Frequent users of US emergency departments: characteristics and opportunities for intervention

Receiving home care forms and the risk for emergency department visits in community-dwelling Dutch older adults, a retrospective cohort study using national data

BACKGROUND

Older adults receiving home care have a higher risk of visiting the emergency department (ED) than community-dwelling older adults not receiving home care. This may result from a higher incidence of comorbidities and reduced functional autonomy in home care recipients. Since people receive different types of home care because of their different comorbidities and autonomy profiles, it is possible that distinguishing between the form of home care can help identify subpopulations with different risks for ED visits and help develop targeted interventions. This study aimed to compare the risk of visiting the ED in older adults receiving different forms of home care with those living at home without receiving home care in a national cohort in one year.

METHODS

A retrospective cohort study using claims data collected in 2019 on the Dutch population aged ≥ 65 years (N = 3,314,440) was conducted. Participants were classified as follows: no claimed home care (NO), household help (HH), personal care (PC), HH + PC, and nursing home care at home (NHH). The primary outcome was the number of individuals that visited the ED. Secondary outcomes were the number of individuals whose home care changed, who were institutionalized, or who died. Exploratory logistic regression was applied.

RESULTS

There were 2,758,093 adults in the NO group, 131,260 in the HH group, 154,462 in the PC group, 96,526 in the HH + PC group, and 34,612 in the NHH group. More ED visits were observed in the home care groups than in the NO group, and this risk increased to more than two-fold for the PC groups. There was a significant change to a more intensive form of home care, institutionalization, or death in all groups.

CONCLUSIONS

Distinguishing between the form of home care older adults receive identifies subpopulations with different risks for ED visits compared with community-dwelling older adults not receiving home care on a population level. Home care transitions are frequent and mostly involve more intensive care or death. Although older adults not receiving home care have a lower risk of ED visits, they contribute most to the absolute volume of ED visits.

Community Hospital Interventions Addressing the Medical and Social Needs of Patients : Patient Perspectives From the CHART Investment Program

High utilizers of acute care in nonurban settings are at risk for poor health outcomes. Much of Massachusetts is nonurban, with many residents experiencing limited access to health care providers, fragmented health care services, inadequate housing, and low health literacy. This study examines patient perspectives on the Community Hospital Acceleration, Revitalization, and Transformation (CHART) investment program, a state-based grant program focused on advancing community hospitals toward value-based care. We found that CHART staff engaged patients in care coordination and patient advocacy, promoted patient agency and health literacy, and provided socioemotional support. These findings may help inform future program development around meeting the medical and social needs of high utilizers of health care services.

Evaluating barriers and facilitators to healthcare providers' use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework

OBJECTIVE

Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services.

METHODS

The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis.

RESULTS

Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers.

CONCLUSIONS

Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.

Substance Use Disorders, Mental Illness, and Health Care Utilization Among Adults With Recent Criminal Legal Involvement

OBJECTIVE

Individuals involved with the criminal legal system have higher rates of mental illness, addiction, and health care utilization. The authors examined whether substance use disorders and mental illness alone or in combination drive health care utilization among those with recent criminal legal involvement.

METHODS

This cross-sectional analysis used nationally representative data from U.S. adults with past-year criminal legal involvement (N=9,039) recorded in the National Survey on Drug Use and Health (2015-2019). Using adjusted negative binomial regression models, the authors estimated relative risks for health care utilization. Primary independent variable categories included neither substance use disorder nor mental illness, substance use disorder only, mental illness only, and both conditions. Health care utilization included emergency department (ED) visits and nights spent in inpatient care.

RESULTS

Relative to neither mental illness nor substance use disorder, mental illness alone was associated with significantly increased acute health care services use: for ED visits, incidence risk ratio (IRR)=1.43 (95% CI=1.18-1.75) and for inpatient stays, IRR=2.14 (95% CI=1.47-3.11). Having both conditions was associated with increased ED visits (IRR=1.62, 95% CI=1.38-1.91) and inpatient stays (IRR=4.16, 95% CI=2.98-5.82). Substance use disorder alone was associated only with higher risk for ED visits compared with neither condition (IRR=1.23, 95% CI=1.01-1.50).

CONCLUSIONS

Mental illness with or without co-occurring substance use disorder is a strong driver of acute health care utilization after interaction with the criminal legal system. Interventions tailored to the unique needs of individuals with mental illness or substance use disorder are needed for those with recent criminal legal involvement.

Association between patient-reported social and behavioral risks and health care costs in high-risk Veterans health administration patients

OBJECTIVE

Social risks complicate patients' ability to manage their conditions and access healthcare, but their association with health expenditures is not well established. To identify patient-reported social risk, behavioral, and health factors associated with health expenditures in Veterans Affairs (VA) patients at high risk for hospitalization or death.

DATA SOURCES, STUDY SETTING, AND STUDY DESIGN

Prospective cohort study among high-risk Veterans obtaining VA care. Patient-reported social risk, function, and other measures derived from a 2018 survey sent to 10,000 VA patients were linked to clinical and demographic characteristics extracted from VA data. Response-weighted generalized linear and marginalized two-part models were used to examine VA expenditures (total, outpatient, medication, inpatient) 1 year after survey completion in adjusted models.

PRINCIPAL FINDINGS

Among 4680 survey respondents, the average age was 70.9 years, 6.3% were female, 16.7% were African American, 20% had body mass index ≥35, 42.4% had difficulty with two or more basic or instrumental activities of daily living, 19.3% reported transportation barriers, 12.5% reported medication insecurity and 21.8% reported food insecurity. Medication insecurity was associated with lower outpatient expenditures (-$1859.51 per patient per year, 95% confidence interval [CI]: -3200.77 to -518.25) and lower total expenditures (-$4304.99 per patient per year, 95% CI: -7564.87 to -1045.10). Transportation barriers were negatively associated with medication expenditures (-$558.42, 95% CI: -1087.93 to -31.91). Patients with one functional impairment had higher outpatient expenditures ($2997.59 per patient year, 95% CI: 1185.81-4809.36) than patients without functional impairments. No social risks were associated with inpatient expenditures.

CONCLUSIONS

In this study of VA patients at high risk for hospitalization and mortality, few social and functional measures were independently associated with the costs of VA care. Individuals with functional limitations and those with barriers to accessing medications and transportation may benefit from targeted interventions to ensure that they are receiving the services that they need.

Social Risk, Social Need, and Use of the Emergency Department

This cohort study examines the association of social risk and social need with emergency department use by patients within a Medicaid accountable care organization who were screened for adverse social determinants of health in primary care.

Multiple emergency department encounters for acute musculoskeletal presentation with an existing mental health diagnosis

Reconceptualising acute Musculoskeletal (MSK) injuries with both stress- and tissue- based factors is required to consider prior influences of mental health disorders on acute persistent MSK pain presentations. This report describes repeated emergency presentations of an individual with acute persistent MSK pain in their twenties living with mental health. Their mental health diagnoses included depression, mood disorders, and anorexia nervosa. This person also had mental health related inpatient admissions that were not captured under the retrospective record review for a large district hospital emergency department using the Systematized Nomenclature of Medicine Clinical Terms (SNOMED CT) classification system. This case report attempts to demonstrate that improving the understanding of preexisting vulnerabilities and mental health diagnoses may assist with informing healthcare design to develop specialised care pathways for acute injury presentations within triage settings.

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.

Demographic predictors of emergency service utilization patterns in youth at risk of suicide

OBJECTIVE

To explore demographic predictors of Emergency Department (ED) utilization among youth with a history of suicidality (i.e., ideation or behaviors).

METHODS

Electronic health records were extracted from 2017 to 2021 for 3094 8-22 year-old patients with a history of suicidality at an urban academic medical center ED in the Mid-Atlantic. Logistic regression analyses were used to assess for demographic predictors of ED utilization frequency, timing of subsequent visits, and reasons for subsequent visits over a 24-month follow-up period.

