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Fried AJ, Gladman C, DeWalt DA. How Healthcare Providers Decide on a Referral Location in Telephone Triage: A Cross-sectional Study. J Gen Intern Med 2024:10.1007/s11606-024-08841-4. [PMID: 38831250 DOI: 10.1007/s11606-024-08841-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 05/20/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Approximately 25% of patients that present to the emergency department (ED) do so after contact with a healthcare professional. Many of these patients could be effectively managed in non-ED ambulatory settings. Aligning patients with safe and appropriate outpatient care has the potential to improve ED overcrowding, patient experience, outcomes, and costs. Little is understood about how healthcare providers approach triage decision-making and what factors influence their choices. OBJECTIVES To evaluate how providers think about patient triage, and what factors influence their decision-making when triaging patient calls. DESIGN Cross-sectional survey-based study in which participants make triage decisions for hypothetical clinical scenarios. PARTICIPANTS Healthcare providers in the specialties of internal medicine, family medicine, or emergency medicine within a large integrated healthcare system in the Southeast. MAIN MEASURES Differences in individual training and practice characteristics were used to compare observed differences in triage outcomes. Free-response data were evaluated to identify themes and factors affecting triage decisions. KEY RESULTS Out of 72 total participants, substantial variability in triage decision-making was observed among all patient cases. Attending physicians triaged 1.4 fewer cases to ED care compared with resident physicians (p < 0.001, 95% CI 0.62-2.1). Academic attendings demonstrated a trend toward fewer cases to ED care compared with community attendings (0.61, p = 0.188, 95% CI - 0.31-1.5). Qualitative data highlighted the complex considerations in provider triage and led to the development of a novel conceptual model to describe the cognitive triage process and the main influencing factors. CONCLUSIONS Triage decision-making for healthcare providers is influenced by many factors related to clinical resources, care coordination, patient factors, and clinician factors. The complex considerations involved yield variability in triage decisions that is largely unexplained by descriptive physician factors.
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Affiliation(s)
- Aaron J Fried
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
| | - Christine Gladman
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Darren A DeWalt
- Department of Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
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Aljahany M, Doumi R, Alhuthail RA, Alshangiti HY, Alsugair RA, Aldokhail LS, Aljohani LH, Alqasimi NA, Alotaibi EM, Alaradi LM, Alabdullah NA, Alkelabi NS, Aleyeidi NA, Fayed A. Public Health Literacy and Emergency Department Utilization in Saudi Arabia: A Cross-Sectional Study. Risk Manag Healthc Policy 2024; 17:995-1004. [PMID: 38680480 PMCID: PMC11055523 DOI: 10.2147/rmhp.s440872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2023] [Accepted: 04/11/2024] [Indexed: 05/01/2024] Open
Abstract
Purpose Health literacy (HL) is the degree in which individuals are able to access, comprehend, and use publicly available health resources and services. A previous study was done in the Kingdom of Saudi Arabia (KSA) assessing the prevalence of HL, the study shows that almost half of KSA residents had limited HL. Most studies that show the level of HL and its relationship to emergency department (ED) utilization were conducted outside KSA. This study aims to assess the association between HL and utilization of ED services and to estimate the prevalence, factors, and outcomes of low HL in KSA. Patients and methods A cross-sectional study was conducted among 903 participants in KSA over a period of 2 months (April and May 2023) using an online survey. Participants were asked about sociodemographic characteristics (age, sex, nationality, marital status, education, work status, income), associated factors (chronic diseases, psychiatric disorders, Covid-19 infection, Covid-19 vaccination, ED visits), and Health Literacy (read, access, understand, evaluation, decision). A health literacy instrument for adults (HELIA), which consists of the previously mentioned five subscales, was used to estimate the level of HL and its association with the risk factors. Results Almost 529 (58.58%) and 374 (41.42%) had limited HL and adequate HL, respectively. Participants with limited HL were mostly aged 35-45 years (61.7%), men (p < 0.05) (68.9%), divorced (65.9%), non-Saudi (69.6%), and had elementary level of education (66.7%). Participants with adequate HL had master's and PhD degree (48.1%), were healthcare students or graduates (62.8%, p < 0.05), had an income >30 thousand riyals (55.6%, p < 0.05), were previously infected with COVID-19 (43%), and did not visit ED in the preceding year (42.3%). Conclusion A high prevalence of low HL among KSA residents was observed. There was no significant difference in ED utilization between participants who had adequate and limited HL.
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Affiliation(s)
- Muna Aljahany
- Department of Internal Medicine, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Rasha Doumi
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Ruba Adel Alhuthail
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Hind Yahiya Alshangiti
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Reem Abdullah Alsugair
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Laila Salah Aldokhail
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Lujain Hatim Aljohani
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Nuwayyir Abdullah Alqasimi
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Enar Mohammed Alotaibi
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Lujain Mohamed Alaradi
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Norah Abdulaziz Alabdullah
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Nadeen Saad Alkelabi
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Nouran A Aleyeidi
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
| | - Amel Fayed
- Family and Community Medicine Department, College of Medicine, Princess Nourah bint Abdulrahman University, Riyadh, Saudi Arabia
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Dhodapkar MM, Modrak M, Halperin SJ, Gouzoulis MJ, Rubio DR, Grauer JN. Low Back Pain: Utilization of Urgent Cares Relative to Emergency Departments. Spine (Phila Pa 1976) 2024; 49:513-517. [PMID: 37982595 DOI: 10.1097/brs.0000000000004880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Accepted: 11/12/2023] [Indexed: 11/21/2023]
Abstract
STUDY DESIGN/SETTING Retrospective study. OBJECTIVE To understand why patients utilize emergency departments (EDs) versus urgent care centers for low back pain (LBP). SUMMARY OF BACKGROUND DATA LBP is a common reason for ED visits. In the setting of trauma or recent surgery, the resources of EDs may be needed. However, urgent care centers may be appropriate for other cases. MATERIALS AND METHODS Adult patients below 65 years of age presenting to the ED or urgent care on the day of diagnosis of LBP were identified from the 2019 PearlDiver M151 administrative database. Exclusion criteria included history of radiculopathy or sciatica, spinal surgery, spinal cord injury, other traumatic, neoplastic, or infectious diagnoses in the 90 days prior, or Medicare insurance. Patient age, sex, Elixhauser comorbidity index, geographic region, insurance, and management strategies were extracted. Factors associated with urgent care relative to ED utilization were assessed using multivariable analysis. RESULTS Of 356,284 LBP patients, ED visits were identified for 345,390 (96.9%) and urgent care visits for 10,894 (3.1%). Factors associated with urgent care use relative to the ED were: geographic region [relative to Midwest; Northeast odds ratio (OR): 5.49, South OR: 1.54, West OR: 1.32], insurance (relative to Medicaid; commercial OR: 4.06), lower Elixhauser comorbidity index (OR: 1.28 per two-point decrease), and higher age (OR: 1.10 per decade), female sex (OR: 1.09), and use of advanced imaging (OR: 0.08) within 1 week ( P <0.001 for all). CONCLUSIONS Most patients presenting for a first diagnosis of isolated LBP went to the ED relative to urgent care. The greatest drivers of urgent care versus ED utilization for LBP were insurance type and geographic region. Utilization of advanced imaging was higher among ED patients, but rates of surgical intervention were similar between those seen in the ED and urgent care.
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Whitehead DC, Li KY, Hayden E, Jaffe T, Karam A, Zachrison KS. Evaluating the Quality of Virtual Urgent Care: Barriers, Motivations, and Implementation of Quality Measures. J Gen Intern Med 2024; 39:731-738. [PMID: 38302813 PMCID: PMC11043309 DOI: 10.1007/s11606-024-08636-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/26/2023] [Accepted: 01/16/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Experts estimate virtual urgent care programs could replace approximately 20% of current emergency department visits. In the absence of widespread quality guidance to programs or quality reporting from these programs, little is known about the state of virtual urgent care quality monitoring initiatives. OBJECTIVE We sought to characterize ongoing quality monitoring initiatives among virtual urgent care programs. APPROACH Semi-structured interviews of virtual health and health system leaders were conducted using a pilot-tested interview guide to assess quality metrics captured related to care effectiveness and equity as well as programs' motivations for and barriers to quality measurement. We classified quality metrics according to the National Quality Forum Telehealth Measurement Framework. We developed a codebook from interview transcripts for qualitative analysis to classify motivations for and barriers to quality measurement. KEY RESULTS We contacted 13 individuals, and ultimately interviewed eight (response rate, 61.5%), representing eight unique virtual urgent care programs at primarily academic (6/8) and urban institutions (5/8). Most programs used quality metrics related to clinical and operational effectiveness (7/8). Only one program reported measuring a metric related to equity. Limited resources were most commonly cited by participants (6/8) as a barrier to quality monitoring. CONCLUSIONS We identified variation in quality measurement use and content by virtual urgent care programs. With the rapid growth in this approach to care delivery, more work is needed to identify optimal quality metrics. A standardized approach to quality measurement will be key to identifying variation in care and help focus quality improvement by virtual urgent care programs.
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Affiliation(s)
- David C Whitehead
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA.
