-up survey responses as proportions of total responses. Interviews were coded by multiple readers, and interview themes were identified by consensus.

Results

A total of 49 participants received ED-PN. Of those, 80% (39/49) completed the post-intervention survey. After receiving ED-PN, participants reported high satisfaction, fewer barriers to medical care, and increased confidence in their ability to coordinate and manage their medical care. Interviews were conducted until thematic saturation was reached. Four main themes emerged from 11 interviews: 1) PNs were perceived as effective navigators and advocates; 2) health-related social needs were frequent drivers of and barriers to healthcare; 3) primary care utilization depended on clinic accessibility and quality of relationships with providers and staff; and 4) the ED was viewed as providing convenient, comprehensive care for urgent needs.

Conclusions

Medicaid-enrolled frequent ED users receiving ED-PN had high satisfaction and reported improved ability to manage their health conditions.

Identifying medication-related problems in pharmacist-run home visits

BACKGROUND

Home visits (HVs) may be warranted for many reasons (e.g., uncontrolled disease states, suspected psychosocial issues, frequent hospitalizations, poor health literacy). Patients who frequently visit the emergency department (ED) are high-risk individuals, oftentimes exhibiting health-related barriers and medication-related problems (MRPs).

OBJECTIVES

This study seeks to answer whether HVs for frequent ED users conducted by a pharmacist with pharmacy students will detect more MRPs compared to office visits (OVs) and enhance patient perception of HV services.

METHODS

Patients who visited the ED at least twice over a 12-month period were included in a retrospective chart review. Eligible patients were randomized into an HV group or OV group. Patients in the HV group were visited by a pharmacist and pharmacy students to identify and resolve MRPs, whereas patients in the OV arm brought their medications into the office for review. Patients in the HV group completed a pre- and postvisit survey about their experiences.

RESULTS

Eighteen patients participated in the study: 10 patients were randomized to the OV arm and 8 patients were randomized to the HV arm. A total of 39 MRPs were identified in 8 HVs versus 33 MRPs in 10 OVs (mean 5 ± 0.926 vs. 3.3 ± 1.89, P = 0.034). Overall, nonadherence was the most common MRP and medication reconciliation was the most common intervention. All 8 HV patients completed the pre- and post-HV surveys. Post-HV survey results indicated that patients agreed that student pharmacists were professional team members and that their HV was needed. The patients agreed to recommend a pharmacist-run HV.

CONCLUSION

Patient homes serve as alternative and convenient spaces for pharmacists to help manage their medications, specifically to identify MRPs and provide meaningful recommendations.

[The evolution of child psychiatry emergencies: Results and reflections from a Nancy University Hospital study]

INTRODUCTION

Mental illness is one of the most common causes of disability, morbidity and mortality in childhood. According to the scientific literature, the prevalence of mental health disorders is an estimated 10% to 20% in the USA and similar results are found in France. Although primordial, outpatient care often appears insufficient with inequalities in its geographical distribution and its accessibility. These past decades have been marked by an increase in consultations for mental disorders in pediatric emergency departments. Is this trend indicative of a "defect" in the healthcare organization? Identifying the root causes of this inflation in psychiatric consultations seems of paramount importance in the improvement of healthcare policies. In France and worldwide, only a few studies deal with this subject. That is why we proposed to observe the evolution of the number of consultations for mental health reasons in the pediatric emergency department of Nancy University Hospital and to detail their characteristics.

MATERIALS AND METHODS

Ancillary comparative and retrospective study (2003-2013) on minors having received a child psychiatry consultation within the pediatric emergency department of Nancy University Hospital.

RESULTS

The number of consultations for mental health reasons increased by 119% (97 in 2003; 212 in 2013), while consultations for pediatrics reasons remained stable over the period studied. Consultations mainly dealt with females representing 55.6% of consultations in 2003 and 63.7% in 2013. Mean age of consultants was stable: 13.9 years (standard deviation=3.3 years) in 2003; 14.1 (2.5) years in 2013. Family structure witnessed a three-fold increase in the single-parent model. Regarding consultation motives, behavioral disorders were significantly more represented in 2013: 27.7% (RR=1.7; 95% CI 1.0-2.8; P<0.05) versus 16.5%. As far as diagnosis is concerned (ICD-10), emotional and behavioral disorders increased to 35.9% from 12.6% (RR=2.8; IC95% 1.6-5.1; P=0.0001).