RESULTS

Black race (OR = 1.45, 95% CI = 1.11-1.92), Female sex (OR = 1.59, 95% CI = 1.26-2.03), and having Medicaid insurance (OR = 1.71, 95% CI = 1.37-2.14) were associated with increased utilization, while being under 18 was associated with lower utilization (<12: OR = 0.38, 95% CI = 0.26-0.56; 12-18: OR = 0.47, 95% CI = 0.35-0.63). These demographics were also associated with ED readmission within 90 days, while being under 18 was associated with a lower odds of readmission.

CONCLUSIONS

Among patients with a history of suicidality, those who identify as Black, young adults, patients with Medicaid, and female patients were more likely to be frequent utilizers of the ED within the 2 years following their initial visit. This pattern may suggest inadequate health care access for these groups, and a need to develop better care coordination with an intersectional focus to facilitate utilization of other health services.

Using network analyses to characterise Australian and Canadian frequent attenders to the emergency department

OBJECTIVE

To explore and compare the characteristics of frequent attenders to the ED at an Australian and a Canadian tertiary hospitals by utilising a network analysis approach.

METHODS

We conducted a retrospective population-based study using administrative data over the 2018 and 2019 calendar years. Participants were from a tertiary hospital in Melbourne, Australia, and Toronto, Canada. Frequent attenders were defined as patients with four or more visits in 12 months. Characteristics of younger (18-39 years), middle-aged (40-69 years) and older (70 years and older) frequent attenders were described using descriptive statistics and network analyses.

RESULTS

Younger frequent attenders were characterised by mental illness and substance use, while older frequent attenders had high rates of physical (including chronic) diseases. Middle-aged frequent attenders were characterised by a combination of mental and physical illnesses. These findings were observed at both hospitals. Across all age groups, the network analyses between the Melbourne and Toronto hospitals were different. Among older frequent attender visits, more diagnoses were associated with high triage acuity at the Toronto hospital than at the Melbourne hospital. Some associations were similar at both sites, for example, the negative correlation between high triage acuity and joint pain.

CONCLUSION

Younger, middle-aged and older frequent attenders have distinct characteristics, made readily apparent by using network analyses. Future interventions to reduce ED visits should consider the heterogeneity of frequent attenders who have needs specific to their age, presenting problems and jurisdiction.

Profile of emergency department overuse in hospitalized patients with pulmonary disease and its impact on mortality

INTRODUCTION AND OBJECTIVES

Portugal is one of the countries with the highest number of visits to the emergency department (ED), 31% classified as "non-urgent" or "avoidable." The objectives of our study were to evaluate the size and characteristics of patients with pulmonary disease who overuse the ED, and identify factors associated with mortality.

MATERIALS AND METHODS

A retrospective cohort study was conducted, based on the medical records of ED frequent users (ED-FU) with pulmonary disease who attended a university hospital center in the northern inner city of Lisbon from January 1 to December 31, 2019. To evaluate mortality, a follow-up until December 31, 2020 was performed.

RESULTS

Over 5,567 (4.3%) patients were identified as ED-FU and 174 (0.14%) had pulmonary disease as the main clinical condition, accounting for 1,030 ED visits. 77.2% of ED visits were categorized as "urgent/very urgent." A high mean age (67.8 years), male gender, social and economic vulnerability, high burden of chronic disease and comorbidities, with a high degree of dependency, characterized the profile of these patients. A high proportion (33.9%) of patients did not have a family physician assigned and this was the most important factor associated with mortality (p<0.001; OR: 24.394; CI 95%: 6.777-87.805). Advanced cancer disease and autonomy deficit were other clinical factors that most determined the prognosis.

CONCLUSIONS

Pulmonary ED-FU are a small group of ED-FU who constitute an aged and heterogeneous group with a high burden of chronic disease and disability. The lack of an assigned family physician was the most important factor associated with mortality, as well as advanced cancer disease and autonomy deficit.

Machine learning to improve frequent emergency department use prediction: a retrospective cohort study

Frequent emergency department use is associated with many adverse events, such as increased risk for hospitalization and mortality. Frequent users have complex needs and associated factors are commonly evaluated using logistic regression. However, other machine learning models, especially those exploiting the potential of large databases, have been less explored. This study aims at comparing the performance of logistic regression to four machine learning models for predicting frequent emergency department use in an adult population with chronic diseases, in the province of Quebec (Canada). This is a retrospective population-based study using medical and administrative databases from the Régie de l'assurance maladie du Québec. Two definitions were used for frequent emergency department use (outcome to predict): having at least three and five visits during a year period. Independent variables included sociodemographic characteristics, healthcare service use, and chronic diseases. We compared the performance of logistic regression with gradient boosting machine, naïve Bayes, neural networks, and random forests (binary and continuous outcome) using Area under the ROC curve, sensibility, specificity, positive predictive value, and negative predictive value. Out of 451,775 ED users, 43,151 (9.5%) and 13,676 (3.0%) were frequent users with at least three and five visits per year, respectively. Random forests with a binary outcome had the lowest performances (ROC curve: 53.8 [95% confidence interval 53.5-54.0] and 51.4 [95% confidence interval 51.1-51.8] for frequent users 3 and 5, respectively) while the other models had superior and overall similar performance. The most important variable in prediction was the number of emergency department visits in the previous year. No model outperformed the others. Innovations in algorithms may slightly refine current predictions, but access to other variables may be more helpful in the case of frequent emergency department use prediction.

Characteristics of High-Need, High-Cost Patients : A "Best-Fit" Framework Synthesis

BACKGROUND

Accurately identifying high-need, high-cost (HNHC) patients to reduce their preventable or modifiable health care use for their chronic conditions is a priority and a challenge for U.S. policymakers, health care delivery systems, and payers.

PURPOSE

To identify characteristics and criteria to distinguish HNHC patients.

DATA SOURCES

Searches of multiple databases and gray literature from 1 January 2000 to 22 January 2022.

STUDY SELECTION

English-language studies of characteristics and criteria to identify HNHC adult patients, defined as those with high use (emergency department, inpatient, or total services) or high cost.

DATA EXTRACTION

Independent, dual-review extraction and quality assessment.

DATA SYNTHESIS

The review included 64 studies comprising multivariate exposure studies (n = 47), cluster analyses (n = 11), and qualitative studies (n = 6). A National Academy of Medicine (NAM) taxonomy was an initial "best-fit" framework for organizing the synthesis of the findings. Patient characteristics associated with being HNHC included number and severity of comorbid conditions and having chronic clinical conditions, particularly heart disease, chronic kidney disease, chronic lung disease, diabetes, cancer, and hypertension. Patients' risk for being HNHC was often amplified by behavioral health conditions and social risk factors. The reviewers revised the NAM taxonomy to create a final framework, adding chronic pain and prior patterns of high health care use as characteristics associated with an increased risk for being HNHC.

LIMITATION

Little evidence distinguished potentially preventable or modifiable health care use from overall use.

CONCLUSION

A combination of characteristics can be useful for identifying HNHC patients. Because of the complexity of their conditions and circumstances, improving their quality of care will likely also require an individualized assessment of care needs and availability of support services.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality. (PROSPERO: CRD42020161179).

Describing the Patient Population of a Pediatric Emergency Department Based on Visit Frequency

OBJECTIVE

A small number of children in the United States use a disproportionate share of emergency healthcare services. Our study objective was to examine characteristics associated with frequent pediatric emergency department (PED) utilization.

METHODS

A retrospective cohort-sequential study of patients seen in the PED of an urban children's hospital was conducted. Patients were categorized into 2 groups: infrequent users (<4 visits during index year 2017) and frequent users (≥4 visits in 2017). Frequent PED users were further divided into persistent frequent (≥4 visits in the year before and after 2017) and incidental frequent (≥4 visits in 2017). Patient- and visit-level characteristics were analyzed for associations with PED utilization.