- Harvard Medical School, Boston, MA, USA.
| | | | - Emily Hayden
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Todd Jaffe
- University of Pennsylvania, Philadelphia, PA, USA
| | - Alessandra Karam
- Central Michigan University College of Medicine, Mount Pleasant, MI, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Ziemnik L, Parker N, Bufi K, Waters K, Almeda J, Stolfi A. Low-Acuity Pediatric Emergency Department Utilization: Caregiver Motivations. Pediatr Emerg Care 2024:00006565-990000000-00421. [PMID: 38534003 DOI: 10.1097/pec.0000000000003195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/28/2024]
Abstract
OBJECTIVES Proper emergency department (ED) utilization is a hallmark of population health. Emergency department overcrowding due to nonurgent visits causes increased stress to healthcare staff, higher costs, and longer wait times for more urgent cases. This study sought to better understand post pandemic reasons caregivers have when bringing in their children for nonurgent visits and devise effective interventions to improve caregiver choice for non-ED care for nonurgent conditions. METHODS Surveys were conducted at an urban pediatric hospital for Emergency Severity Index (ESI) level 3 to 5 visits. A total of 602 surveys were completed with 8 being excluded from analysis. Survey responses and anonymized demographic information were collected. Responses were compared between surveys grouped by respondent age category, relation to child, child's race, insurance type, and ESI levels. RESULTS Primary reasons given for nonurgent ED visits were perceived urgency (74.2%, n = 441), ED superiority to other locations (23.9%, n = 142), and referral to the ED by a third party (17.7%, n = 105). Of those who cited perceived urgency as a reason, 80.5% (n = 355) wanted to lessen their child's pain/discomfort as soon as possible, but only 13.6% said that their child was too ill to be seen anywhere else (n = 60). Demographic differences occurred in the proportions of respondents citing some of the primary and secondary reasons for bringing their child to the ED. CONCLUSIONS This study highlights 3 key findings. An immediate desire for care plays a key role in caregiver decision making for low-acuity visits. There is potential socioeconomic and racial bias in where care is recommended that needs to be further explored in this region. Cross community interventions that target key reasons for seeking low-acuity care have the highest likelihood of impacting the use of the ED for low-acuity conditions.
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Rayburn WF, Armstrong J, Fairchild D. Women Accessing Care at a National Network of Retail Health Clinics. J Womens Health (Larchmt) 2024. [PMID: 38501329 DOI: 10.1089/jwh.2023.0933] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/20/2024] Open
Abstract
Background: Retail health clinics offer easy access and lower costs in seeking nonemergent and usually focused care. The objective of this observational study was to describe the use of retail clinic services by women at MinuteClinic at CVS, the largest network of retail clinics in the United States. Methods: The retail clinic's large database included complete national data for every in-person encounter as recorded on the same electronic health record. Virtual care and pharmacist-delivered services like COVID-19 testing were excluded from the analysis. The primary reason for the visit and the patient's age group (<15, 15-44, 45-64, ≥65 years) and self-reported sex were recorded at each encounter from the most recent 5 years (January 1, 2018, to December 31, 2022). Results: There were 17,969,483 encounters by women seeking care, and women ≥15 years old were more likely than men to attend the clinics. Half of all encounters (50.6%) were for non-gynecologic acute care, whereas one-third (33.6%) dealt with either an infection or the need for a vaccination. Gynecologic reasons involved 5.6% of all encounters in women ≥15 years of age. No obstetrical care was provided except for pregnancy testing with referral, acute non-obstetric needs, or guideline-recommended vaccinations. Conclusion: Women, especially of reproductive age, are more inclined than men to seek care at retail clinics. Acute care is the most common need, although requests for immunizations, infection screening and treatment, and reproductive health issues occurred often.
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Affiliation(s)
- William F Rayburn
- Department of Obstetrics and Gynecology, Medical University of South Carolina, Charleston, South Carolina, USA
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O'Connor L, Behar S, Refuerzo J, Mele X, Sundling E, Johnson SA, Faro JM, Lindenauer PK, Mattocks KM. Factors Impacting the Implementation of Mobile Integrated Health Programs for the Acute Care of Older Adults. PREHOSP EMERG CARE 2024:1-16. [PMID: 38498782 DOI: 10.1080/10903127.2024.2333034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2023] [Accepted: 03/12/2024] [Indexed: 03/20/2024]
Abstract
Objective: Emergency services utilization is increasing in older adult populations. Many such encounters may be preventable with better access to acute care in the community. Mobile integrated health (MIH) programs leverage mobile resources to deliver care and services to patients in the out-of-hospital environment and have the potential to improve clinical outcomes and decrease health care costs; however, they have not been widely implemented. We assessed barriers, potential facilitators, and other factors critical to the implementation of MIH programs with key vested partners.Methods: Professional and community-member partners were purposefully recruited to participate in recorded structured interviews. The study team used the Practical Robust Implementation and Sustainability Model (PRISM) framework to develop an interview guide and codebook. Coders employed a combination of deductive and inductive coding strategies to identify common themes across partner groups.Results: The study team interviewed 22 participants (mean age 56, 68% female). A cohort of professional subject matter experts included physicians, paramedics, public health personnel, and hospital administrators. A cohort of lay community partners included patients and caregivers. Coders identified three prominent themes that impact MIH implementation. First, MIH is disruptive to existing clinical workflows. Second, using MIH to improve patients' experience during acute care encounters is key to intervention adoption. Finally, legislative action is needed to augment central financial and regulatory policies to ensure the adoption of MIH programs.Conclusions: Common themes impacting the implementation of MIH programs were identified across vested partner groups. Multilevel strategies are needed to address patient adoption, clinical partners' workflow, and legislative policies to ensure the success of MIH programs.
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Affiliation(s)
- Laurel O'Connor
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester Massachusetts, United States
| | - Stephanie Behar
- Department of Medicine, University of Massachusetts Chan Medical School, Worcester Massachusetts, United States
| | - Jade Refuerzo
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester Massachusetts, United States
| | - Xhenifer Mele
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester Massachusetts, United States
| | - Elsa Sundling
- Department of Industrial Management, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Sharon A Johnson
- Robert A. Foisie School of Business, Worcester Polytechnic Institute, Worcester Massachusetts, United States
| | - Jamie M Faro
- Department of Population Health and Quantitative Sciences, University of Massachusetts Chan Medical School Worcester Massachusetts, United States
| | - Peter K Lindenauer
- Department of Healthcare Delivery and Population Sciences and Department of Medicine, University of Massachusetts Chan Medical School-Baystate, Springfield, MA
| | - Kristin M Mattocks
- Department of Population Health and Quantitative Sciences, University of Massachusetts Chan Medical School Worcester Massachusetts, United States
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Kelly JT, Mitchell N, Campbell KL, Furlong K, Langley M, Clark S, Rushbrook E, Hansen K. Implementing a virtual emergency department to avoid unnecessary emergency department presentations. Emerg Med Australas 2024; 36:125-132. [PMID: 37941299 DOI: 10.1111/1742-6723.14328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Revised: 09/17/2023] [Accepted: 09/20/2023] [Indexed: 11/10/2023]
Abstract
OBJECTIVE EDs are necessary for urgent health concerns; however, many physical ED visits could be better treated in alternate settings. The present study aimed to describe the feasibility, acceptability and effectiveness of a Virtual ED to reduce unnecessary physical ED presentations at a large tertiary health service in Australia. METHODS This observational study using the RE-AIM framework (Reach, Efficacy, Adoption, Implementation and Maintenance) evaluated the feasibility of a Virtual ED using routinely collected health service data and process-evaluation to assess intervention fidelity and adherence between April 2020 and 31 March 2022. The primary outcome for the present study was the feasibility of the Virtual ED model of care. RESULTS The Virtual ED received 2080 direct calls for patients with a mean age of 50.3 years, with 70.4% managed in the Virtual ED alone and 29.6% referred for physical ED presentation. Of the 2080 direct referrals, 95.8% were potentially avoidable ED presentations. Of those referred, 28.3% required an admission. Of calls managed entirely by Virtual ED, 18 (1.2%) unexpectedly required a hospital admission within 48 h. General practitioner respondents rated the Virtual ED service as helpful to very helpful. The service had an average of 212 referrals per month, with a 65.2% average growth rate. The Virtual ED service was considered helpful and clinically appropriate, with a high level of ED avoidance. CONCLUSION The Virtual ED prevented 70% of community triaged patients from presenting to the physical ED, with good uptake from all referrers, supporting the use of virtual care pathways in emergency care management.
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Affiliation(s)
- Jaimon T Kelly
- Centre for Online Health, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
| | - Nicole Mitchell
- Healthcare Excellence and Innovation, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
- Virtual Emergency Department, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Katrina L Campbell
- Centre for Health Services Research, Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
- Healthcare Excellence and Innovation, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Karen Furlong
- Virtual Emergency Department, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
- Caboolture Emergency Department, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Matthew Langley
- Healthcare Excellence and Innovation, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
- Virtual Emergency Department, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Sean Clark
- Healthcare Excellence and Innovation, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
- Virtual Emergency Department, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
- Caboolture Emergency Department, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Elizabeth Rushbrook
- Virtual Emergency Department, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
| | - Kim Hansen
- Virtual Emergency Department, Metro North Hospital and Health Service, Brisbane, Queensland, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, Queensland, Australia
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Giannouchos TV, Ukert B, Wright B. Concordance in Medical Urgency Classification of Discharge Diagnoses and Reasons for Visit. JAMA Netw Open 2024; 7:e2350522. [PMID: 38198140 PMCID: PMC10782231 DOI: 10.1001/jamanetworkopen.2023.50522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/11/2023] [Accepted: 11/09/2023] [Indexed: 01/11/2024] Open
Abstract
Importance Current policies to divert emergency department (ED) visits for less medically urgent conditions to more cost-effective settings rely on retrospective adjudication of discharge diagnoses. However, patients present to the ED with concerns, making it challenging for clinicians. Objective To characterize ED visits based on the medical urgency of the presenting reasons for visit and to explore the concordance between discharge diagnoses and reasons for visit. Design, Setting, and Participants In this retrospective, cross-sectional study, a nationwide sample of ED visits by adults (aged ≥18 years) in the US from the 2018 and 2019 calendar years' ED data of the National Hospital Ambulatory Medical Care Survey was used. An algorithm to probabilistically assign ED visits into medical urgency categories based on the presenting reason for visit was developed. A 3-step, look-back method was applied using an updated version of the New York University ED algorithm, and a map of all possible discharge diagnoses to the same reasons for visit was developed. Analyses were conducted in July and August 2023. Main Outcomes and Measures The main outcome was probabilistic medical urgency classification of reasons for visits and discharge diagnoses and their concordance. Results We analyzed 27 068 ED visits (mean age, 48.2% years [95% CI, 47.5%-48.9% years]) representing 190.7 million visits nationwide. Women (mean, 57.0% [95% CI, 55.9%-58.1%]) and patients with public health insurance coverage, including Medicare (mean, 24.9% [95% CI, 21.9%-28.0%]) and Medicaid (mean, 25.1% [95% CI, 21.0%-29.2%]), accounted for the largest share of ED visits, and a mean of 13.2% (95% CI, 11.4%-15.0%) of all visits resulted in a hospital admission. Overall, about 38.5% and 53.9% of all ED visits were classified with 100% and 75% probabilities, respectively, as injury related, emergency care needed, emergent but primary care treatable, nonemergent, or mental health or substance use disorders related based on discharge diagnosis compared with 0.4% and 12.4%, respectively, of all encounters based on patients' reason for visit. Among discharge diagnoses assigned with high certainty to only 1 urgency category using the New York University ED algorithm, between 38.0% (95% CI, 36.3%-39.6%) and 57.4% (95% CI, 56.0%-58.8%) aligned with the probabilistic categorical assignments of their corresponding reasons for visit. Conclusions and Relevance In this cross-sectional study of 190.7 million ED visits among adults aged 18 years or older, a smaller percentage of reasons for visit could be prospectively categorized with high accuracy to a specific medical urgency category compared with all visits based on discharge diagnoses, and a limited concordance between reasons for visit and discharge diagnoses was found. Alternative methods are needed to identify the medical necessity of ED encounters more accurately.