CONCLUSIONS

In France, as well as in other western countries, the number of visits in pediatric emergency departments for mental health reasons more than doubled over a 10-year span. This growth mostly concerned externalizing disorders as a motive for consultation. Causes for this increase are multifactorial and closely related to the prevalence of psychiatric disorders in children. Some studies showed that economic factors played a major role on mental illness during such a downturn as the financial crisis of 2007-2008. Unemployment caused by economic crises can weaken pediatric caregivers and therefore their patients. Evolution of family structure and value also explains this trend. These past decades, the two-parent model, relevant till the 1960s, has evolved to a point where single parents are more quickly overwhelmed. Family values are now focused on consensus rather than duty and hedonism has become a central value. Women are more involved in the working world which became for all a performance field. Several studies have shown that social settings where competitiveness is the norm breed externalized disorders in children by advocating short-term efficiency. Moreover, the widespread use of screens in households as well as early exposure impact the psychomotor development, decrease the amount of sleep and may be responsible for the occurrence of many psychiatric disorders. There are some epidemiological reasons too. In 1971, Omran introduced a concept called "epidemiological transition" explaining how mental health issues appeared in the limelight through to the decline of infectious and cardiovascular diseases. This phenomenon has already occurred in western countries which could explain the increase in the prevalence of psychiatric disorders. In Africa, there is evidence it may have already started. Beyond all these considerations, the increase in consultations for mental disorders in pediatric emergency departments can be explained by a change in care consumption habits. Going straight to the local emergency department, accessible on a 24/7 basis, is easier than waiting for an outpatient appointment and is also free for the have-nots lacking proper insurance coverage. Scarce resources in ambulatory care may also explain the increased recourse to emergency services. Several reports have shown a lack of child psychiatrists and their uneven geographical distribution. For example, in the US only a third of children with mental disorders receive proper care, a lack which doubled between 1997 and 2010. Despite the reason for this trend, it is important to propose a better fitting of the healthcare system to the population needs, and to improve prevention and early identification. All these changes require further collective reflection.

Unscheduled Care Access in the United States-A Tale of Two Emergency Departments

BACKGROUND

Rural communities face challenges in accessing healthcare services due to physician shortages and limited unscheduled care capabilities in office settings. As a result, rural hospital-based Emergency Departments (ED) may disproportionately provide acute, unscheduled care needs. We sought to examine differences in ED utilization and the relative role of the ED in providing access to unscheduled care between rural and urban communities.

METHODS

Using a 20% sample of the 2012 Medicare Chronic Condition Warehouse, we studied the overall ED visit rate and the unscheduled care rate by geography using the Dartmouth Atlas' hospital referral regions (HRR). We calculated HRR urbanicity as the proportion of beneficiaries residing in an urban zip code within each HRR. We report descriptive statistics and utilize K-means clustering based on the ED visit rates and unscheduled care rates.

RESULTS

We found rural ED use is more common and disproportionately the site of unscheduled care delivery when compared to urban communities. The ED visit and. unscheduled care proportions were negatively correlated with increased urbanicity (r =. -0.48, p < 0.001; r = -0.58, p < 0.001).

CONCLUSION

The use and role of EDs by Medicare beneficiaries appears to be substantially different between urban and rural areas. This suggests that the ED may play a distinct role within the healthcare delivery system of rural communities that face disproportionate barriers to care access.

Screening for Health-Related Social Needs of Emergency Department Patients

STUDY OBJECTIVE

There has been increasing attention to screening for health-related social needs. However, little is known about the screening practices of emergency departments (EDs). Within New England, we seek to identify the prevalence of ED screening for health-related social needs, understand the factors associated with screening, and understand how screening patterns for health-related social needs differ from those for violence, substance use, and mental health needs.

METHODS

We analyzed data from the 2018 National Emergency Department Inventory-New England survey, which was administered to all 194 New England EDs during 2019. We used descriptive statistics to compare ED characteristics by screening practices, and multivariable logistic regression models to identify factors associated with screening.

RESULTS

Among the 166 (86%) responding EDs, 64 (39%) reported screening for at least one health-related social need, 160 (96%) for violence (including intimate partner violence or other violent exposures), 148 (89%) for substance use disorder, and 159 (96%) for mental health needs. EDs reported a wide range of social work resources to address identified needs, with 155 (93%) reporting any social worker availability and 41 (27%) reporting continuous availability.

CONCLUSION

New England EDs are screening for health-related social needs at a markedly lower rate than for violence, substance use, and mental health needs. EDs have relatively limited resources available to address health-related social needs. We encourage research on the development of scalable solutions for identifying and addressing health-related social needs in the ED.

Patients' perceptions of frequent hospital admissions: a qualitative interview study with older people above 65 years of age

BACKGROUND

Although 'frequent flyer' hospital admissions represent barely 3 to 8% of the total patient population in a hospital, they are responsible for a disproportionately high percentage (12 to 28%) of all admissions. Moreover, hospital admissions are an important contributor to health care costs and overpopulation in various hospitals. The aim of this research is to obtain a deeper insight into the phenomenon of frequent flyer hospital admissions. Our objectives were to understand the patients' perspectives on the cause of their frequent hospital admissions and to identify the perceived consequences of the frequent flyer status.

METHODS

This qualitative study took place at the University Hospital of Leuven. The COREQ guidelines were followed to provide rigor to the study. Patients were included when they had at least four overnight admissions in the past 12 months, an age above 65 years and hospital admission at the time of the study. Data were collected via semi-structured interviews and encoded in NVivo.

RESULTS

Thirteen interviews were collected. A total of 17 perceived causes for frequent hospital admission were identified, which could be divided into the following six themes: patient, drugs, primary care, secondary care, home and family. Most of the causes were preventable or modifiable. The perceived consequences of being a frequent flyer were divided into the following six themes: body, daily life functioning, social participation, mental status and spiritual dimension. Negative experiences were linked to frequent flying and could be situated mainly in the categories of social participation, mental status and spiritual dimensions.