RESULTS

In 2017, there were 82,361 visits by 56,767 patients to our PED. Frequent users comprised 4% of the total patient volume but accounted for 13% of visits. Compared with infrequent users, frequent users were younger, more likely publicly insured, and English speaking. Frequent user visits were more likely to occur outside clinic hours, be triaged as emergent, and involve subspecialists. Compared with visits by incidental frequent users, visits by persistent frequent users were more likely to be emergent or urgent, and involve subspecialists, diagnostic imaging, laboratory testing, and medication administration.

CONCLUSIONS

Although the percentage of frequent users to a PED in 2017 was low, they made up a disproportionate share of total visits. Differences between persistent and incidental frequent PED users suggest that these subgroups may benefit from tailored interventions to reduce frequent PED utilization.

Where Have All the FLOWERS Gone? A Multicenter Investigation of Frequent Users of Midwest Emergency Department Services During the COVID-19 Stay-at-home Orders

Introduction: In this study we aimed to determine the impact of the mandatory coronavirus disease 2019 (COVID-19) pandemic stay-at-home order on the proportional makeup of emergency department (ED) visits by frequent users and super users. Methods: We conducted a secondary analysis of existing data using a multisite review of the medical records of 280,053 patients to measure the impact of the COVID-19 pandemic stay-at-home order on ED visits. The primary outcomes included analysis before and during the lockdown in determining ED use and unique characteristics of non-frequent, frequent, and super users of emergency services. Results: During the mandatory COVID-19 stay-at-home order (lockdown), the percentage of frequent users increased from 7.8% (pre-lockdown) to 21.8%. Super users increased from 0.7% to 4.7%, while non-frequent users dropped from 91.5% to 73.4%. Frequent users comprised 23.7% of all visits (4% increase), while super user encounters (4.7%) increased by 53%. Patients who used Medicaid and Medicare increased by 39.3% and 4.6%, respectively, while those who were uninsured increased ED use by 190.3% during the lockdown. Conclusion: When barriers to accessing healthcare are implemented as part of a broader measure to reduce the spread of an infectious agent, individuals reliant on these services are more likely to seek out the ED for their medical needs. Policymakers considering future pandemic planning should consider this finding to ensure that vital healthcare resources are allocated appropriately.

Nationwide study of the characteristics of frequent attenders with multiple emergency department attendance patterns

INTRODUCTION

The burden of frequent attenders (FAs) of emergency departments (EDs) on healthcare resources is underestimated when single-centre analyses do not account for utilisation of multiple EDs by FAs. We aimed to quantify the extent of multiple ED use by FAs and to characterise FAs.

METHODS

We reviewed nationwide ED attendance in Singapore data from 1 January 2006 to 31 December 2018 (13 years). FAs were defined as patients with ≥4 ED visits in any calendar year. Single ED FAs and multiple ED FAs were patients who attended a single ED exclusively and ≥2 distinct EDs within the year, respectively. Mixed ED FAs were patients who attended a mix of a single ED and multiple EDs in different calendar years. We compared the characteristics of FAs using multivariable logistic regression.

RESULTS

We identified 200,130 (6.3%) FAs who contributed to1,865,704 visits (19.6%) and 2,959,935 (93.7%) non-FAs who contributed to 7,671,097 visits (80.4%). After missing data were excluded, the study population consisted of 199,283 unique FAs. Nationwide-linked data identified an additional 15.5% FAs and 29.7% FA visits, in addition to data from single centres. Multiple ED FAs and mixed ED FAs were associated with male sex, younger age, Malay or Indian ethnicity, multiple comorbidities, median triage class of higher severity, and a higher frequency of ED use.

CONCLUSION

A nationwide approach is needed to quantify the national FA burden. The multiple comorbidities and higher frequency of ED use associated with FAs who visited multiple EDs and mixed EDs, compared to those who visited a single ED, suggested a higher level of ED burden in these subgroups of patients. The distinct characteristics and needs of each FA subgroup should be considered in future healthcare interventions to reduce FA burden.

Predictors of Pediatric Frequent Emergency Department Use Among 7.6 million Pediatric Patients in New York

OBJECTIVE

This study examines the characteristics and factors associated with frequent emergency department (ED) utilization among the pediatric population.

METHODS

We conducted a pooled cross-sectional secondary analysis using the Healthcare Cost and Utilization Project State Emergency and Inpatient Databases on ED visits to all hospitals in New York from 2011 to 2016 by patients aged 0 to 21. We used multivariable logistic and negative binomial regressions to investigate the predictors of multiple ED visits in the pediatric population.

RESULTS

Overall, our study included 7.6 million pediatric patients who accounted for more than 12 million ED visits. Of those, 6.2% of patients were frequent ED users (≥4 visits/year), accounting for 20.8% of all ED visits (5.4 ED visits/year on average). The strongest predictors of frequent ED use were having at least one ED visit related to asthma (aOR = 8.37 [95% CI: 6.34-11.04]), mental health disorders (aOR = 9.67 [95% CI: 8.60-10.89]), or multiple comorbidities compared to none. Larger shares of ED visits for not-emergent conditions were also associated with frequent ED use (aOR = 6.63 [95% CI = 5.08-8.65]). Being covered by Medicaid compared to private (aOR = 0.45 [95% CI: 0.42-0.47]) or no insurance (aOR = 0.41 [95% CI: 0.38-0.44]) were further associated with frequent ED use. The results from the negative binomial regression yielded consistent findings.

CONCLUSIONS

Pediatric patients who exhibit increased ED use are more medically complex and have increased healthcare needs that are inextricably tied to social determinants of health. Better integrated health systems should emphasize connecting vulnerable patients to appropriate social and primary care services outside of emergency settings.

Characteristics of frequent emergency department users in Korea: a 4-year retrospective analysis using Korea Health Panel Study data

Objective

We aimed to investigate the characteristics of frequent emergency department (ED) users in Korea.

Methods

We analyzed the Korea Health Panel Study data of a sampled population from the 2005 Population Census of Korea data, and adults (age ≥18 years) who visited the ED at least once a year between 2014 and 2017 were included in the study. People who visited three or more times a year were classified as frequent users. We compared demographic, socioeconomic, and health-related factors between nonfrequent and frequent users. We used a multivariable logistic regression analysis to determine factors related to frequent ED visits. We also compared the characteristics of ED use in both nonfrequent and frequent users.

Results

A total of 5,090 panels were included, comprising 6,853 visits. Frequent users were 333 (6.5% of all panels), and their ED visits were 1,364 (19.9% of all ED visits). In the multivariable regression analysis, medical aid coverage (adjusted odds ratio [aOR] of the National Health Service coverage, 0.55; 95% confidence interval [CI], 0.40–0.75), unemployment (aOR of employment, 0.72; 95% CI, 0.56–0.91), prior ward admission in a year (aOR, 2.14; 95% CI, 1.67–2.75), and frequent outpatient department use (aOR, 1.72; 95% CI, 1.35–2.20) were associated with frequent use. Moreover, frequent users visited the ED of public hospitals more often than than nonfrequent users (19.2% vs. 9.8%). Medical problems rather than injury/poisoning were the more common reasons for visiting the ED (84.5% vs. 71.2%).

Conclusion

We found that frequent ED users were likely to be those with socioeconomic disadvantage or with high demand for medical service. Based on this study, further studies on interventions to reduce frequent ED use are required for better ED services.

Socioeconomic Status Predicts Short-Term Emergency Department Utilization Following Supratentorial Meningioma Resection

Introduction By identifying drivers of healthcare disparities, providers can better support high-risk patients and develop risk-mitigation strategies. Household income is a social determinant of health known to contribute to healthcare disparities. The present study evaluates the impact of household income on short-term morbidity and mortality following supratentorial meningioma resection. Methods A total of 349 consecutive patients undergoing supratentorial meningioma resection over a six-year period (2013-2019) were analyzed retrospectively. Primary outcomes were unplanned hospital readmission, reoperations, emergency department (ED) visits, return to the operating room, and all-cause mortality within 30 days of the index operation. Standardized univariate regression was performed across the entire sample to assess the impact of household income on outcomes. Subsequently, outcomes were compared between the lowest (household income ≤ $51,780) and highest (household income ≥ $87,958) income quartiles. Finally, stepwise regression was executed to identify potential confounding variables. Results Across all supratentorial meningioma resection patients, lower household income was correlated with a significantly increased rate of 30-day ED visits (p = 0.002). Comparing the lowest and highest income quartiles, the lowest quartile was similarly observed to have a significantly higher rate of 30-day ED evaluation (p = 0.033). Stepwise regression revealed that the observed association between household income and 30-day ED visits was not affected by confounding variables. Conclusion This study suggests that household income plays a role in short-term ED evaluation following supratentorial meningioma resection.