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Affiliation(s)
- Theodoros V. Giannouchos
- Department of Health Policy and Organization, School of Public Health, The University of Alabama at Birmingham
| | - Benjamin Ukert
- Department of Health Policy and Management, School of Public Health, Texas A&M University, College Station
| | - Brad Wright
- Department of Health Services Policy and Management, Arnold School of Public Health, University of South Carolina, Columbia
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Bachmann R, Gunes G, Hangaard S, Nexmann A, Lisouski P, Boesen M, Lundemann M, Baginski SG. Improving traumatic fracture detection on radiographs with artificial intelligence support: a multi-reader study. BJR Open 2024; 6:tzae011. [PMID: 38757067 PMCID: PMC11096271 DOI: 10.1093/bjro/tzae011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Revised: 10/13/2023] [Accepted: 04/21/2024] [Indexed: 05/18/2024] Open
Abstract
Objectives The aim of this study was to evaluate the diagnostic performance of nonspecialist readers with and without the use of an artificial intelligence (AI) support tool to detect traumatic fractures on radiographs of the appendicular skeleton. Methods The design was a retrospective, fully crossed multi-reader, multi-case study on a balanced dataset of patients (≥2 years of age) with an AI tool as a diagnostic intervention. Fifteen readers assessed 340 radiographic exams, with and without the AI tool in 2 different sessions and the time spent was automatically recorded. Reference standard was established by 3 consultant radiologists. Sensitivity, specificity, and false positives per patient were calculated. Results Patient-wise sensitivity increased from 72% to 80% (P < .05) and patient-wise specificity increased from 81% to 85% (P < .05) in exams aided by the AI tool compared to the unaided exams. The increase in sensitivity resulted in a relative reduction of missed fractures of 29%. The average rate of false positives per patient decreased from 0.16 to 0.14, corresponding to a relative reduction of 21%. There was no significant difference in average reading time spent per exam. The largest gain in fracture detection performance, with AI support, across all readers, was on nonobvious fractures with a significant increase in sensitivity of 11 percentage points (pp) (60%-71%). Conclusions The diagnostic performance for detection of traumatic fractures on radiographs of the appendicular skeleton improved among nonspecialist readers tested AI fracture detection support tool showed an overall reader improvement in sensitivity and specificity when supported by an AI tool. Improvement was seen in both sensitivity and specificity without negatively affecting the interpretation time. Advances in knowledge The division and analysis of obvious and nonobvious fractures are novel in AI reader comparison studies like this.
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Affiliation(s)
| | | | - Stine Hangaard
- Department of Radiology, Herlev and Gentofte, Copenhagen University Hospital, Denmark
| | | | | | - Mikael Boesen
- Department of Radiology and Radiological AI Testcenter (RAIT) Denmark, Bispebjerg and Frederiksberg, Copenhagen University Hospital, Denmark
- Department of Clinical Medicine, Faculty of Health, and Medical Sciences, University of Copenhagen, Denmark
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Mayfield CA, Priem JS, Effinger T, McGinnis S, Grinton P. School-Based Telemedicine and Reduced Avoidable Emergency Care Among Rural Pediatric Patients. Telemed J E Health 2023; 29:1819-1827. [PMID: 37172309 DOI: 10.1089/tmj.2023.0013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/14/2023] Open
Abstract
Objective: Children living in rural communities have disparate access to preventive health care, shifting the burden of care delivery to emergency services. This study examined the association of school-based telemedicine (SBT) and avoidable emergency department (ED) utilization in rural historically underserved pediatric patients served through an SBT program. Methods: A retrospective analysis was conducted using electronic medical records and claims data from a large integrated health care system serving as the majority health care provider in the area. Participants included all pediatric patients served through an SBT program between 2017 and 2020 across three rural North Carolina counties. The study was a quasi-experimental before/after design comparing 12-month time periods before and after a patient's index virtual care visit. A subset of patients served 12 months before the start of the coronavirus 2019 (COVID-19) pandemic in 2020 was extracted and analyzed separately for a sensitivity analysis. Results: The complete sample included 1,236 patients. The odds of having an avoidable ED visit were reduced by 33% between time periods, and the estimated count of visits was reduced by 26%. (Models were adjusted for race/ethnicity, gender, age, and insurance payer.) No significant differences in unavoidable ED utilization were observed. The sensitivity analysis showed similar trends. Conclusions: Results demonstrate that telemedicine can improve access to health care and may offset the burden of avoidable care through emergency health services. Policy changes and increased use during the COVID-19 pandemic have created an optimal environment for telemedicine expansion to reduce health care access disparities.
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Affiliation(s)
- Carlene A Mayfield
- Department of Community Health, Atrium Health, Charlotte, North Carolina, USA
| | - Jennifer S Priem
- Center for Outcomes Research and Evaluation, Atrium Health, Charlotte, North Carolina, USA
| | - Tiffany Effinger
- Information and Analytics Services, Population Health Analytics, Atrium Health, Charlotte, North Carolina, USA
| | - Sam McGinnis
- Levine Children's Pediatric Center, Atrium Health, Charlotte, North Carolina, USA
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Matheson AI, Colombara DV, Pennucci A, Chan A, Shannon T, Suter M, Laurent AA. A Good Farewell? Positive Exits from Federal Housing Assistance and Lower Acute Healthcare Utilization. J Urban Health 2023; 100:1202-1211. [PMID: 38012503 PMCID: PMC10728032 DOI: 10.1007/s11524-023-00789-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/13/2023] [Indexed: 11/29/2023]
Abstract
Little is known regarding the health outcomes of people who exit from housing assistance and if that experience varies by the circumstances under which a person exits. We asked two questions: (1) does the type of exit from housing assistance matter for healthcare utilization? And (2) how does each exit type compare to remaining in housing assistance in terms of healthcare utilization? This retrospective cohort study of 5550 exits between 2012 and 2018 used data from two large, urban public housing authorities in King County, Washington. Exposures were exiting from housing assistance and type of exit (positive, neutral, negative). Outcomes were emergency department visits, hospitalizations, and well-child checks (among those aged < 6) in the year following exit from housing assistance. After adjustment for demographics and baseline healthcare utilization, people with positive exits had 26% (95% confident interval: 6-39%) lower odds of having 1 + ED visits in the year following exit than people with negative exits and 20% (95% CI: 6-31%) lower odds than those who continued receiving housing assistance. Neutral and negative exits did not differ substantially from each other, and both exit types appear to be detrimental to health, with higher levels of ED visits and hospitalizations and lower levels of well-child checks. Why people exit from housing assistance matters. Those with negative exits experience poorer outcomes and efforts should be made to both prevent this kind of exit and mitigate its impact.
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Affiliation(s)
- Alastair I Matheson
- Public Health - Seattle & King County, Seattle, WA, USA.
- Department of Epidemiology, University of Washington, Seattle, WA, USA.
| | - Danny V Colombara
- Public Health - Seattle & King County, Seattle, WA, USA
- Department of Epidemiology, University of Washington, Seattle, WA, USA
| | | | - Andy Chan
- Seattle Housing Authority, Seattle, WA, USA
| | | | - Megan Suter
- Public Health - Seattle & King County, Seattle, WA, USA
| | - Amy A Laurent
- Public Health - Seattle & King County, Seattle, WA, USA
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13
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Tran LD, Rose L, Suzuki K, Urech T, Vashi A. Medical advice lines offering on-demand access to providers reduced emergency department visits. HEALTH AFFAIRS SCHOLAR 2023; 1:qxad079. [PMID: 38756361 PMCID: PMC10986286 DOI: 10.1093/haschl/qxad079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 10/26/2023] [Accepted: 12/01/2023] [Indexed: 05/18/2024]
Abstract
Instant access to clinicians through virtual care is designed to allow patients to receive care they need while avoiding high-cost visits in acute-care settings. This study investigates the effect of offering patients the option to instantly connect with emergency care providers instead of being referred to the emergency department (ED) following calls to a medical advice line. We used a staggered rollout design to assess the effects of implementing this program on key outcomes among Veterans Affairs enrollees. Analyzing over 1 million calls from 2019 to 2022, we found that access to a provider reduced the proportion of patients who subsequently visited the ED compared with those with access to the standard medical advice line (38% vs 36%). There was no significant difference observed in subsequent inpatient admissions or 30-day mortality. We found that a majority of callers (65%) achieved issue resolution or were directed to lower acuity settings for further evaluation. Although substantial direct cost savings were not evident, our findings demonstrate that on-demand access to a virtual provider can effectively decrease ED visits.