CONCLUSIONS

Frequent hospital admissions may be conceived as an indicator, i.e., a 'red flag', of patients' situations characterized by physical, mental, spiritual and social deprivation in their home situation.

Differentiating middle-aged long-term and short-term frequent attenders by means of the Northern Finland Birth Cohort 1966 Study

BACKGROUND

Frequent attendance is largely a temporary phenomenon, but only few previous studies have made a distinction between long-term frequent attenders (FAs) and short-term FAs.

AIMS

The aim of this study is to compare the characteristics of middle-aged long-term FAs and short-term FAs.

METHODS

Data from a large Northern Finland Birth Cohort 1966 study's (NFBC1966) 46-year follow-up study (performed in 2012, N = 10 321) were used. The participants (n = 4390) had used public primary healthcare (PPHC) services at least once during 2013-2016 according to Finnish national register data on outpatient visits. A FA was considered a patient who had used PPHC services ≥8 times during 1 year. A long-term FA: a patient who was a FA in at least 3 years during 2013-2016. A short-term FA: a patient who was a FA in 1 or 2 years in 2013-2016. Cross-tabulation, Pearson's chi-squared test, Mann-Whitney U test, and univariate and multivariate binary logistic regression analyses were used.

RESULTS

Of the 4390 participants, 132 (3.0%) were long-term FAs, 645 (14.7%) were short-term FAs, and 3613 (82.3%) were non-FAs. During 2013-2016, long-term FAs accounted for 34.8% of PPHC visits, while short-term FAs accounted 15.4%. Compared to short-term FAs, depression and high income (preventive attribute) were associated with long-term FAs. Female gender and managing usual activities were associated with short-term FAs. Poor self-reported health was associated with both long-term FAs and short-term FAs but increased the risk of being a long-term FA over three times compared to short-term FAs.

CONCLUSIONS

Middle-aged long-term FAs and short-term FAs have distinct characteristics; namely, depression and high income differentiate long-term FAs from short-term FAs. Poor self-reported health was associated with long-term FAs in particular. In order to identify FAs with prolonged service needs and to develop far-reaching interventions, the focus of research should be on long-term FAs.

Evaluation of a National Care Coordination Program to Reduce Utilization Among High-cost, High-need Medicaid Beneficiaries With Diabetes

BACKGROUND

Medical, behavioral, and social determinants of health are each associated with high levels of emergency department (ED) visits and hospitalizations.

OBJECTIVE

The objective of this study was to evaluate a care coordination program designed to provide combined "whole-person care," integrating medical, behavioral, and social support for high-cost, high-need Medicaid beneficiaries by targeting access barriers and social determinants.

RESEARCH DESIGN

Individual-level interrupted time series with a comparator group, using person-month as the unit of analysis.

SUBJECTS

A total of 42,214 UnitedHealthcare Medicaid beneficiaries (194,834 person-months) age 21 years or above with diabetes, with Temporary Assistance to Needy Families, Medicaid expansion, Supplemental Security Income without Medicare, or dual Medicaid/Medicare.

MEASURES

Our outcome measures were any hospitalizations and any ED visits in a given month. Covariates of interest included an indicator for intervention versus comparator group and indicator and spline variables measuring changes in an outcome's time trend after program enrollment.

RESULTS

Overall, 6 of the 8 examined comparisons were not statistically significant. Among Supplemental Security Income beneficiaries, we observed a larger projected decrease in ED visit risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -6.6%; 95% confidence interval: -11.2%, -2.1%). Among expansion beneficiaries, we observed a greater decrease in hospitalization risk among the intervention sample versus the comparator sample at 12 months postenrollment (difference-in-difference: -5.8%; 95% confidence interval: -11.4%, -0.2%).

CONCLUSION

A care coordination program designed to reduce utilization among high-cost, high-need Medicaid beneficiaries was associated with fewer ED visits and hospitalizations for patients with diabetes in selected Medicaid programs but not others.

Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured, Frequent ED Users: A Randomized Controlled Trial

BACKGROUND

Some Medicaid enrollees frequently utilize the emergency department (ED) due to barriers accessing health care services in other settings.

OBJECTIVES

To determine whether an ED-initiated Patient Navigation program (ED-PN) designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs.

METHODS

We conducted a prospective, randomized controlled trial comparing ED-PN with usual care (UC) among 100 Medicaid-enrolled frequent ED users (defined as 4-18 ED visits in the prior year), assessing ED utilization during the 12 months pre- and post-enrollment. Secondary outcomes included hospitalizations, outpatient utilization, hospital costs, and Medicaid costs. We also compared characteristics between ED-PN patients with and without reduced ED utilization.

RESULTS

Of 214 eligible patients approached, 100 (47%) consented to participate. Forty-nine were randomized to ED-PN and 51 to UC. Sociodemographic characteristics and prior utilization were similar between groups. ED-PN participants had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with UC, averaging 1.4 fewer ED visits per patient (p = 0.01) and 1.0 fewer hospitalizations per patient (p = 0.001). Both groups increased outpatient utilization. ED-PN patients showed a trend toward reduced per-patient hospital costs (-$10,201, p = 0.10); Medicaid costs were unchanged (-$5,765, p = 0.26). Patients who demonstrated a reduction in ED usage were older (mean age 42 vs. 33 years, p = 0.03) and had lower health literacy (78% low health literacy vs. 40%, p = 0.02).