Impact of an addiction medicine consult team intervention in a Canadian inner city hospital on acute care utilization: a pragmatic quasi-experimental study

BACKGROUND

Inner city patients have a higher illness burden and need for care, but experience more unmet care needs. Hospital Addiction Medicine Consult Teams (AMCTs) are a promising emerging intervention. The objective of this study was to assess the impact of a Canadian AMCT-like intervention for inner city patients on reduction in high emergency department (ED) use, hospital admission, and inpatient length of stay.

METHODS

Using a community-engaged, two-arm, pre-post, longitudinal quasi-experimental study design, 572 patients reporting active substance use, unstable housing, unstable income, or a combination thereof (302 at intervention site, 270 at control sites) were enrolled. Survey and administrative health service data were collected at baseline, six months post-enrolment, and 12 months post-enrolment. Multivariable regression models tested the intervention effect, adjusting for clinically important covariables (inpatient status at enrolment, medical complexity, age, gender, Indigenous identity, shelter use, opioid use).

RESULTS

Initial bivariable analyses demonstrated an intervention effect on reduction in admissions and length of stay, however, this effect was no longer significant after adjusting for covariables. There was no evidence of reduction in high ED use on either bivariable or subsequent multivariable analysis.

CONCLUSIONS

After adjusting for covariables, no AMCT intervention effect was detected for reduction in high ED use, inpatient admission, or hospital length of stay. Further research is recommended to assess other patient-oriented intervention outcomes.

Impact of a Statewide Emergency Department Information Exchange on Health Care Use and Expenditures

OBJECTIVE

To assess the effects of a program mandating the statewide adoption of an emergency department information exchange (EDIE) on health care utilization and spending among Medicaid enrollees in Washington state.

DATA SOURCE

Medicaid claims and managed care encounters from the Washington Health Care Authority.

STUDY DESIGN

A difference-in-differences analysis with trends was used to compare changes in ED visits, inpatient admissions, primary care visits, and expenditures among frequent ED users (≥5 ED visits in past year) to those of infrequent users through the second year Washington's program.

DATA EXTRACTION

The study population included adult Medicaid enrollees with ED visits between January 2010-October 2014.

PRINCIPAL FINDINGS

There were 505,667 ED visits among 153,543 unique enrollees included in the analysis. Washington's program was associated with a small, but statistically significant differential change of -0.70 ED visits per enrollee per year (95% CI: -1.24, -0.16) in the first year after EDIE was mandated, or 8.2% of the baseline ED visit rate among frequent users. However, by the second year of implementation, these effects on ED use were no longer significant, nor were there any measurable effects on inpatient admissions, primary care use or expenditures in any period.

CONCLUSIONS

Statewide implementation of EDIE was associated with a small reduction in ED use among frequent users in the first year of the program but did not change overall spending or other utilization outcomes.

Factors that Increase Risk of an HIV Diagnosis Following a Diagnosis of Syphilis: A Population-Based Analysis of Texas Men

Studies have consistently shown that diagnosis of a syphilis infection increases the risk of human immunodeficiency virus (HIV) infection. This study examines patterns in HIV incidence among men following a Primary and Secondary (P&S) syphilis diagnosis. P&S syphilis cases among men reported to the Texas Department of State Health Services between January 2010 and June 2018 were linked to the Enhanced HIV/AIDS Reporting System. Risk factors for HIV diagnosis were identified using univariate and multivariate extended Cox proportional hazards models. The 9113 men with syphilis without a concurrent or prior HIV diagnosis contributed a cumulative 35,674 person-years with a mean follow-up time of 3.9 years. The multivariate model showed that among men with a P&S syphilis diagnosis, age, race/ethnicity, transmission risk, comorbid STDs, subsequent STDs, and syphilis diagnosing facility were independently associated with a new HIV diagnosis. The results highlight disparities in HIV diagnoses, despite current prevention recommendations. Reducing these disparities will require multi-level, comprehensive interventions that are appropriate for the diverse populations around the state.

The Role of Telehealth and Clinical Informatics in Data Driven Primary Care Redesign

Clinical informatics linked inpatient and emergency department use to clinical data to evaluate utilization for population segments. Trend analysis demonstrates how remote registered nurse care management and the COVID-79 pandemic reduced emergency department utilization in adult populations with high social needs.

Abdominopelvic CT-scan in emergency departments for patients with suspected complications of Crohn's disease: a single tertiary center experience

BACKGROUND

Crohn's disease (CD) is a chronic disorder with frequent complications. The objective of this study was to assess the predictive factors of finding a complication of CD using abdominopelvic CT-scan in patients with a visit to the emergency department.

METHODS

Patients with at least one visit to the gastroenterology department of our University hospital during the year with a CD were retrospectively included. All visits to the emergency department of the hospital during the follow-up of these patients were identified.

RESULTS

A total of 638 patients were included and 318 (49.8%) had at least one visit to the emergency department since the beginning of their follow-up. Abdominopelvic CT-scan was performed in 141 (23.7%) of the 595 visits for digestive symptoms. Only 4.3% of these CT-scans were considered as normal; there was luminal inflammation without complication in 24.8%, abscess, fistula or perforation in 22.7%, mechanical bowel obstruction in 36.9% and diagnosis unrelated to CD in 11.3%. In univariate analysis, stricturing phenotype (OR, 2.48; 95% CI, 1.16-5.29; p = 0.02) and previous surgery (OR, 2.90; 95% CI, 1.37-6.14; p = 0.005) were predictive factors of finding a complication of CD using abdominopelvic CT-scan, whereas no independent predictive factor was statistically significant in multivariate analysis.

CONCLUSION

In CD patients consulting in emergency department, CT-scan examination was performed in 24% of visits for digestive symptoms and complications of CD were found in 60%. Complications were more frequent in patients with stricturing phenotype and previous surgery.

The Effect of the Medicaid Expansion on Frequent Emergency Department Use in New York

BACKGROUND

There is limited evidence on the effect of the Affordable Care Act (ACA) on frequent emergency department (ED) use.

OBJECTIVES

To estimate the effect of the ACA Medicaid expansion on frequent ED use in New York.

METHODS

We used data from the Healthcare Cost and Utilization Project State Emergency Department Databases and State Inpatient Databases from 2011 to 2016. A consistent and unique patient identifier enabled us to identify ED visits by the same patient across different facilities within the state for each calendar year. Multivariate logistic regressions were used to quantify the policy's effect on frequent ED use (≥ 4 ED visits/year). We included in-state residents 18 to 64 years of age who were covered by Medicaid, private insurance, or were uninsured. Sensitivity analyses were conducted using alternative definitions of frequent use. To validate the findings, a falsification analysis was also conducted using only the 3 pre-expansion years.

RESULTS

Our study included 14.3 million ED patients with 23.8 million ED visits from 2011 to 2016. Frequent users (7.2%) accounted for 26.6% of all ED visits. The likelihood of frequent ED use declined by 4% among Medicaid beneficiaries (adjusted odds ratio [AOR] 0.96, 95% confidence intervals (CI) 0.95-0.97) and by 12% for the uninsured (AOR 0.88, 95% CI 0.86-0.89) in the post-expansion period, compared with the pre-expansion period. Private insurance enrollees were 9% more likely to exhibit frequent use in the post-expansion period (AOR 1.09, 95% CI 1.08-1.11). The sensitivity analyses yielded results similar to those of the main model. The falsification analyses revealed small and insignificant year-to-year changes in the 3 pre-expansion years.