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Affiliation(s)
- Linda Diem Tran
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA 94025, United States
- Stanford Surgery Policy Improvement and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, United States
| | - Liam Rose
- Health Economics Resource Center, VA Palo Alto Health Care System, Menlo Park, CA 94025, United States
- Stanford Surgery Policy Improvement and Education Center, Department of Surgery, Stanford University School of Medicine, Palo Alto, CA 94304, United States
| | - Ken Suzuki
- Department of Economics, University of California, Santa Cruz, Santa Cruz, CA 95064, United States
| | - Tracy Urech
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, CA 94025, United States
| | - Anita Vashi
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, CA 94025, United States
- Department of Emergency Medicine, University of California, San Franciso, CA 94143, United States
- Department of Emergency Medicine (Affiliated), Stanford University School of Medicine, Stanford, CA 94305, United States
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Brush PL, Tomlak A, Pohl N, Lee Y, Narayanan R, Meade MH, Lambrechts MJ, Lawall CL, Weber J, Syal A, O'Connor P, Canseco JA, Kaye ID, Kurd MF, Vaccaro AR, Kepler CK, Hilibrand AS, Schroeder GD. Utilization of In-Hospital Orthopaedic Spine Consultations: Evaluating the Impact of Health Care Policy. Am J Med Qual 2023; 38:300-305. [PMID: 37908033 DOI: 10.1097/jmq.0000000000000155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2023]
Abstract
Access to specialty and private practice providers has been a divisive policy issue over the last decade, complicated by the conflict between a reduction in government-funded health care reimbursement and the need for health care providers to sustain a financially sound practice. This study evaluates the orthopedic spine consult service at an academic tertiary care center at 2 separate time points over a 5-year period to better understand the impact of decreasing orthopedic reimbursement rates and the increasing prevalence of federally supported medical insurance on the access to specialty care. In total 500 patients in 2017 and 480 patients in 2021 were included for the final analysis. A higher percentage of consults in 2021 came from the emergency department (74.0% versus 60.4%, P < 0.001); however, the emergency department saw fewer spinal cord injuries (11.9% versus 21.4%, P < 0.001), and the spinal cord injuries were less severe (3.1% versus 6.2% Association Impairment Scale A or B, P = 0.034). A smaller percentage of patients in 2021 went on to receive orthopedic spine surgery following consultation (35.2% versus 43.8%, P = 0.007), and those receiving surgery had an operation performed farther out from the initial consultation (4.73 versus 4.09 days, P < 0.001). Additionally, fewer patients with Medicare insurance (23.5% versus 30.8%) and more patients with Medicaid insurance (20.2% versus 12.4%) were seen in 2021 compared with 2017 (P = 0.003). Overall, this study found an increased proportion of Medicaid patients seen by the spine consult service but a decrease in the acuity of consults. Measures to improve access to health insurance under the Affordable Care Act have revealed the complexity of this issue in health care. This study's findings have demonstrated that while more patients did have insurance coverage following the Affordable Care Act, they still face a barrier to accessing outpatient orthopedic spine providers.
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Affiliation(s)
- Parker L Brush
- Department of Orthopaedic Spine Surgery, Rothman Orthopaedic Institute at Thomas Jefferson University, Philadelphia, PA, USA
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15
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Müller F, Munagala A, Arnetz JE, Achtyes ED, Alshaarawy O, Holman HT. Racial disparities in emergency department utilization among patients with newly diagnosed depression. Gen Hosp Psychiatry 2023; 85:163-170. [PMID: 37926052 DOI: 10.1016/j.genhosppsych.2023.10.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2023] [Revised: 10/25/2023] [Accepted: 10/28/2023] [Indexed: 11/07/2023]
Abstract
OBJECTIVE To test the hypothesis that racial and ethnic minorities have increased emergency department visit rates, despite being established with a primary care provider. METHODS In this retrospective cohort study, ED visits without hospital admission in a 12-month period among patients with a new primary care provider-issued diagnosis of depression were assessed. Electronic medical record (EMR) data was obtained from 47 family medicine clinics in a large Michigan-based healthcare system. General linear regression models with Poisson distribution were used to predict frequency of ED visits. RESULTS A total of 4159 patients were included in the analyses. In multivariable analyses, Black / African American race was associated with an additional 0.90 (95% CI 0.64, 1.16) ED visits and American Indian or Alaska Native race was associated with an additional 1.39 (95% CI 0.92, 1.87) ED visits compared to White or Caucasians (null value 0). These risks were only exceeded by patients who received a prescription for a typical antipsychotic drug agent. CONCLUSION Despite being established patients at primary care providers and having follow-up encounters, Black / African American and American Indian or Alaska Native patients with depression were considerably more likely to seek ED treatment compared to White/Caucasian patients with depression.
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Affiliation(s)
- Frank Müller
- Department of Family Medicine, Michigan State University, Grand Rapids, MI, USA; Corewell Health Family Medicine Residency Clinic, Grand Rapids, MI, USA; Department of General Practice, University Medical Center Göttingen, Göttingen, Germany.
| | - Akhilesh Munagala
- Department of Family Medicine, Michigan State University, Grand Rapids, MI, USA.
| | - Judith E Arnetz
- Department of Family Medicine, Michigan State University, Grand Rapids, MI, USA.
| | - Eric D Achtyes
- Western Michigan University Homer Stryker M.D. School of Medicine, Kalamazoo, MI, USA.
| | - Omayma Alshaarawy
- Department of Family Medicine, College of Human Medicine, Michigan State University, East Lansing, MI, USA.
| | - Harland T Holman
- Department of Family Medicine, Michigan State University, Grand Rapids, MI, USA; Corewell Health Family Medicine Residency Clinic, Grand Rapids, MI, USA.
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O'Connor L, Reznek M, Hall M, Inzerillo J, Broach JP, Boudreaux E. A mobile integrated health program for the management of undifferentiated acute complaints in older adults is safe and feasible. Acad Emerg Med 2023; 30:1110-1116. [PMID: 37597241 PMCID: PMC10884993 DOI: 10.1111/acem.14791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Revised: 07/26/2023] [Accepted: 08/09/2023] [Indexed: 08/21/2023]
Abstract
BACKGROUND Poor care access and lack of proper triage of medical complaints leads to inappropriate use of acute care resources. Mobile integrated health (MIH) programs may offer a solution by providing adaptable on-demand care. There is little information describing programs that manage undifferentiated complaints in the community. The objective of this study was to assess the safety and feasibility of an MIH program that responds to the community to manage medical complaints in older adults. METHODS This was a prospective observational study examining a pilot MIH program. Seven ambulatory clinics and their affiliated patients aged 65 and older were oriented to the program and invited to use its services. Visit and follow-up data for all patients who underwent an MIH visit were abstracted, along with 30-day follow-up information. All demographic data and outcomes were reported descriptively. RESULTS In 21 months, 153 MIH visits were completed, involving 91 patients (mean age 81 years, 60.4% female). The most common chief complaints were generalized weakness (28.8%) and shortness of breath (18.9%). Electrocardiogram (57.5%) and point-of-care bloodwork (34.6%) were the most common diagnostic tests performed. Sixteen visits (10.4%) were followed by an emergency department (ED) visit within 72 h. In 11 encounters, the patient was referred to the ED; in five cases, the ED visit was unforeseen. Fifteen patients (9.8%) were admitted to the hospital after an MIH visit. There were two deaths within 30 days following an index visit. CONCLUSIONS An MIH program designed to address the acute complaints of community-dwelling older adults was feasible and safe, with low rates of unforeseen emergency services utilizations. MIH programs have valuable diagnostic and therapeutic capabilities and may serve to help triage the acute medical needs of patients. Further study is required to validate the efficacy and cost-effectiveness of MIH programs.
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Affiliation(s)
- Laurel O'Connor
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Martin Reznek
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Michael Hall
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Julie Inzerillo
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - John P Broach
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
| | - Edwin Boudreaux
- Department of Emergency Medicine, University of Massachusetts Chan Medical School, Worcester, Massachusetts, USA
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Lebovitz S, Estryk M, Zimmerman DR, Pollak A, Luria D, Amir O, Biton Y. Trends in Atrial Fibrillation Management-Results from a National Multi-Center Urgent Care Network Registry. J Clin Med 2023; 12:6704. [PMID: 37959170 PMCID: PMC10650842 DOI: 10.3390/jcm12216704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Revised: 10/18/2023] [Accepted: 10/18/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND Atrial fibrillation (AF) is a common diagnosis in patients presenting to urgent care centers (UCCs), yet there is scant research regarding treatment in these centers. While some of these patients are managed within UCCs, some are referred for further care in an emergency department (ED). OBJECTIVES We aimed to identify the rate of patients referred to an ED and define predictors for this outcome. We analyzed the rates of AF diagnosis and hospital referral over the years. Finally, we described trends in patient anticoagulation (AC) medication use. METHODS This retrospective study included 5873 visits of patients over age 18 visiting the TEREM UCC network with a diagnosis of AF over 11 years. Multivariate analysis was used to identify predictors for ED referral. RESULTS In a multivariate model, predictors of referral to an ED included vascular disease (OR 1.88 (95% CI 1.43-2.45), p < 0.001), evening or night shifts (OR 1.31 (95% CI 1.11-1.55), p < 0.001; OR 1.68 (95% CI 1.32-2.15), p < 0.001; respectively), previously diagnosed AF (OR 0.31 (95% CI 0.26-0.37), p < 0.001), prior treatment with AC (OR 0.56 (95% CI 0.46-0.67), p < 0.001), beta blockers (OR 0.63 (95% CI 0.52-0.76), p < 0.001), and antiarrhythmic medication (OR 0.58 (95% CI 0.48-0.69), p < 0.001). Visits diagnosed with AF increased over the years (p = 0.030), while referrals to an ED decreased over the years (p = 0.050). The rate of novel oral anticoagulant prescriptions increased over the years. CONCLUSIONS The rate of referral to an ED from a UCC over the years is declining but remains high. Referrals may be predicted using simple clinical variables. This knowledge may help to reduce the burden of hospitalizations.