CONCLUSION

An ED-PN program targeting Medicaid-insured high ED utilizers demonstrated significant reductions in ED visits and hospitalizations in the 12 months after enrollment.

Drivers of ‘clinically unnecessary’ use of emergency and urgent care: the DEUCE mixed-methods study

Background

There is widespread concern about the pressure on emergency and urgent services in the UK, particularly emergency ambulances, emergency departments and same-day general practitioner appointments. A mismatch between supply and demand has led to interest in what can be termed ‘clinically unnecessary’ use of services. This is defined by the research team in this study as ‘patients attending services with problems that are classified as suitable for treatment by a lower urgency service or self-care’. This is a challenging issue to consider because patients may face difficulties when deciding the best action to take, and different staff may make different judgements about what constitutes a legitimate reason for service use.

Objectives

To identify the drivers of ‘clinically unnecessary’ use of emergency ambulances, emergency departments and same-day general practitioner appointments from patient and population perspectives.

Design

This was a sequential mixed-methods study with three components: a realist review; qualitative interviews (n = 48) and focus groups (n = 3) with patients considered ‘clinically unnecessary’ users of these services, focusing on parents of young children, young adults and people in areas of social deprivation; and a population survey (n = 2906) to explore attitudes towards seeking care for unexpected, non-life-threatening health problems and to identify the characteristics of someone with a tendency for ‘clinically unnecessary’ help-seeking.

Results

From the results of the three study components, we found that multiple, interacting drivers influenced individuals’ decision-making. Drivers could be grouped into symptom related, patient related and health service related. Symptom-related drivers were anxiety or need for reassurance, which were caused by uncertainty about the meaning or seriousness of symptoms; concern about the impact of symptoms on daily activities/functioning; and a need for immediate relief of intolerable symptoms, particularly pain. Patient-related drivers were reduced coping capacity as a result of illness, stress or limited resources; fear of consequences when responsible for another person’s health, particularly a child; and the influence of social networks. Health service-related drivers were perceptions or previous experiences of services, particularly the attractions of emergency departments; a lack of timely access to an appropriate general practitioner appointment; and compliance with health service staff’s advice.

Limitations

Difficulty recruiting patients who had used the ambulance service to the interviews and focus groups meant that we were not able to add as much as we had anticipated to the limited evidence base regarding this service.

Conclusions

Patients use emergency ambulances, emergency departments and same-day general practitioner appointments when they may not need the level of clinical care provided by these services for a multitude of inter-related reasons that sometimes differ by population subgroup. Some of these reasons relate to health services, in terms of difficulty accessing general practice leading to use of emergency departments, and to population-learnt behaviour concerning the positive attributes of emergency departments, rather than to patient characteristics. Social circumstances, such as complex and stressful lives, influence help-seeking for all three services. Demand may be ‘clinically unnecessary’ but completely understandable when service accessibility and patients’ social circumstances are considered.

Future work

There is a need to evaluate interventions, including changing service configuration, strengthening general practice and addressing the stressors that have an impact on people’s coping capacity. Different subgroups may require different interventions.

Study registration

This study is registered as PROSPERO CRD42017056273.

Funding

This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 15. See the NIHR Journals Library website for further project information.

Data mining techniques utilizing latent class models to evaluate emergency department revisits

BACKGROUND

The use of machine learning techniques is especially pertinent to the composite and challenging conditions of emergency departments (EDs). Repeat ED visits (i.e. revisits) are an example of potentially inappropriate utilization of resources that can be forecasted by these techniques.

OBJECTIVE

To track the ED revisit risk over time using the hidden Markov model (HMM) as a major latent class model. Given the HMM states, we carried out forecasting of future ED revisits with various data mining models.

METHODS

Information integrated from four distributed sources (e.g. electronic health records and health information exchange) was integrated into four HMMs which capture the relationships between an observed and a hidden progression that shift over time through a series of hidden states in an adult patient population.

RESULTS

Assimilating a pre-analysis of the various patients by applying latent class models and directing them to well-known classifiers functioned well. The performance was significantly better than without utilizing pre-analysis of HMM for all prediction models (classifiers(.

CONCLUSIONS

These findings suggest that one prospective approach to advanced risk prediction is to leverage the longitudinal nature of health care data by exploiting patients' between state variation.

'Clinically unnecessary' use of emergency and urgent care: A realist review of patients' decision making

Background

Demand is labelled ‘clinically unnecessary’ when patients do not need the levels of clinical care or urgency provided by the service they contact.

Objective

To identify programme theories which seek to explain why patients make use of emergency and urgent care that is subsequently judged as clinically unnecessary.

Design

Realist review.

Methods

Papers from four recent systematic reviews of demand for emergency and urgent care, and an updated search to January 2017. Programme theories developed using Context‐Mechanism‐Outcome chains identified from 32 qualitative studies and tested by exploring their relationship with existing health behaviour theories and 29 quantitative studies.