CONCLUSION

The likelihood of frequent ED use decreased 3 years after New York implemented the ACA Medicaid expansion, particularly for Medicaid beneficiaries and the uninsured, highlighting the importance of expanding health insurance and provisions tailored at high-need populations.

Factors Associated With Increased Emergency Department Utilization in Patients With Acute Optic Neuritis

BACKGROUND

Symptoms of acute vision loss and eye pain may lead patients with optic neuritis to seek care in the emergency department (ED). Given the availability of lower cost alternatives for providing medical care for optic neuritis, this study aimed to identify factors associated with higher ED utilization.

METHODS

Subjects with acute optic neuritis were identified through a chart review of adults with International Classification of Diseases-9 (ICD-9) or ICD-10 codes for optic neuritis with corresponding gadolinium contrast enhancement of the optic nerve on MRI in the medical record research repository of a tertiary care institution. Subjects were grouped based on the number of ED visits (0-1 and 2-3) within 2 months of either ICD code or MRI. Demographics, characteristics of disease presentation, type and location of medical care, testing (chest imaging, lumbar puncture, optical coherence tomography, spine MRI, visual field, and laboratory tests), treatment, provider specialty of follow-up visits, and duration of care were extracted from the medical record.

RESULTS

Of 30 acute optic neuritis subjects (age 41 ± 16 years, range 18-76, 53% [16/30] female), 19 had 0-1 ED visit and 11 had 2-3 ED visits. Most subjects were Caucasian, non-Hispanic (47%), followed by Asian (23%), Hispanic/Latino (17%), Black (10%), and others (3%). Subjects had an initial clinical encounter primarily in the outpatient setting (63%) as compared with the ED (37%). The median time from symptom onset to initial clinical encounter was 4 days with a range of 0-13. Subjects were mostly insured through a private insurance (60%), followed by Medicare/Medicaid (23%) and uninsured (17%). Fewer ED visits were associated with an initial clinical encounter in an outpatient setting (P = 0.02, chi-square), but not residential distance from the hospital or insurance type. Subjects with a higher number of ED visits were more likely to be of Hispanic/Latino ethnicity (P = 0.047, Fisher exact). There was no significant difference in the ophthalmic, radiologic, or laboratory testing performed in both groups. Both groups presented in a similar time frame with similar symptoms and clinical signs. Treatment was similar in both groups.

CONCLUSIONS

Subjects with their first clinical encounter for optic neuritis in the ED had more visits to the ED overall when compared with those first seen in an outpatient setting and thus strategies aimed at facilitating outpatient care may help reduce unnecessary ED visits, although some, such as insurance status, may be difficult to modify. Further study in a larger sample is needed to refine these observations.

Emergency Department Visits in the Year Prior to Total Shoulder Arthroplasty as a Risk Factor for Postoperative Emergency Department Visits

Background: Recent research has found a high rate of emergency department (ED) use after lower extremity arthroplasty; one study found a risk factor for ED presentation after lower extremity arthroplasty was presentation to the ED in the year prior to surgery. It is not known whether a similar association exists for total shoulder arthroplasty (TSA). Questions/Purposes: The goal of this study was to investigate the relationship between preoperative ED visits and postoperative ED visits after anatomic TSA. Methods: The 100% Medicare database was queried for patients who underwent anatomic TSA from 2005 to 2014. Emergency department visits within the year prior to the date of TSA were identified. Patients were additionally stratified by the number and timing of preoperative ED visits. The primary outcome measure was one or more postoperative ED visits within 90 days. A multivariate logistic regression analysis was used to control for patient demographics and comorbidities. Results: Of the 144,338 patients identified, 32,948 (22.8%) had an ED visit in the year prior to surgery. Patients with at least 1 ED visit in the year before surgery presented to the ED at a significantly higher rate than patients without preoperative ED visits (16% versus 6%). An ED visit in the year prior to TSA was the most significant risk factor for postoperative ED visits (in the multivariate analysis). The number of preoperative ED visits in the year prior to surgery demonstrated a significant dose-response relationship with increasing risk of postoperative ED visits. Conclusions: Postoperative ED visits occurred in nearly 10% of Medicare patients who underwent TSA in the period studied. More frequent presentation to the ED in the year prior to anatomic TSA was associated with increasing risk of postoperative ED visits. Future studies are needed to investigate the reasons for preoperative ED visits and if any modifiable risk factors are present to improve the ability to risk stratify and optimize patients for elective TSA.

Heterogeneity of reasons for attendance in frequent attenders of emergency departments and its relationship to future attendance

BACKGROUND

EDs globally are under increasing pressure through rising demand. Frequent attenders are known to have complex health needs and use a disproportionate amount of resources. We hypothesised that heterogeneity of patients' reason for attendance would be associated with multimorbidity and increasing age, and predict future attendance.

METHOD

We analysed an anonymised dataset of all ED visits over the course of 2014 in Yorkshire, UK. We identified 15 986 patients who had five or more ED encounters at any ED in the calendar year. Presenting complaint was categorised into one of 14 categories based on the Emergency Care Data Set (ECDS). We calculated measures of heterogeneity (count of ECDs categories and entropy of categories) and examined their relationship to total number of ED visits and to patient characteristics. We examined the predictive value of these and other features on future attendance.

RESULTS

Most frequent attenders had more than one presenting complaint type. Heterogeneity increased with number of attendances, but heterogeneity adjusted for number of attendances did not vary substantially with age or sex. Heterogeneity was associated with the presence of one or more contacts for a mental health problem. For a given number of attendances, prior mental health contact but not heterogeneity was associated with further attendance.

CONCLUSIONS

Heterogeneity of presenting complaint can be quantified and analysed for ED use: it is increased where there is a history of mental disorder but not with age. This suggests it reflects more than the number of medical conditions.

Association between knowledge and attitudes towards advance directives in emergency services

Background

Implementing the routine consultation of patient advance directives in hospital emergency departments and emergency medical services has become essential, given that advance directives constitute the frame of reference for care personalisation and respect for patients’ values and preferences related to healthcare. The aim of this study was to assess the levels and relationship of knowledge and attitudes of nursing and medical professionals towards advance directives in hospital emergency departments and emergency medical services, and to determine the correlated and predictor variables of favourable attitudes towards advance directives.

Methods

Observational, descriptive, and cross-sectional study. The study was conducted in the emergency department of a second-level hospital and in the emergency medical service. Data collection was performed from January 2019 to February 2020. The STROBE guidelines were followed for the preparation of the study.

Results

A total of 173 healthcare professionals responded to the questionnaire. Among them, 91.3% considered that they were not sufficiently informed about advance directives, and 74% acknowledged not having incorporated them into their usual practice. Multinomial analysis indicated a statistically significant relationship between the variable emergency medical service and having more favourable attitudes towards consulting the advance directives in their practical application (OR 2.49 [95% CI 1.06–5.88]; p = 0.037) and compliance in complex scenarios (OR 3.65 [95% CI 1.58 − 8.41]; p = 0.002). Working the afternoon and night shift was a predictor variable for obtaining a higher score with respect to attitudes in complex scenarios.

Conclusion

There is an association between the level of knowledge that nursing and medical professionals have about advance directives and the scores obtained on the attitude scales at the time of practical implementation and in complex scenarios. This shows that the more knowledge professionals have, the more likely they are to consult patients' advance directives and to respect their wishes and preferences for care and/or treatment.

Epidemiology of Frequent Visits to the Emergency Department at a Tertiary Care Hospital in Saudi Arabia: Rate, Visitors' Characteristics, and Associated Factors

Background

Emergency department overcrowding is becoming a challenge for the healthcare management system globally and locally. This study aimed to estimate the frequency of ED visits, describe the patients’ profile along with visit-related characteristics, and associated factors in a tertiary care hospital.