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Affiliation(s)
- Shalom Lebovitz
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
- TEREM—Emergency Medical Centers, Jerusalem 97775, Israel
| | | | | | - Arthur Pollak
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
| | - David Luria
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
| | - Offer Amir
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
| | - Yitschak Biton
- Department of Cardiology, Hadassah Medical Center, Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem 91904, Israel (O.A.)
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Janca E, Keen C, Willoughby M, Young JT, Kinner SA. Sex differences in acute health service contact after release from prison in Australia: a data linkage study. Public Health 2023; 223:240-248. [PMID: 37688844 DOI: 10.1016/j.puhe.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 07/18/2023] [Accepted: 08/04/2023] [Indexed: 09/11/2023]
Abstract
OBJECTIVES Women released from prison typically experience worse health outcomes than their male counterparts. We examined sex differences in the patterns, characteristics, and predictors of acute health service contact (AHSC) (i.e. ambulance and/or emergency department use) after release from prison. STUDY DESIGN Data linkage study. METHODS Baseline survey data from 1307 adults (21% women) within six weeks of expected release from prisons in Queensland, Australia (2008-2010) were linked prospectively with state-wide ambulance and emergency department, correctional, mental health, and death records. Crude and adjusted incidence rates and incidence rate ratios of AHSC were calculated overall and by sex. An Andersen-Gill model was fit to examine whether sex predicted AHSC. The interaction effect between sex and each model covariate was tested. RESULTS The crude incidence rates of AHSC after release from prison were 1.4 (95% confidence interval [CI]: 1.3-1.5) and 1·1 (95%CI: 1.1-1.2) per person-year for women and men, respectively. The relationship between perceived physical health-related functioning at the baseline and AHSC was modified by sex (P = 0·039). The relationship between perceived health-related functioning and AHSC also differed among women. Compared to women who perceived their physical health as fair or good at the baseline, women who perceived their physical health as poor were at greater risk of AHSC (hazard ratio = 2.4, 95%CI: 1.4-3·9, P = 0.001) after release from prison. CONCLUSIONS Among people released from prison, women's and men's AHSC differs depending on how they perceive their own physical health. The specific needs of women and men must be considered in transitional support policy and planning to improve their health outcomes.
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Affiliation(s)
- E Janca
- School of Population Health, Curtin University, Perth, Western Australia, Australia; Justice Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia.
| | - C Keen
- Justice Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia
| | - M Willoughby
- Justice Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia
| | - J T Young
- Justice Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; School of Population and Global Health, The University of Western Australia, Perth, Western Australia, Australia; National Drug Research Institute, Curtin University, Perth, Western Australia, Australia
| | - S A Kinner
- School of Population Health, Curtin University, Perth, Western Australia, Australia; Justice Health Unit, Melbourne School of Population and Global Health, The University of Melbourne, Parkville, Victoria, Australia; Centre for Adolescent Health, Murdoch Children's Research Institute, Parkville, Victoria, Australia; Griffith Criminology Institute, Griffith University, Queensland, Australia
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Burke LG, Burke RC, Duggan CE, Figueroa JF, John Orav E, Marcantonio ER. Trends in healthy days at home for Medicare beneficiaries using the emergency department. J Am Geriatr Soc 2023; 71:3122-3133. [PMID: 37300394 PMCID: PMC10592590 DOI: 10.1111/jgs.18464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Revised: 05/04/2023] [Accepted: 05/08/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status. METHODS We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status. RESULTS We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD. CONCLUSIONS Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.
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Affiliation(s)
- Laura G. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ciara E. Duggan
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - E. John Orav
- Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, MA, USA
| | - Edward R. Marcantonio
- Divisions of General Medicine and Gerontology, Department of Medicine, Beth Israel Deaconess Medical Center, and Harvard Medical School, Boston, MA, USA
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Langer S, Xu Y, Kong S, Puddy J, Quan ML. Investigating Factors Associated with Postmastectomy Emergency Department Visits: A Population-Based Analysis. Ann Surg Oncol 2023; 30:6499-6505. [PMID: 37454012 DOI: 10.1245/s10434-023-13727-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 05/23/2023] [Indexed: 07/18/2023]
Abstract
BACKGROUND In 2016, a multi-pronged pathway was implemented across 13 hospitals to improve the mastectomy perioperative care experience with one objective being to safely allow same day surgery mastectomy. While the pathway successfully increased same day mastectomy rates from 1.7 to 73.0%, the rate of postoperative emergency department (ED) visits remained high at > 20%, despite focused interventions to enhance perioperative support. AIM To investigate potential factors associated with high postoperative ED visits following mastectomies in Alberta, Canada. METHODS Data was collected using the Discharge Abstract Database and the National Ambulatory Care Reporting System database. Eligible patients included all women over 18 years old who underwent a mastectomy province-wide between 2004 and 2020. Patient demographics were collected. Primary outcome of interest was ED visit within 30 days of mastectomy. Univariate and multivariable analyses were performed to identify independent predictors for post-operative ED visits. RESULTS A total of 19,974 patients had mastectomy during the study period, of which 4590 (23%) had an ED visit within 30 days of surgery. Independent factors associated with ED visits were increasing age, overnight stay mastectomy, reconstruction, certain comorbidities, and living rurally. CONCLUSIONS Post-operative ED visits remain high despite initiating a province-wide surgical pathway in 2016 which emphasizes patient education and improved perioperative care and supports. Currently, the majority of ED visits are manageable in non-emergent settings. Patient populations at higher risk for ED visits groups may benefit from additional targeted support and resources to reduce unplanned ED visits.
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Affiliation(s)
- Steven Langer
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada.
| | - Yuan Xu
- Department of Oncology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Shiying Kong
- Alberta Health Services, Department of Analytics, University of Calgary, Calgary, Canada
| | - Jennifer Puddy
- Department of Emergency Medicine, University of Calgary, Calgary, Canada
| | - May Lynn Quan
- Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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Balziano S, Greenstein N, Apterman S, Fogel I, Baran I, Prat D. Subtype consideration in hip fracture research: patient variances in inter- and intra-classification levels highlight the need for future research deliberation. A 2-years follow-up prospective-historical cohort. Arch Osteoporos 2023; 18:123. [PMID: 37770694 DOI: 10.1007/s11657-023-01334-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 09/25/2023] [Indexed: 09/30/2023]
Abstract
Current research on elderly patients with hip fractures often neglects specific subtypes, either grouping all fracture types or overlooking them entirely. By categorizing elderly patients based on fracture subtypes, we observed diverse baseline characteristics but found no discrepancies in measured outcomes. This emphasizes the need for caution in future research dealing with different or broader measured outcomes that were not covered by the scope of this research. PURPOSE/INTRODUCTION Existing research in elderly patients with hip fractures often overlooks the distinct subtypes or lumps all fracture types together. We aim to examine the differences between hip fracture subtypes to assess if these differences are meaningful for clinical outcomes and should be considered in future research. METHODS Patients above 65 years who underwent hip fracture surgeries during a three-year period were retrospectively reviewed. Cases were grouped based on fracture subtype: non-displaced femoral neck (nDFN), displaced femoral neck (DFN), stable intertrochanteric (sIT), and unstable intertrochanteric (uIT). RESULTS Among the 1,285 included cases, the nDFN-group had lower ASA scores (p = 0.009) and younger patients (p < 0.001), followed by the DFN-group (p = 0.014). The uIT-group had a higher proportion of female patients (72.3%, p = 0.004). Differences in preoperative ambulation status were observed (p = 0.001). However, no significant associations were found between fracture type and postoperative outcomes, including ambulation, transfusions, complications, reoperations, or mortality. Gender and preoperative ambulation status were predictors of mortality across all time frames. ASA score predicted mortality only within the first year after surgery. Age and gender were predictors of postoperative blood transfusions, while age and preoperative ambulation status were predictors of postoperative complications. CONCLUSIONS Variations in baseline characteristics of hip fractures were observed, but no significant differences were found in measured outcomes. This indicates that the hip fracture group is not homogeneous, emphasizing the need for caution in research involving this population. While grouping all types of proximal femur fractures may be acceptable depending on the outcome being studied, it's essential not to extrapolate these results to outcomes beyond the study's scope. Therefore, we recommend consider hip fracture subtypes when researching different outcomes not covered by this study.