Results

Six mechanisms, based on ten interrelated programme theories, explained why patients made clinically unnecessary use of emergency and urgent care: (a) need for risk minimization, for example heightened anxiety due to previous experiences of traumatic events; (b) need for speed, for example caused by need to function normally to attend to responsibilities; (c) need for low treatment‐seeking burden, caused by inability to cope due to complex or stressful lives; (d) compliance, because family or health services had advised such action; (e) consumer satisfaction, because emergency departments were perceived to offer the desired tests and expertise when contrasted with primary care; and (f) frustration, where patients had attempted and failed to obtain a general practitioner appointment in the desired timeframe. Multiple mechanisms could operate for an individual.

Conclusions

Rather than only focusing on individuals' behaviour, interventions could include changes to health service configuration and accessibility, and societal changes to increase coping ability.

Drivers of preventable high health care utilization: a qualitative study of patient, physician and health system leader perspectives

OBJECTIVES

A small percentage of patients account for the bulk of population health care utilization and costs in many countries including the United States (US). In the US, 5% of the population has high health care utilization accounting for nearly 50% of health care costs. A subset of this utilization is deemed preventable, and thus potentially cost saving to patients as well as to the health care system. This study sought to identify drivers of preventable utilization from the perspectives of three stakeholder groups in the US: health system leaders; high-need, high-cost (HNHC) patients or their primary caregivers; and physicians.

METHODS

We performed a qualitative study using interviews of health system leaders and focus groups of HNHC patients, caregivers and physicians. We used a mixed inductive deductive approach to analyse transcripts and identify themes.

RESULTS

We identified three key drivers of preventable high health care utilization: (1) unmet behavioural health needs, (2) socio-economic determinants of health and (3) challenges associated with accessing health care delivery systems.

CONCLUSIONS

To be potentially more effective, interventions to reduce preventable high health care utilization should incorporate the perspectives of patients, health system leaders and physicians. Particularly important to stakeholders is increased access to mental-health resources, support for patients with low socio-economic resources and systemic changes that reduce wait times for primary care visits and allow providers more time during patient visits.

Prevalence of Screening for Food Insecurity, Housing Instability, Utility Needs, Transportation Needs, and Interpersonal Violence by US Physician Practices and Hospitals

Importance

Social needs, including food, housing, utilities, transportation, and experience with interpersonal violence, are linked to health outcomes. Identifying patients with unmet social needs is a necessary first step to addressing these needs, yet little is known about the prevalence of screening.

Objective

To characterize screening for social needs by physician practices and hospitals.

Design, Setting, and Participants

Cross-sectional survey analyses of responses by physician practices and hospitals to the 2017-2018 National Survey of Healthcare Organizations and Systems. Responses were collected from survey participants from June 16, 2017, to August 17, 2018.

Exposures

Organizational characteristics, including participation in delivery and payment reform.

Main Outcomes and Measures

Self-report of screening patients for food insecurity, housing instability, utility needs, transportation needs, and experience with interpersonal violence.

Results

Among 4976 physician practices, 2333 responded, a response rate of 46.9%. Among hospitals, 757 of 1628 (46.5%) responded. After eliminating responses because of ineligibility, 2190 physician practices and 739 hospitals remained. Screening for all 5 social needs was reported by 24.4% (95% CI, 20.0%-28.7%) of hospitals and 15.6% (95% CI, 13.4%-17.9%) of practices, whereas 33.3% (95% CI, 30.5%-36.2%) of practices and 8.0% (95% CI, 5.8%-11.0%) of hospitals reported no screening. Screening for interpersonal violence was most common (practices: 56.4%; 95% CI, 53.3%-2 59.4%; hospitals: 75.0%; 95% CI, 70.1%-79.3%), and screening for utility needs was least common (practices: 23.1%; 95% CI, 20.6%-26.0%; hospitals: 35.5%; 95% CI, 30.0%-41.0%) among both hospitals and practices. Among practices, federally qualified health centers (yes: 29.7%; 95% CI, 21.5%-37.8% vs no: 9.4%; 95% CI, 7.2%-11.6%; P < .001), bundled payment participants (yes: 21.4%; 95% CI, 17.1%-25.8% vs no: 10.7%; 95% CI, 7.9%-13.4%; P < .001), primary care improvement models (yes: 19.6%; 95% CI, 16.5%-22.6% vs no: 9.6%; 95% CI, 6.0%-13.1%; P < .001), and Medicaid accountable care organizations (yes: 21.8%; 95% CI, 17.4%-26.2% vs no: 11.2%; 95% CI, 8.6%-13.7%; P < .001) had higher rates of screening for all needs. Practices in Medicaid expansion states (yes: 17.7%; 95% CI, 14.8%-20.7% vs no: 11.4%; 95% CI, 8.1%-14.6%; P = .007) and those with more Medicaid revenue (highest tertile: 17.1%; 95% CI, 11.4%-22.7% vs lowest tertile: 9.0%; 95% CI, 6.1%-11.8%; P = .02) were more likely to screen. Academic medical centers were more likely than other hospitals to screen (49.5%; 95% CI, 34.6%-64.4% vs 23.0%; 95% CI, 18.5%-27.5%; P < .001).