Methods

A retrospective cohort study was conducted at a tertiary care hospital. The study included patients age 14 years and above visiting the main emergency department in year 2013. Data were extracted from electronic medical records by a qualified data extraction team. Statistical analyses were performed, including the odds ratio and 95% confidence interval for the factors associated with highly frequent (≥14 visits) ED visits using logistic regression models.

Results

There were 150,727 visits to the emergency department within a year. The number of frequent visitors was 7696 (9.38%), with 42,226 visits (28.01% of total ED visits). Highly frequent visitors totaled 249 (0.30%), with 5173 visits (3.43% of total ED visits). The frequent visitors’ average age was 42.55 (SD 20.14), and 48.99 (SD 21.33) for the highly frequent visitors’ group. More than half of the emergency visitors were females. The most common complaints among the highly frequent visitors were Gastrointestinal (21.34%), followed by Respiratory (13.47%), Orthopedic (12.57%), and Cardiovascular (12.43%). Multivariate analysis indicated that age, history of diabetes, history of cardiac diseases, insurance status, and nationality were significant predicators of highly frequent visits to the hospital emergency.

Conclusion

Frequent and highly frequent visitors to emergency departments represent a significant proportion of adult patients presenting to ED. Their visits constitute almost one-third of total ED visits. Several factors associated with highly frequent ED visits have been identified. This study provides local empirical evidence to develop improvement policy and actions related to chronic issue of frequent and highly frequent visitation to hospital ED.

"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.

Frequent emergency department use in the paediatric population: A systematic literature review

OBJECTIVE

We systematically reviewed the literature on paediatric frequent emergency department (ED) users to identify and to synthesize characteristics and factors associated with frequent ED utilization among this population in the United States.

METHODS

We searched Medline (Ovid), CINAHL (Ebsco), and Embase (Ovid) to identify all relevant studies after 1990. We focused on US studies analysing paediatric frequent ED (PFED) users excluding those focused on specific subgroups. Two reviewers independently selected articles and extracted data on predisposing, enabling, behavioural, need and reinforcing factors.

RESULTS

Fifteen studies met the inclusion criteria. PFED users comprised 3% to 14% of all paediatric ED users and accounted for 9% to 42% of all paediatric ED visits in 11 studies that defined frequent use as four to six ED visits per year. Most PFED users were less than 5 years old who had public insurance coverage and a regular provider. Public insurance compared to private residency in disadvantaged areas, having at least one chronic or complex condition and a history of hospitalization, were associated with frequent use. Children who had a regular primary care provider were less likely to exhibit frequent ED use.

CONCLUSIONS

Minimizing unnecessary ED visits by frequent utilizers is a quality improvement and cost-saving priority for health systems. Our findings indicate that many PFED users have greater healthcare needs and face barriers accessing care in a timely manner, even though some have regular providers. To better address the needs of this vulnerable group, health systems should focus on educating caregivers and expanding access to providers in other settings.

Health care providers' perception of the frequent emergency department user issue and of targeted case management interventions: a cross-sectional national survey in Switzerland

Background

Frequent users of emergency departments (FUEDs) (≥5 ED visits/year) represent a vulnerable population with complex needs accounting for a significant number of emergency department (ED) consultations, thus contributing to EDs overcrowding. Research exploring ED staff perceptions of FUEDs is scarce.

Objectives

The current study aimed to evaluate in ED staff a) the extent to which FUEDs are perceived as an issue; b) their perceived levels of knowledge and understanding of FUEDs; c) levels of perceived usefulness of case management (CM) and interest in implementing this intervention in their ED service.

Methods

Head physicians of the EDs at all public hospitals in Switzerland (of various level of specialization) were sent a 19-item web-based survey, pilot tested prior to its dissemination. The head physicians were asked to forward the survey to ED staff members from different health professional backgrounds.

Results

The hospital response rate was 81% (85/106). The exploitable hospital response rate was 71% (75/106 hospitals) including 208 responding health professionals. Issues and difficulties around FUEDs were perceived as important by 64% of respondents. The perceived frequency of being confronted with FUEDs was higher among nurses in more specialized EDs. In total, 64% of respondents felt poorly informed about FUEDs, nurses feeling less informed than physicians. The understanding of FUEDs was lower in the French-Italian-speaking parts (FISP) of Switzerland than in the German-speaking part. Eighty-one percent of respondents had no precise knowledge of FUED-related interventions. The perceived usefulness of CM interventions after receiving explanations about it was high (92%). However, the overall level of interest for CM implementation was 59%. The interest in CM by physicians was low across all regions and ED categories. Nurses, on the other hand, showed more interest, especially those in EDs of high specialization.

Conclusions

The majority of ED staff reported being confronted with FUEDs on a regular basis. Staff perceived FUEDs as a vulnerable population, yet, they felt poorly informed about how to manage the issue. The majority of ED staff thought a CM intervention would be useful for FUEDs, however there appears to be a gap in their desire or willingness to implement such interventions.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12873-020-00397-w.

Economic analysis of 90-day return to the emergency room and readmission after elective lumbar spine surgery: a single-center analysis of 5444 patients

OBJECTIVE

In the future, payers may not cover unplanned 90-day emergency room (ER) visits or readmissions after elective lumbar spine surgery. Prior studies using large administrative databases lack granularity and/or use a proxy for actual cost. The purpose of this study was to identify risk factors and subsequent costs associated with 90-day ER visits and readmissions after elective lumbar spine surgery.

METHODS

A prospective, multisurgeon, single-center electronic medical record was queried for elective lumbar spine fusion surgeries from 2013 to 2017. Predictive models were created for 90-day ER visits and readmissions.

RESULTS

Of 5444 patients, 729 (13%) returned to the ER, most often for pain (n = 213, 29%). Predictors of an ER visit were prior ER visit (OR 2.5), underserved zip code (OR 1.4), and number of chronic medical conditions (OR 1.4). In total, 421 (8%) patients were readmitted, most frequently for wound infection (n = 123, 2%), exacerbation of chronic obstructive pulmonary disease (n = 24, 0.4%), and sepsis (n = 23, 0.4%). Predictors for readmission were prior ER visit (OR 1.96), multiple chronic conditions (OR 1.69), obesity (nonobese, OR 0.49), race (African American, OR 1.43), admission status (ER admission, OR 2.29), and elevated hemoglobin A1c (OR 1.80). The mean direct hospital cost for an ER visit was $1971, with 75% of visits costing less than $1890, and the average readmission cost was $7347, with 75% of readmissions costing less than $8820. Over the 5-year study period, the cost to the institution for 90-day return ER visits was $5.1 million.

CONCLUSIONS

Risk factors for 90-day ER visit and readmission after elective lumbar spine surgery include medical comorbidities and socioeconomic factors. Proper patient counseling, appropriate postoperative pain management, and optimization of modifiable risk factors prior to surgery are areas to focus future efforts to lower 90-day ER visits and readmissions and reduce healthcare costs.

Integrated care effectiveness for adults with co-occurring disorders

Purpose

This study examined effectiveness of an integrated care program on emergency department visits within a longitudinal sample of patients with both primary care and behavioral health diagnoses.

Design/methodology/approach

Patients with co-occurring disorders enrolled in an integrated care clinic and were followed over time to determine whether participation in the clinic, including engagement in wellness/peer services, predicted decreases in Emergency Department (ED) use. Associations between socio-demographic characteristics of patients and ED use were also analyzed.

Findings

After 6 months, clinic patients had decreases in ED use that continued for twelve months, albeit to a lesser degree. Demographics and program services were not related to ED use; however, multiple associations existed between high ED utilizers, severe mental illness (SMI), substance use disorders (SUD) and non-retention in services.

Research limitations/implications

The study lacked a comparison group and there was no distinction between avoidable and unavoidable ED visits. A small sample size across time points led to inconclusive post hoc findings.