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Affiliation(s)
- Snir Balziano
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel.
| | - Nechemia Greenstein
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Sagy Apterman
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Itay Fogel
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Isaac Baran
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
| | - Dan Prat
- Department of Orthopedic Surgery, Chaim Sheba Medical Center, Tel Aviv University, Ramat Gan, Israel
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22
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Dhodapkar MM, Gouzoulis MJ, Halperin SJ, Modrak M, Yoo BJ, Grauer JN. Urgent Care Versus Emergency Department Utilization for Foot and Ankle Fractures. J Am Acad Orthop Surg 2023; 31:984-989. [PMID: 37253245 DOI: 10.5435/jaaos-d-22-01097] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Accepted: 03/22/2023] [Indexed: 06/01/2023] Open
Abstract
INTRODUCTION Foot and ankle fractures are common injuries for which patients may need urgent evaluation and care. Many such injuries are managed in emergency departments (EDs), but urgent care facilities may sometimes be an appropriate setting. Understanding which foot and ankle fractures are managed at which facility might help define care algorithms, improve patient experience, and suggest directions for containing costs. METHODS This retrospective cohort study used the 2010 to 2020 M151 PearlDiver administrative database. Adult patients less than 65 years old presenting to EDs and urgent care facilities for foot and ankle fractures were identified using ICD-9 and ICD-10 diagnosis codes, excluding polytrauma, and Medicare patients. Patient/injury variables associated with urgent care utilization relative to ED utilization and utilization trends of urgent care relative to ED were assessed with univariable and multivariable analyses. RESULTS From 2010 to 2020, 1,120,422 patients with isolated foot and ankle fractures presented to EDs and urgent care facilities. Urgent care visits evolved from 2.2% in 2010 to 4.4% in 2020 (P , 0.0001). Independent predictors of urgent care relative to ED utilization were defined. In decreasing odds ratios (ORs), these were insurance (relative to Medicaid, commercial OR 8.03), geographic region (relative to Midwest, Northeast OR 3.55, South OR 1.74, West OR 1.06), anatomic location of fracture (relative to ankle, forefoot OR 3.45, midfoot 2.20, hindfoot 1.63), closed fracture (OR 2.20), female sex (OR 1.29), lower ECI (OR 1.11 per unit decrease), and younger age (OR 1.08 per decade decrease) (P , 0.0001 for all). DISCUSSION A small but increasing minority of patients with foot and ankle fractures are managed in urgent care facilities relative to EDs. While patients with certain injury types were associated with increased odds of urgent care relative to ED utilization, the greatest predictors were nonclinical, such as geographic regions and insurance type, suggesting areas for optimizing access to certain care pathways. LEVEL OF EVIDENCE III.
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Affiliation(s)
- Meera M Dhodapkar
- From the Yale Department of Orthopaedics and Rehabilitation, New Haven, CT
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23
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Pourat N, Lu C, Chen X, Zhou W, Hair B, Bolton J, Hoang H, Sripipatana A. Factors associated with frequent emergency department visits among health centre patients receiving primary care. J Eval Clin Pract 2023; 29:964-975. [PMID: 36788435 DOI: 10.1111/jep.13818] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2022] [Revised: 01/23/2023] [Accepted: 01/29/2023] [Indexed: 02/16/2023]
Abstract
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.
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Affiliation(s)
- Nadereh Pourat
- UCLA Center for Health Policy Research, Los Angeles, California, USA
- UCLA Fielding School of Public Health, Department of Health Policy and Management, Los Angeles, California, USA
| | - Connie Lu
- UCLA Center for Health Policy Research, Los Angeles, California, USA
| | - Xiao Chen
- UCLA Center for Health Policy Research, Los Angeles, California, USA
| | - Weihao Zhou
- UCLA Center for Health Policy Research, Los Angeles, California, USA
| | - Brionna Hair
- U.S. Department of Health and Human Services, Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, Rockville, Maryland, USA
| | - Joshua Bolton
- U.S. Department of Health and Human Services, Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, Rockville, Maryland, USA
| | - Hank Hoang
- U.S. Department of Health and Human Services, Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, Rockville, Maryland, USA
| | - Alek Sripipatana
- U.S. Department of Health and Human Services, Office of Quality Improvement, Bureau of Primary Health Care, Health Resources and Services Administration, Rockville, Maryland, USA
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24
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DeMass R, Gupta D, Self S, Thomas D, Rudisill C. Emergency department use and geospatial variation in social determinants of health: a pilot study from South Carolina. BMC Public Health 2023; 23:1527. [PMID: 37563566 PMCID: PMC10416539 DOI: 10.1186/s12889-023-16136-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 06/16/2023] [Indexed: 08/12/2023] Open
Abstract
BACKGROUND Health systems are increasingly addressing patients' social determinants of health (SDoH)-related needs and investigating their effects on health resource use. SDoH needs vary geographically; however, little is known about how this geographic variation in SDoH needs impacts the relationship between SDoH needs and health resource use. METHODS This study uses data from a SDoH survey administered to a pilot patient population in a single health system and the electronic medical records of the surveyed patients to determine if the impact of SDoH needs on emergency department use varies geospatially at the US Census block group level. A Bayesian zero-inflated negative binomial model was used to determine if emergency department visits after SDoH screening varied across block groups. Additionally, the relationships between the number of emergency department visits and the response to each SDoH screening question was assessed using Bayesian negative binomial hurdle models with spatially varying coefficients following a conditional autoregressive (CAR) model at the census block group level. RESULTS Statistically important differences in emergency department visits after screening were found between block groups. Statistically important spatial variation was found in the association between patient responses to the questions concerning unhealthy home environments (e.g. mold, bugs/rodents, not enough air conditioning/heat) or domestic violence/abuse and the mean number of emergency department visits after the screen. CONCLUSIONS Notable spatial variation was found in the relationships between screening positive for unhealthy home environments or domestic violence/abuse and emergency department use. Despite the limitation of a relatively small sample size, sensitivity analyses suggest spatially varying relationships between other SDoH-related needs and emergency department use.
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Affiliation(s)
- Reid DeMass
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 915 Greene St., Columbia, SC, 29208, USA
| | - Deeksha Gupta
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, Columbia, SC, 29208, USA
| | - Stella Self
- Department of Epidemiology and Biostatistics, Arnold School of Public Health, University of South Carolina, 300 E. McBee Ave. Greenville, Columbia, SC, 29601, USA.
| | - Darin Thomas
- Addiction Medicine Center, Prisma Health, 605 Grove Road Greenville, Columbia, SC, 29605, USA
| | - Caroline Rudisill
- Department of Health Promotion, Education and Behavior, Arnold School of Public Health, University of South Carolina, 300 E. McBee Ave. Greenville, Columbia, SC, 29601, USA
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25
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Tian Y, Osgood ND, Stempien J, Onaemo V, Danyliw A, Fast G, Osman BA, Reynolds J, Basran J. The impact of alternate level of care on access block and operational strategies to reduce emergency wait times: a multi-center simulation study. CAN J EMERG MED 2023; 25:608-616. [PMID: 37261614 DOI: 10.1007/s43678-023-00514-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Accepted: 04/22/2023] [Indexed: 06/02/2023]
Abstract
OBJECTIVES Lengthy emergency department (ED) wait times caused by hospital access block is a growing concern for the Canadian health care system. Our objective was to quantify the impact of alternate-level-of-care on hospital access block and evaluate the likely effects of multiple interventions on ED wait times. METHODS Discrete-event simulation models were developed to simulate patient flows in EDs and acute care of six Canadian hospitals. The model was populated with administrative data from multiple sources (April 2017-March 2018). We simulated and assessed six different intervention scenarios' impact on three outcome measures: (1) time waiting for physician initial assessment, (2) time waiting for inpatient bed, and (3) patients who leave without being seen. We compared each scenario's outcome measures to the baseline scenario for each ED. RESULTS Eliminating 30% of medical inpatients' alternate-level-of-care days reduced the mean time waiting for inpatient bed by 0.25 to 4.22 h. Increasing ED physician coverage reduced the mean time waiting for physician initial assessment (∆ 0.16-0.46 h). High-quality care transitions targeting medical patients lowered the mean time waiting for inpatient bed for all EDs (∆ 0.34-6.85 h). Reducing ED visits for family practice sensitive conditions or improving continuity of care resulted in clinically negligible reductions in wait times and patients who leave without being seen rates. CONCLUSIONS A moderate reduction in alternate-level-of-care hospital days for medical patients could alleviate access block and reduce ED wait times, although the magnitude of reduction varies by site. Increasing ED physician staffing and aligning physician capacity with inflow demand could also decrease wait time. Operational strategies for reducing ED wait times should prioritize resolving output and throughput factors rather than input factors.
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Affiliation(s)
- Yuan Tian
- Department of Computer Science, University of Saskatchewan, Saskatoon, SK, Canada.
| | - Nathaniel D Osgood
- Department of Computer Science, University of Saskatchewan, Saskatoon, SK, Canada
| | - James Stempien
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
- Saskatchewan Health Authority, Saskatoon, SK, Canada
| | - Vivian Onaemo
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
| | | | - Graham Fast
- Saskatchewan Health Authority, Saskatoon, SK, Canada
| | | | - Janet Reynolds
- Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Jenny Basran
- College of Medicine, University of Saskatchewan, Saskatoon, SK, Canada
- Saskatchewan Health Authority, Saskatoon, SK, Canada
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Wang N, Chen J. Decreasing Racial Disparities in Preventable Emergency Department Visits Through Hospital Health Information Technology Patient Engagement Functionalities. Telemed J E Health 2023; 29:841-850. [PMID: 36374942 PMCID: PMC10277978 DOI: 10.1089/tmj.2022.0199] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2022] [Revised: 09/17/2022] [Accepted: 10/04/2022] [Indexed: 11/15/2022] Open
Abstract
Introduction: Hospitals are a major source of care for underserved populations in the United States. However, little is known about how hospital-based health information technology (HIT) can improve the efficiency of care and reduce disparities. Objective: We examined the variation of preventable emergency department (ED) visits and associated racial disparities by hospital adoption of HIT patient engagement (HIT-PE) functionalities. Methods: This was an observational study of 6,543,514 non-Hispanic Black (Black) and non-Hispanic White (White) adult patients using 2019 datasets of seven states (Arizona, Florida, Kentucky, Maryland, North Carolina, Vermont, Wisconsin) from the State Emergency Department Databases, American Hospital Association Annual Survey & Information Technology Supplement, and Area Health Resources File. Results: High HIT-PE adoption was associated with lower rates of preventable ED (odds ratio [OR] = 0.992, p < 0.001). Specific HIT-PE functions such as importing medical records from other organizations into the patient portal (OR = 0.977, p < 0.001), electronically sending medical information to a third party (OR = 0.970, p < 0.001), and scheduling appointments online (OR = 0.987, p < 0.001) were also associated with reduced preventable ED rates. Black patients had higher rates of preventable ED compared with Whites (OR = 1.386, p < 0.001); however, the interaction of Black patients and high HIT-PE adoption was associated with lower rates of preventable ED (OR = 0.977, p < 0.001). Our results also showed that higher HIT-PE adoption was associated with a reduction in preventable ED visits among Black patients with comorbidities and Black patients living in low-income areas. Conclusions: The results of our study suggest that there is potential to reduce preventable ED rates and racial disparities through hospital-based HIT-PE functionalities.