Conclusions and Relevance

This study's findings suggest that few US physician practices and hospitals screen patients for all 5 key social needs associated with health outcomes. Practices that serve disadvantaged patients report higher screening rates. The role of physicians and hospitals in meeting patients' social needs is likely to increase as more take on accountability for cost under payment reform. Physicians and hospitals may need additional resources to screen for or address patients' social needs.

Barriers to Primary Care After the Affordable Care Act: A Qualitative Study of Los Angeles Safety-Net Patients' Experiences

Purpose: Millions of people gained health care coverage in Los Angeles after the Affordable Care Act (ACA); however, challenges with obtaining and utilizing primary care still persist, particularly in the safety net. In this study, we explore barriers to accessing primary care services among safety-net patients in Los Angeles after Medicaid expansion and implementation of other programs for safety-net patients after the ACA. Methods: We conducted qualitative interviews, in Spanish and English, with 34 nonelderly adult patients in 1 of 3 insurance groups: Medicaid, MyHealthLA (a health care program for low-income undocumented individuals), or uninsured. We recruited participants from three sites in Los Angeles in 2017. We analyzed our interviews using a framework approach and included emerging concepts from participant responses. Results: We identified seven themes regarding barriers to accessing primary care: understanding the concept of primary care, finding a primary care provider (PCP), switching PCPs, getting timely appointments, geography and transportation, perceived cost or coverage barriers, and preferring emergency or urgent care over primary care. Patients with Medicaid were more likely to report barriers compared with other groups. Uninsured patients were less likely to understand the concept of primary care. Patients with MyHealthLA noted getting timely appointments and cost of care to be significant barriers. Conclusion: Despite Medicaid and other coverage expansions for safety-net patients after the ACA, substantial barriers to accessing primary care persist. Addressing such barriers through the development of targeted interventions or broader policy solutions could improve access to primary care for safety-net patients in Los Angeles.

Characterization of high healthcare utilizer groups using administrative data from an electronic medical record database

Background

High utilizers (HUs) are a small group of patients who impose a disproportionately high burden on the healthcare system due to their elevated resource use. Identification of persistent HUs is pertinent as interventions have not been effective due to regression to the mean in majority of patients. This study will use cost and utilization metrics to segment a hospital-based patient population into HU groups.

Methods

The index visit for each adult patient to an Academic Medical Centre in Singapore during 2006 to 2012 was identified. Cost, length of stay (LOS) and number of specialist outpatient clinic (SOC) visits within 1 year following the index visit were extracted and aggregated. Patients were HUs if they exceeded the 90th percentile of any metric, and Non-HU otherwise. Seven different HU groups and a Non-HU group were constructed. The groups were described in terms of cost and utilization patterns, socio-demographic information, multi-morbidity scores and medical history. Logistic regression compared the groups’ persistence as a HU in any group into the subsequent year, adjusting for socio-demographic information and diagnosis history.

Results

A total of 388,162 patients above the age of 21 were included in the study. Cost-LOS-SOC HUs had the highest multi-morbidity and persistence into the second year. Common conditions among Cost-LOS and Cost-LOS-SOC HUs were cardiovascular disease, acute cerebrovascular disease and pneumonia, while most LOS and LOS-SOC HUs were diagnosed with at least one mental health condition. Regression analyses revealed that HUs across all groups were more likely to persist compared to Non-HUs, with stronger relationships seen in groups with high SOC utilization. Similar trends remained after further adjustment.

Conclusion

HUs of healthcare services are a diverse group and can be further segmented into different subgroups based on cost and utilization patterns. Segmentation by these metrics revealed differences in socio-demographic characteristics, disease profile and persistence. Most HUs did not persist in their high utilization, and high SOC users should be prioritized for further longitudinal analyses. Segmentation will enable policy makers to better identify the diverse needs of patients, detect gaps in current care and focus their efforts in delivering care relevant and tailored to each segment.

Electronic supplementary material

The online version of this article (10.1186/s12913-019-4239-2) contains supplementary material, which is available to authorized users.

An Unmet Need Meets an Untapped Resource: Pharmacist-Led Pathways for Hypertension Management for Emergency Department Patients

PURPOSE OF REVIEW

The purpose of this review is to describe the role of the pharmacist in innovative pathways of care for hypertension (HTN) management for emergency department (ED) patients, particularly in under-resourced communities. Due to intersecting socioeconomic and personal health risk factors, these patients bear a disproportionate share of cardiovascular disease, yet often have limited access to high-quality primary care.

RECENT FINDINGS

Recent meta-analyses demonstrate a clear advantage associated with pharmacist-physician collaborative models over traditional physician-only care in achieving blood pressure control. However, no prior study has evaluated use of pharmacist-led follow-up for ED patients with uncontrolled blood pressure (BP). Thus, we developed a pharmacist-driven transitional care clinic (TCC) that utilizes a collaborative practice agreement with ED physicians to improve HTN management for ED patients. We have successfully implemented the TCC in a high-volume urban ED and in a pilot study have shown clinically relevant BP reductions with our collaborative model. The use of pharmacist-led follow-up for HTN management is highly effective. Novel programs such as our TCC, which extend the reach of such a model to ED patients, are promising, and future studies should focus on implementation through larger, multicenter, randomized trials. However, to be most effective, policy advocacy is needed to expand pharmacist prescriptive authority and develop innovative financial models to incentivize this practice.