Originality/value

This study explored effectiveness of primary care integration into a behavioral health clinic for persons with multiple morbidities. Although initial decreases in ED visits were present, results indicate that these models may not be effective for persons with SMI or SMI/SUD who are already high ED users. This study provides support for integrated care in reducing ED use among persons with multiple morbidities and calls for further research on designing effective integrated models for persons with SMI and SUD.

Single and Repeated Use of the Emergency Department for Chlamydia and Gonorrhea Care

OBJECTIVE

Chlamydia and gonorrhea infection rates are rising in the United States, and the emergency department (ED) is increasingly a site where individuals seek care for these infections, sometimes more than once. This article investigates how individuals who use the ED more than once and receive chlamydia and gonorrhea care differ from individuals who are single users of the ED, as well as characteristics associated with being a repeat user of the ED.

METHODS

We analyzed 46,964 visits made by individuals who attended 1 of 4 EDs from January 1, 2010, to May 31, 2016, and received a test for chlamydia and gonorrhea infection. We used negative binomial regression to test the ability of age, sex, race, infection status, and insurance status to predict number of visits.

RESULTS

Individuals who used the ED more than once and received chlamydia and gonorrhea care were at their first visit more likely to be younger (incident rate ratio [IRR], 0.98; 95% confidence interval [CI], 0.97-0.98 per year) nonpregnant female (IRR, 1.23; 95% CI, 1.06-1.42), black (IRR, 1.27; 95% CI, 1.04-1.57), and have no or public insurance compared with single users of the ED.

DISCUSSIONS

Individuals likely to make multiple visits to the ED and receive chlamydia and gonorrhea care may be identifiable on their first visit and potentially directed elsewhere during subsequent visits for more comprehensive and potentially less expensive sexually transmitted disease care.

Managing ethical aspects of advance directives in emergency care services

BACKGROUND

In Hospital Emergency Department and Emergency Medical Services professionals experience situations in which they face difficulties or barriers to know patient's advance directives and implement them.

OBJECTIVES

To analyse the barriers, facilitators, and ethical conflicts perceived by health professionals derived from the management of advance directives in emergency services.

RESEARCH DESIGN, PARTICIPANTS, AND CONTEXT

This is a qualitative phenomenological study conducted with purposive sampling including a population of nursing and medical professionals linked to Hospital Emergency Department and Emergency Medical Services. Three focus groups were formed, totalling 24 participants. We performed an inductive-type thematic discourse analysis.

ETHICAL CONSIDERATIONS

This study was approved by ethical committees of Ethical Commitee of Clínic Hospital (Barcelona) and Comittee of Emergency Medical Services (Barcelona). The participants received information about the purpose of the study. Patients' anonymity and willingness to participate in the study were guaranteed.

FINDINGS

There were four types of barriers that hindered the proper management of patients' advance directives in Hospital Emergency Department and Emergency Medical Services: personal and professional, family members, organisational and structural, and those derived from the health system. These barriers caused ethical conflicts and hindered professionals' decision-making.

DISCUSSION

These results are in line with those of previous studies and indicate that factors such as gender, professional category, and years of experience, in addition to professionals' beliefs and the opinions of colleagues and family members, can also influence the professionals' final decisions.

CONCLUSION

The different strategies described in this study can contribute to the development of health policies and action protocols to help reduce both the barriers that hinder the correct management and implementation of advance directives and the ethical conflicts generated.

Patterns of emergency department utilization between transplant and non-transplant centers and impact on clinical outcomes in kidney recipients

There is a high rate of Emergency Department (ED) utilization in kidney recipients post-transplant; ED visits are associated with readmission rates and lower survival rates. However, utilization within and outside transplant centers may lead to different outcomes. The objective was to analyze ED utilization patterns at transplant and non-transplant centers as well as common etiologies of ED visits and correlation with hospitalization, graft, and patient outcomes. This was a longitudinal, retrospective, single-center cohort study in kidney transplant recipients evaluating ED utilization. Comparator groups were determined by ED location, time from transplant, and disposition/readmission from ED visit. 1,106 kidney recipients were included in the study. ED utilization dropped at the transplant center after the 1st year (P < .001), while remaining at a similar rate at non-transplant centers (0.22 vs 1.06 VPPY). Infection and allograft complications were the most common causes of ED visits. In multivariable Cox modeling, an ED visit due to allograft complication at a non-transplant center >1 year post-transplant was associated with higher risk for graft loss and death (aHR 2.93 and aHR 1.75, P < .0001). The results of this study demonstrate an increased risk of graft loss among patients who utilize non-transplant center emergency departments. Improved communication and coordination between transplant centers and non-transplant centers may contribute to better long-term outcomes.

Health care utilization as a predictor of death anxiety in older adults

The relationship between health care utilization and death anxiety in older adults is underexplored. This secondary analysis of the 2012 Health and Retirement Study examined health care utilization as a predictor of death anxiety in a nationally representative sample of American older adults (N = 3,960). Hierarchical binary logistic regression results revealed that overnight hospitalization, overnight nursing home placement, and outpatient visit were all statistically significant predictors of death anxiety. Outpatient visit was the strongest health care utilization predictor in the model. Increased end-of-life training for providers may improve patient-provider communication and alleviate patients' death anxiety. Future research should explore the directionality between study variables.

Methamphetamine, Amphetamine, and MDMA Use and Emergency Department Recidivism

BACKGROUND

Emergency department (ED) recidivism and the use of amphetamine and associated derivatives such as methamphetamine and MDMA (MAE), are intersecting public health concerns.

OBJECTIVE

This study aims to determine the frequency of ED recidivism of patients who use MAE and associated factors.

METHODS

The study was a retrospective 6-year electronic medical record review of patients with MAE-positive toxicology screens and single and multiple ED visits in the span of 12 months.

RESULTS

There were 7844 ED visits by 5568 MAE-positive patients. Average age was 42 ± 13 years. The majority were male (65%), white (46%), tobacco smokers (55%), and in the psychiatric discharge diagnostic-related group (41%), followed by blunt trauma (20%). Admission rate was 35%, with another 17% transferred to inpatient psychiatric treatment facilities. Occasional (2-5 visits/year), heavy (6-11 visits/year), and super users (≥12 visits/year) altogether accounted for 20% of patients and 43% of visits. Heavy and super users combined represented 2% of patients and 10% of visits, with significant differences for race/ethnicity, health insurance, tobacco smoking, and psychiatric/cardiovascular/trauma discharge diagnostic-related groups. Heavy and super users were less likely to be admitted and more likely to be discharged to an inpatient psychiatric treatment facility. Regression analysis revealed racial/ethnic differences, female gender, and tobacco smoking to be associated with super and heavy use. Heavy users were more likely to have cardiovascular-related discharge diagnoses.

CONCLUSIONS

The prevalence of ED recidivism in patients who use MAE is similar to published ranges for general ED users. Significant differences in demographics, discharge diagnoses, insurance, smoking, and disposition exist between nonfrequent and frequent ED users.

Association of Patients' Perception of Primary Care Provider Listening With Emergency Department Use

Introduction

This study examined whether patients' perceptions of their primary care providers' (PCP) listening frequency were associated with emergency department (ED) utilization, including a comparison to patients without PCPs.

Methods

Data were obtained from the 2015 California Health Interview Survey. Respondents were asked if they had a PCP and how often their PCPs listened, resulting in five groups: patients without a PCP (n=4,407), and patients with a PCP who perceived the PCP's listening frequency to be never (n=254), sometimes (n=1,282), usually (n=3,440), or always (n=11,651). Multiple linear regression was performed to determine if patient-perceived listening frequency of the PCP was associated with the patient's number of ED visits in the prior year, adjusting for various demographic, social, and health factors.

Results

Compared to patients without a PCP, patients with a PCP had on average 0.15 more ED visits in a year, highest among those whose PCPs were perceived as listening the least: never=0.55 more visits per year (95% CI: 0.09-1.02, P=.02), sometimes=0.26 (0.01-0.51, P=.04), usually=0.03 (-0.17-0.24, P=.73), and always=0.16 (-0.05-0.36, P=.13). Other significant increases in ED visits were associated with public insurance, African-American race, English proficiency, younger age, self-rated fair-to-poor health, asthma, and hypertension.