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Affiliation(s)
- Nianyang Wang
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Maryland, USA
| | - Jie Chen
- Department of Health Policy and Management, University of Maryland School of Public Health, College Park, Maryland, USA
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27
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Currier J, Wallace N, Bigler K, O'Connor M, Farris P, Shannon J. Community paramedicine in Central Oregon: A promising model to reduce non-urgent emergency department utilization among medically complex Medicaid beneficiaries. J Am Coll Emerg Physicians Open 2023; 4:e12988. [PMID: 37313452 PMCID: PMC10258641 DOI: 10.1002/emp2.12988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2022] [Revised: 05/04/2023] [Accepted: 05/19/2023] [Indexed: 06/15/2023] Open
Abstract
Background Community paramedicine has emerged as a promising model to redirect persons with nonmedically emergent conditions to more appropriate and less expensive community-based health care settings. Outreach through community paramedicine to patients with a history of high hospital emergency department (ED) use and chronic health conditions has been found to reduce ED use. This study examined the effect of community paramedicine implemented in 2 rural counties in reducing nonemergent ED use among a sample of Medicaid beneficiaries with complex medical conditions and a history of high ED utilization. Methods A cluster randomized trial approach with a stepped wedge design was used to test the effect of the community paramedicine intervention. ED utilization for non-urgent care was measured by emergency medicine ED visits and avoidable ED visits. Results The community paramedicine intervention reduced ED utilization among a sample of 102 medically complex Medicaid beneficiaries with a history of high ED utilization. In the unadjusted models, emergency medical ED visits decreased by 13.9% (incidence rate ratio [IRR], 0.86; 95% confidence interval [CI], 0.76-0.98) or 6.1 visits saved for every 100 people. Avoidable emergency department visits decreased by 38.9% (IRR, 0.61; 95% CI, 0.44-0.84) or 2.3 visits saved for every 100 people. Conclusion Our results suggest community paramedicine is a promising model to achieve a reduction in ED utilization among medically complex patients by managing complex health conditions in a home-based setting.
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Affiliation(s)
- Jessica Currier
- Oregon Health & Science UniversityKnight Cancer InstituteBendOregonUSA
| | - Neal Wallace
- Oregon Health & Science University‐Portland State University School of Public HealthBendOregonUSA
| | | | | | - Paige Farris
- Oregon Health & Science UniversityKnight Cancer InstituteBendOregonUSA
| | - Jackilen Shannon
- Oregon Health & Science UniversityKnight Cancer InstituteBendOregonUSA
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Currie J, Karpova A, Zeltzer D. Do urgent care centers reduce Medicare spending? JOURNAL OF HEALTH ECONOMICS 2023; 89:102753. [PMID: 37011520 PMCID: PMC10122710 DOI: 10.1016/j.jhealeco.2023.102753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/02/2021] [Revised: 01/30/2023] [Accepted: 03/19/2023] [Indexed: 05/03/2023]
Abstract
We ask how urgent care centers (UCCs) impact healthcare costs and utilization among nearby Medicare beneficiaries. When residents of a zip code are first served by a UCC, total Medicare spending rises while mortality remains flat. In the sixth year after entry, 4.2% of the Medicare beneficiaries in a zip code that is served use a UCC, and the average per-capita annual Medicare spending in the zip code increases by $268, implying an incremental spending increase of $6,335 for each new UCC user. UCC entry is also associated with a significant increase in hospital stays and increased hospital spending accounts for half of the total increase in annual spending. These results raise the possibility that, on balance, UCCs increase costs by steering patients to hospitals.
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Affiliation(s)
- Janet Currie
- Princeton Center for Health and Wellbeing, Princeton, New Jersey, United States of America; National Bureau of Economic Research, Cambridge, Massachusetts, United States of America.
| | - Anastasia Karpova
- Princeton University, Princeton, New Jersey, United States of America.
| | - Dan Zeltzer
- Princeton Center for Health and Wellbeing, Princeton, New Jersey, United States of America; School of Economics, Tel Aviv University, POBox 39040, Tel Aviv, 69978, Israel.
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Kula R, Popela S, Klučka J, Charwátová D, Djakow J, Štourač P. Modern Paediatric Emergency Department: Potential Improvements in Light of New Evidence. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10040741. [PMID: 37189990 DOI: 10.3390/children10040741] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 04/12/2023] [Accepted: 04/13/2023] [Indexed: 05/17/2023]
Abstract
The increasing attendance of paediatric emergency departments has become a serious health issue. To reduce an elevated burden of medical errors, inevitably caused by a high level of stress exerted on emergency physicians, we propose potential areas for improvement in regular paediatric emergency departments. In an effort to guarantee the demanded quality of care to all incoming patients, the workflow in paediatric emergency departments should be sufficiently optimised. The key component remains to implement one of the validated paediatric triage systems upon the patient's arrival at the emergency department and fast-tracking patients with a low level of risk according to the triage system. To ensure the patient's safety, emergency physicians should follow issued guidelines. Cognitive aids, such as well-designed checklists, posters or flow charts, generally improve physicians' adherence to guidelines and should be available in every paediatric emergency department. To sharpen diagnostic accuracy, the use of ultrasound in a paediatric emergency department, according to ultrasound protocols, should be targeted to answer specific clinical questions. Combining all mentioned improvements might reduce the number of errors linked to overcrowding. The review serves not only as a blueprint for modernising paediatric emergency departments but also as a bin of useful literature which can be suitable in the paediatric emergency field.
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Affiliation(s)
- Roman Kula
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Physiology, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Stanislav Popela
- Emergency Department, University Hospital Olomouc and Faculty of Medicine, Palacký University, I.P. Pavlova 185/6, 779 00 Olomouc, Czech Republic
- Emergency Medical Service of the South Moravian Region, Kamenice 798, 625 00 Brno, Czech Republic
| | - Jozef Klučka
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
| | - Daniela Charwátová
- Department of Surgery, Vyškov Hospital, Purkyňova 235/36, 682 01 Vyškov, Czech Republic
| | - Jana Djakow
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Paediatric Intensive Care Unit, NH Hospital Inc., 268 01 Hořovice, Czech Republic
| | - Petr Štourač
- Department of Paediatric Anaesthesiology and Intensive Care Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
- Department of Simulation Medicine, Faculty of Medicine, Masaryk University, Kamenice 5, 625 00 Brno, Czech Republic
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Gottlieb M, Schipfer R, Shah S, McKinney D, Casey P, Stein B, Thompson D. Cross-sectional analysis of avoidable emergency department visits before and during the COVID-19 pandemic. Am J Emerg Med 2023; 66:111-117. [PMID: 36738569 PMCID: PMC9883066 DOI: 10.1016/j.ajem.2023.01.044] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 12/27/2022] [Accepted: 01/24/2023] [Indexed: 01/30/2023] Open
Abstract
BACKGROUND COVID-19 had a significant impact on Emergency Departments (ED) with early data suggesting an initial decline in avoidable ED visits. However, the sustained impact over time is unclear. In this study, we analyzed ED discharges over a two-year time period after the COVID-19 pandemic began and compared it with a control time period pre-pandemic to evaluate the difference in ED visit categories, including total, avoidable, and unavoidable visits. METHODS This was a retrospective, cross-sectional study assessing the distribution of visits with ED discharges from two hospitals within a health system over a three-year time period (1/1/2019-12/31/2021). Visits were categorized using the expanded NYU-EDA algorithm modified to include COVID-19-related visits. Categories included: Emergent - Not Preventable/Avoidable, Emergent - Preventable/Avoidable, Emergent - Primary Care Treatable, Non-Emergent, Mental Health, Alcohol, Substance Abuse, Injury, and COVID-19. Chi-square testing was conducted to investigate differences within the time period before COVID-19 (1/1/2019-12/31/2019) and both initial (1/1/2020-12/31/2020) and delayed (1/1/2021-12/31/2021) COVID-19 time frames and ED visit categories, as well as post hoc testing using Fisher's exact tests with Bonferroni correction. ANOVA with post hoc Bonferroni testing was used to determine differences based on daily census for each ED visit category. RESULTS A total of 228,010 ED discharges (Hospital #1 = 126,858; Hospital #2 = 101,152) met our inclusion criteria over the three-year period. There was a significant difference in the distribution of NYU-EDA categories between the two time periods (pre-COVID-19 versus during COVID-19) for the combined hospitals (p < 0.001), Hospital #1 (p < 0.001), and Hospital #2 (p < 0.001). When examining daily ED discharges, there was a decline in all categories from 2019 to 2020 except for "Emergent - Not Preventable/Avoidable" which remained stable and "Substance Abuse" which increased. From 2020 to 2021, there were no differences in ED avoidable visits. However, there were increases in discharged visits related to "Injuries", "Alcohol", and "Mental health" and a decrease in "COVID-19". CONCLUSION Our study identified a sustained decline in discharged avoidable ED visits during the two years following the beginning of the COVID-19 pandemic, which was partially offset by the increase in COVID-19 visits. This work can help inform ED and healthcare systems in resource allocation, hospital staffing, and financial planning during future COVID-19 resurgences and pandemics.