From Their Perspective: The Connection between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department

The perspective of homeless adults on their health care service utilization is not well studied. This article describes a study that used in-depth, semistructured interviews with 18 individuals to highlight the viewpoints of homeless people who are frequent users of the emergency department (ED) about the influence of life events on service utilization. Participants reported high levels of pain and comorbid psychiatric, substance use, and medical conditions. They also reported an identifiable pattern of health care utilization, often centered on a crisis event, influenced by high perceived medical needs, inability to cope after crisis, predisposing vulnerability from social determinants of health, and health care system factors. A social work case management intervention often led to a period of stability and use of ED alternatives. Modifiable targets for intervention at the health care system and local levels include improving trust and convenience of ED alternatives, enhancing consistency of care at ED-alternative sites, and educating those at risk of frequent ED use about community alternatives.

Unique characteristics of frequent presenters to the emergency department in a Japanese population: a retrospective analysis

Aim

Little evidence on Japanese frequent presenters (FPs) is available. Therefore, this retrospective cohort study compared characteristics between FPs and non‐frequent presenters (NFPs) in emergency departments (EDs) in Japan.

Methods

Frequent presenters included those who presented to an ED ≥4 times during the study period from August 1, 2012 to July 21, 2013. The primary outcomes were triage level and disposition. Secondary outcomes were ED length of stay, method of arrival, and discharge diagnosis.

Results

During the study period, 195 FPs had 1,154 visits to the ED, compared to 15,953 visits by 13,838 NFPs. The sex distribution between FPs and NFPs was comparable (107 men [54.9%] versus 7,070 men [51.1%], respectively; P = 0.29), but the mean age was significantly higher in the FP group (57.3 versus 46.5 years, respectively; P < 0.0001). Among the FPs, the rate of free governmental health insurance was higher than that of those who pay 30% of health costs (35 patients paid 0% [79.5%] versus 109 patients paid 30% [42.6%], respectively). Condition severity (FP, 84 severe cases [7.28%]; NFP, 1,320 severe cases [8.27%], respectively) and rate of admission (FP, 207 admissions [17.9%]; NFP, 2,987 admissions [18.7%], respectively) were comparable between the groups, although the rate of ambulance use was lower for the FP group. The most frequent diagnostic codes (International Classification of Diseases, 10th Revision) in the FP group were “symptoms and signs”.

Conclusion

Triage levels and hospital admission rates were not significantly different between FPs and NFPs in this single‐center study in Japan.

Emergency Medical Services Utilization Is Associated With Community Deprivation in Children

BACKGROUND

Pediatric emergency medical services (EMS) utilization is costly and resource intensive; significant variation exists across large-scale geographies. Less is known about variation at smaller geographic levels where factors including lack of transportation, low health literacy, and decreased access to medical homes may be more relevant. Our objective was to determine whether pediatric EMS utilization varied across Hamilton County, Ohio, census tracts and whether such utilization was associated with socioeconomic deprivation.

METHODS

This was a retrospective analysis of children living in Hamilton County, Ohio, transported by EMS to the Cincinnati Children's emergency department between July 1, 2014, and July 31, 2016. Participants' addresses were assigned to census tracts and an EMS utilization rate and deprivation index were calculated for each. Pearson's correlation coefficients evaluated relationships between tract-level EMS utilization and deprivation. Tract-level deprivation was used as a predictor in patient-level evaluations of acuity.

RESULTS

During the study period, there were 4,877 pediatric EMS transports from 219 of the 222 county census tracts. The county EMS utilization rate during the study period was 2.4 transports per 100 children (range 0.2-11). EMS utilization rates were positively correlated with increasing deprivation (r = 0.72, 95% confidence interval [CI], 0.65-0.77). Deprivation was associated with lower illness severity at triage, fewer transports resulting in resuscitation suite use, and fewer transports resulting in hospitalizations (all p < 0.05).

CONCLUSIONS

EMS utilization varied substantially across census tracts in Hamilton County, Ohio. A deeper understanding into why certain socioeconomically deprived areas contribute to disproportionately high rates of EMS utilization could support development of targeted interventions to improve use.

Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities.