Conclusions

Patients who perceived their PCP as listening less frequently had more ED visits than patients whose PCPs were perceived as listening more frequently, and compared to patients without a PCP.

Frequent attendances at emergency departments in England

BACKGROUND

A small proportion of patients referred to as 'frequent attenders' account for a large proportion of hospital activity such as ED attendances and admissions. There is a lack of recent, national estimates of the volume of frequent ED attenders. We aimed to estimate the volume and age distribution of frequent ED attenders in English hospitals.

METHOD

We included all attendances at all major EDs across England in the financial year 2016-2017. Patients who attended three times or more were classified as frequent attenders. We used a logistic regression model to predict the odds of being a frequent attender by age group.

RESULTS

14 829 519 attendances were made by 10 062 847 patients who attended at least once. 73.5% of ED attenders attended once and accounted for 49.8% of the total ED attendances. 9.5% of ED attenders attended three times or more; they accounted for 27.1% of the ED attendances. While only 1.2% attended six times or more, their contribution was 7.6% of the total attendances. Infants and adults aged over 80 years were significantly more likely to be frequent attenders than adults aged 30-59 years (OR=2.11, 95% CI 2.09 to 2.13, OR=2.22, 95% CI 2.20 to 2.23, respectively). The likelihood of hospital admission rose steeply with the number of attendances a patient had.

CONCLUSION

One in 10 patients attending the ED are frequent attenders and account for over a quarter of attendances. Emergency care systems should consider better ways of reorganising health services to meet the needs of patients who attend EDs frequently.

Chronic disease management models in nursing homes: a scoping review

OBJECTIVES

Nursing home (NH) residents experience a high burden of chronic disease. Chronic disease management (CDM) can be a challenge, as the context of care provision and the way care is provided impact care delivery. This scoping review aimed to identify types of chronic diseases studied in intervention studies in NHs, influential contextual factors addressed by interventions and future CDM research considerations.

DESIGN

The scoping review followed guidelines by Arksey and O'Malley (2005) and Levac, Colquhoun and O'Brien (2010). Six reviewers screened citations for inclusion. Data extraction was performed by one reviewer and verified by a second reviewer.

DATA SOURCES

We searched four databases: CINAHL, EMBASE, PubMed and Scopus, in March 2018.

ELIGIBILITY CRITERIA

Studies were included if (1) aim of intervention was to improve CDM, (2) intervention incorporated the chronic care model (CCM), (3) included NH residents, (4) analysed the efficacy of the intervention and (5) sample included adults over age 65 years. Studies were limited to English or French language and to those published after 1996, when the CCM was first conceptualised.

DATA EXTRACTION AND SYNTHESIS

Extracted information included the type of chronic disease, the type and number of CCM model components used in the intervention, the method of delivery of the intervention, and outcomes.

RESULTS

On completion of the review of 11 917 citations, 13 studies were included. Most interventions targeted residents living with dementia. There was significant heterogeneity noted among designs, outcomes, and type and complexity of intervention components. There was little evaluation of the sustainability of interventions, including feasibility.

CONCLUSIONS

Research was heavily focused on management of dementia. The most commonly included CCM components were multidisciplinary care, evidence-based care, coordinated care and clinical information systems. Future research should include subjective and objective outcomes, which are meaningful for NH residents, for common chronic diseases.

Evaluation of a Multidisciplinary Care Coordination Program for Frequent Users of the Emergency Department

PURPOSE OF STUDY

The purpose of this study was to evaluate the impact of a quality improvement multidisciplinary care coordination program designed to reduce frequent emergency department (ED) utilization and hospital admissions.

PRIMARY PRACTICE SETTING

The single hospital ED is part of a large, integrated, managed care delivery system in Northern California serving the city of Oakland, California.

METHODOLOGY AND SAMPLE

A retrospective cohort study design was used to analyze a multidisciplinary care coordination program on 58 patients during January 2015 and August 2018. Patients were identified from a high-utilization report when they had 10 or more ED visits in a 6-month period, were 18 years of age or older, and members of the integrated delivery system's health plan. Data were collected at initiation and 6 months postintervention. The pre-/postanalysis consisted of descriptive statistics, Wilcoxon signed ranks test, and binary logistic regression.

RESULTS

There was a statistically significant pre-/postdifference of 7.7 ED visits (95% confidence interval [CI] = 4.44-10.97, p < .001). The program did not result in statistically significant reduced hospital admissions (95% CI =-1.24 to 1.45, p = .875). Prior frequent use, number of pre-ED visits, age, sex, complex medical history, and mental health disorder had a significant effect on frequent ED use (χ[6] =17.62, p = .007, McFadden R = .32]. Sex (odds ratio [OR] = 5.13, p = .070), prior frequent use (OR = 2.87, p = .252), and complex medical history (OR = 2.52, p = .412) had the greatest odds of ongoing frequent ED use.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

We demonstrated reductions in ED use among frequent users with a low-cost care management intervention. Our multidisciplinary care coordination program confirms the positive impact case management has on utilization and health outcomes. We established that a care coordination program can optimize the overall quality of care and control hospital costs incurred by this vulnerable population. The effectiveness of this program contributes to the advancement of case management efforts in undertaking the challenging health care issue of reducing repeated visits by frequent users, a practice that strains emergency medical services.

Frequent Attendance to the Emergency Department after Release from Prison: a Prospective Data Linkage Study

The aim of this paper was to identify characteristics and predictors of frequent emergency department (ED) use among people released from prisons in Queensland, Australia. Baseline interview data from a sample of sentenced adults were linked to ED and hospital records. The association between baseline characteristics and frequent ED attendance was modelled by fitting multivariate logistic regression models. Participants who had ≥ 4 visits to the ED in any 365-day period of community follow-up were defined as frequent attenders (FA). The analyses included 1307 people and mean follow-up time in the community was 1063 days. After adjusting for covariates, those with a dual diagnoses of mental illness and substance use (RR = 2.42, 95% CI 1.47–3.99) and those with mental illness alone (RR = 2.47, 95% CI 1.29–4.73) were at higher risk of frequent ED attendance, compared with those with no disorder. Future research should assess whether individually tailored transition supports from prison to community reduce the frequency of ED use among this population.

Serious Mental Illness and Health-Related Factors Associated with Regional Emergency Department Utilization

Frequent emergency department (ED) utilization is an indicator of unmet health and social needs, especially among patients with mental and physical health problems. The authors aimed to characterize frequent ED utilizers and drivers of multiple ED use, including presence of serious mental illness (SMI), across 2 large health care systems in Northern California. Using electronic health records and a data-sharing platform, a cross-sectional analysis was conducted of patients aged 18+ years with ≥10 ED visits in 2016. Logistic regression was used to determine factors associated with multiple ED use versus single ED use. Among the 8036 patients who met inclusion criteria, the mean age was 55.9 years (95% CI = 55.5-56.4), 53% were female, 54% were non-Hispanic white, and 38% had any SMI. Overall, 51% of patients were single ED utilizers. Patients ages ≥65 years were less likely to use multiple EDs compared to younger patients (ages 18-23) (OR = 0.3, 95% CI = 0.2-0.4). African Americans exhibited more than 3 times the likelihood of multi-ED use compared to non-Hispanic whites (OR = 3.8, 95% CI = 3.3-4.3). A diagnosis of any SMI (OR = 2.3 [95% CI: 2.1-2.6]), major depressive disorder (OR = 1.3, 95% CI = 1.1-1.4), schizophrenia (OR = 2.1, 95% CI = 1.6-2.6), or suicidal attempts/ideation (OR = 2.7, 95% CI = 2.1-3.6) was significantly associated with increased likelihood of multi-ED use. Findings indicate heterogeneity in regional utilization patterns among frequent ED utilizers, with mental illness increasing the likelihood of multi-ED use.