Exploring the Value Proposition of Primary Care for Safety-Net Patients Who Utilize Emergency Departments to Address Unmet Needs

Background: An underlying assumption of strategies intended to promote appropriate primary care over emergency department (ED) use for ongoing health care needs is that patients will understand the “value proposition” of primary care: that they will receive specific benefits from primary care providers over and above what they receive from EDs. However, there is evidence that this value proposition may be unclear to safety-net patients. The goals of this study are to describe factors motivating ED use for low-acuity conditions; describe similarities and differences in usual source of care (USOC) experiences, by ED versus non-ED setting; and assess awareness and perceptions of the patient-centered medical home (PCMH) concept among safety-net patients. Methods: We conducted a cross-sectional descriptive study of adult patients (n = 329) at 3 safety-net hospitals in the Southwest. Results: Key reasons for ED use were perceived urgency, lack of awareness about other options for care, payment flexibility, and perceived quality and convenience. Approximately half of participants indicated they would seek treatment in non-ED settings, if available, but agreement differed by group (non-ED USOC, 60.2%; ED USOC, 50.7%; no USOC, 45.3%; P = .025). Agreement that providers coordinated access to needed medical services was significantly higher among patients with non-ED USOCs; agreement that providers coordinated non-medical services that facilitate access to care was similar (approximately 45%) for patients with ED and non-ED USOCs. Approximately 70% of participants in both groups agreed that every person should have a medical home. Conclusions: Perceived experiences of care in ED and non-ED USOC settings suggest challenges and opportunities for increasing the value proposition of primary care for safety-net patients. Although patients are receptive to the PCMH concept, effective strategies to better highlight the value of primary care in coordinating both medical and related nonmedical services and other PCMH benefits warrant further investigation.

Contributing factors of frequent use of the emergency department: A synthesis

INTRODUCTION

Overcrowding in emergency departments is an issue that has a negative impact worldwide. As attendance in emergency departments has increased, the ability to provide critical services to patients suffering from actual medical emergencies in a timely manner has decreased as these departments are many times at or over capacity. One patient population whose negative influence has been researched with regard to their impact on the overcrowding issue is that of the frequent user.

METHODS

A search of two electronic databases was conducted to identify factors that frequent users state as their reasoning for using an emergency department. Peer reviewed articles in English were searched for in CINAHL Plus and PubMed, as well as a review of reference lists.

RESULTS

A review of the literature identified two predominant factors related to frequent users in the emergency department: a lack of awareness of medical necessity and issues of access.

DISCUSSION

To address the frequent users in emergency departments, implications for practice need to be explored and implemented. Implications for practice include education of medical necessity for the frequent users, expansion of the pre-hospital role in primary care and inappropriate use prevention, and improvement of access to alternative healthcare services.

Geographic Variation in Use of Ambulance Transport to the Emergency Department

STUDY OBJECTIVE

Evidence on variability in emergency medical services use is limited. We obtain national evidence on geographic variation in the use of ambulance transport to the emergency department (ED) among Medicare enrollees and assess the role of health status, socioeconomic status, and provider availability.

METHODS

We used 2010 Medicare claims data for a random sample of 999,999 enrollees aged 66 years and older, and identified ambulance transport and ED use. The main outcome measures were number of ambulance transports to the ED per 100 person-years (ambulance transport rate) and proportion (percentage) of ED visits by ambulance transport by hospital referral regions.

RESULTS

The national ambulance transport rate was 22.2 and the overall proportion of ED visits by ambulance was 36.7%. Relative to hospital referral regions in the lowest rate quartile, those in the highest quartile had a 75% higher ambulance transport rate (incidence rate ratio [IRR] 1.75; 95% confidence interval [CI] 1.69 to 1.81) and a 15.5% higher proportion of ED visits by ambulance (IRR 1.155; 95% CI 1.146 to 1.164). Adjusting for health status, socioeconomic status, and provider availability reduced quartile 1 versus quartile 4 difference in ambulance transport rate by 43% (IRR 1.43; 95% CI 1.38 to 1.48) and proportion of ED visits by ambulance by 7% (IRR 1.145; 95% CI 1.135 to 1.155). Among the 3 covariate domains, health status was associated with the largest variability in ambulance transport rate (30.1%), followed by socioeconomic status (12.8%) and provider availability (2.9%).

CONCLUSION

Geographic variability in ambulance use is large and associated with variation in patient health status and socioeconomic status.

Factors associated with choosing the emergency department as the primary access point to health care: a Canadian population cross-sectional study

Objective

Approximately 4.3 million Canadians are without a primary care physician, of which 13% choose the emergency department (ED) as their regular access point to health care. We sought to identify factors associated with preferential ED use over other health services. We hypothesized that socioeconomic barriers (i.e., employment, health status, education) to primary care would also prevent access to ED alternatives.

Methods

Data from the Canadian Community Health Survey, 2007 to 2008, were analysed (N=134,073; response rate 93.5%). Our study population comprised 14,091 individuals identified without a primary care physician. Socioeconomic variables included employment, health, and education. Covariates included chronic health conditions, immigrant status, gender, age, and mental health. Prevalence estimates and 95% confidence intervals (CIs) for each variable were calculated. Weighted logistic regression models were constructed to evaluate the importance of individual risk factors and their interactions after adjustment for relevant covariates.

Results

The sample comprised 57.2% males from across Canada. Employment (OR 0.73 [95% CI: 0.59-0.90]), good health (OR 0.73 [95% CI 0.57-0.88]), and post-secondary education (OR 0.68 [95% CI 0.53-0.88]) reduced respondents use of the ED. The reduced odds of ED use were independent of chronic conditions, mental health, gender, poor mobility, province, and age.

Conclusions

Low socioeconomic status dictates preferential ED use in those without a primary care physician. Specific policy and system development targeting this at-risk population are indicated to alter ED use patterns in this population.