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Affiliation(s)
- Michael Gottlieb
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America.
| | - Ryan Schipfer
- Center for Quality, Safety, and Value Analytics, Rush University Medical Center, Chicago, IL, United States of America
| | - Shital Shah
- Department of Health Systems Management, Rush University, Chicago, IL, United States of America
| | - Dennis McKinney
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Paul Casey
- Department of Emergency Medicine, Rush University Medical Center, Chicago, IL, United States of America
| | - Brian Stein
- Department of Internal Medicine, Division of Pulmonary, Critical Care and Sleep Medicine, Rush University Medical Center, Chicago, IL, United States of America
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Mayhew M, Denton A, Kenney A, Fairclough J, Ojha A, Bhoite P, Hey MT, Seetharamaiah R, Shaffiey S, Schneider GW. Social deprivation, the Area Deprivation Index, and emergency department utilization within a community-based primary and preventive care program at a Florida medical school. J Public Health (Oxf) 2023. [DOI: 10.1007/s10389-023-01871-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/28/2023] Open
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Shimony-Kanat S, Gofin R, Nator N, Solt I, Abu Ahmad W, Liebergall Wischnitzer M, Lawen H, Kopitman A, Crassac V, Kerem E. Mothers' Knowledge of Infants' Fever Management: A National Prospective Study. Matern Child Health J 2023; 27:815-823. [PMID: 36869983 DOI: 10.1007/s10995-023-03593-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/18/2023] [Indexed: 03/05/2023]
Abstract
OBJECTIVES The aim of this study was to describe mothers' knowledge of infant fever management after birth and six months later and its association with sociodemographic characteristics, perceived support, sources of consultation and health education; and to assess determinants of change in mother's knowledge from birth to six months. METHODS Mothers (n = 2804) answered a self-reporting questionnaire after giving birth in maternity wards in six hospitals in Israel; six months later follow- up interviews were conducted by telephone. RESULTS The mothers' knowledge level of infant fever management was low after birth (mean = 50.5, range 0-100, SD = 16.1), and rose to a moderate level six months later (mean = 65.2, SD = 15.0). Mothers having their first born, with lower household income or education were less knowledgeable about infant fever management after birth. However, these mothers showed the largest improvement after six months. Mothers' perceived support or sources of consultation and health education (partner, family, friends, nurses, and physicians) were not associated with their knowledge at either time. Moreover, mothers stated self-learning from internet and other media as often as receiving health education by health professionals. CONCLUSIONS FOR PRACTICE Public health policy for health professionals in hospitals and community clinics is essential to promote clinical interventions promoting mothers' knowledge of infant fever management. Efforts should focus at first time mothers, those with non-academic education, and those with a moderate or low household income. Public health policy enhancing communication with mothers regarding fever management in hospitals and community health settings, as well as accessible means of self-learning is warranted.
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Affiliation(s)
- Sarit Shimony-Kanat
- Faculty of Medicine, Hadassah Hebrew University School of Nursing, POB 12000, 91120, Jerusalem, Israel.
| | - Rosa Gofin
- School of Public Health and Community Medicine Hadassah, Hebrew University, in the Faculty of Medicine, Jerusalem, Israel
| | - Nidaa Nator
- Faculty of Medicine, Hadassah Hebrew University School of Nursing, POB 12000, 91120, Jerusalem, Israel
| | - Ido Solt
- Rambam Medical Center, Haifa, Israel
| | - Wiessam Abu Ahmad
- School of Public Health and Community Medicine Hadassah, Hebrew University, in the Faculty of Medicine, Jerusalem, Israel
| | | | - Heba Lawen
- Faculty of Medicine, Hadassah Hebrew University School of Nursing, POB 12000, 91120, Jerusalem, Israel
| | | | | | - Eitan Kerem
- Department of Pediatrics, Hadassah Hebrew University Medical Center, Jerusalem, Israel
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Gynaecological pathologies leading to emergency department admissions: A cross-sectional study. Eur J Obstet Gynecol Reprod Biol 2023; 282:38-42. [PMID: 36630817 DOI: 10.1016/j.ejogrb.2023.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Revised: 12/03/2022] [Accepted: 01/05/2023] [Indexed: 01/09/2023]
Abstract
OBJECTIVE Knowing the population's needs in order to plan measures to reduce emergency department (ED) use is fundamental. The objective of this study was to describe gynaecological ED visits and associated findings in women of reproductive age. METHODS This study was a retrospective anonymized chart review analysis of visits to the ED for gynaecological disturbances at the University Hospital of Modena. All consecutive women of reproductive age were included. Women aged <18 years and postmenopausal women were excluded from this study. RESULTS In total, 461 records were analysed. The median age was 41 (interquartile range 34-46) years. The most common symptom was dysmenorrhoea (42.7 %), followed by heavy menstrual bleeding (33.2 %). The most common gynaecological findings in the ED were adenomyosis (86.1 %), endometriosis (37.1 %) and leiomyomas (13.7 %). Adenomyosis was the most common finding, regardless of age. Endometriosis was more prevalent in women aged <41 years (43.8 % vs 31.2 %; p < 0.05). Meanwhile, adenomyosis and leiomyomas were more prevalent in women aged ≥41 years (81.11 % vs 90.57 % and 7.37 % vs 19.26 %, respectively; p < 0.05). Moreover, potentially life-threatening findings had low prevalence [i.e. haemorrhagic ovarian cyst (0.2 %), tubo-ovarian abscess (0.2 %) and pelvic inflammatory disease (0.4 %)]. CONCLUSION In the study setting, chronic pathologies such as adenomyosis, endometriosis and leiomyomas significantly impacted use of the ED. Adenomyosis was the most common pathology, regardless of age. Adenomyosis and leiomyomas were more prevalent in women aged ≥41 years, and endometriosis was more prevalent in women aged <41 years.
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Sommers-Olson B, Christianson J, Neumann T, Pawlikowski SA, Morgan SL, Bouchard MC, Esch KS, Andrews LK. Reducing Nonemergent Visits to the Emergency Department in a Veterans Affairs Multistate System. J Emerg Nurs 2023:S0099-1767(23)00039-9. [PMID: 36977620 DOI: 10.1016/j.jen.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 01/11/2023] [Accepted: 02/13/2023] [Indexed: 03/29/2023]
Abstract
STUDY OBJECTIVE The purpose of this quality improvement study was to reduce nonemergent visits to the emergency department attendance within a multistate Veterans Health Affairs network. METHODS Telephone triage protocols were developed and implemented for registered nurse staff to triage selected calls to a same-day telephonic or video virtual visit with a provider (physician or nurse practitioner). Calls, registered nurse triage dispositions, and provider visit dispositions were tracked for 3 months. RESULTS There were 1606 calls referred by registered nurses for provider visits. Of these, 192 were initially triaged as emergency department dispositions. Of these, 57.3% of calls that would have been referred to the emergency department were resolved via the virtual visit. Thirty-eight percent fewer calls were referred to the emergency department following licensed independent provider visit compared to the registered nurse triage. CONCLUSION Telephone triage services augmented by virtual provider visits may reduce emergency department disposition rates, resulting in fewer nonemergent patient presentations to the emergency department and reducing unnecessary emergency department overcrowding. Reducing nonemergent attendance to emergency departments can improve outcomes for patients with emergent dispositions.
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Mojtahedi Z, Guo Y, Kim P, Khawari P, Ephrem H, Shen JJ. Mental Health Conditions- and Substance Use-Associated Emergency Department Visits during the COVID-19 Pandemic in Nevada, USA. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:4389. [PMID: 36901398 PMCID: PMC10001596 DOI: 10.3390/ijerph20054389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2022] [Revised: 02/21/2023] [Accepted: 02/22/2023] [Indexed: 06/18/2023]
Abstract
Background-Mental health conditions and substance use are linked. During the COVID-19 pandemic, mental health conditions and substance use increased, while emergency department (ED) visits decreased in the U.S. There is limited information regarding how the pandemic has affected ED visits for patients with mental health conditions and substance use. Objectives-This study examined the changes in ED visits associated with more common and serious mental health conditions (suicidal ideation, suicide attempts, and schizophrenia) and more commonly used substances (opioids, cannabis, alcohol, and cigarettes) in Nevada during the COVID-19 pandemic in 2020 and 2021 compared with the pre-pandemic period. Methods-The Nevada State ED database from 2018 to 2021 was used (n = 4,185,416 ED visits). The 10th Revision of the International Classification of Diseases identified suicidal ideation, suicide attempts, schizophrenia, and the use of opioids, cannabis, alcohol, and cigarette smoking. Seven multivariable logistic regression models were developed for each of the conditions after adjusting for age, gender, race/ethnicity, and payer source. The reference year was set as 2018. Results-During both of the pandemic years (2020 and 2021), particularly in 2020, the odds of ED visits associated with suicidal ideation, suicide attempts, schizophrenia, cigarette smoking, and alcohol use were all significantly higher than those in 2018. Conclusions-Our findings indicate the impact of the pandemic on mental health- and substance use-associated ED visits and provide empirical evidence for policymakers to direct and develop decisive public health initiatives aimed at addressing mental health and substance use-associated health service utilization, especially during the early stages of large-scale public health emergencies, such as the COVID-19 pandemic.
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Affiliation(s)
- Zahra Mojtahedi
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV 89154, USA
| | - Ying Guo
- Department of Environmental and Occupational Health, School of Public Health, University of Nevada, Las Vegas, NV 89154, USA
| | - Pearl Kim
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV 89154, USA
| | - Parsa Khawari
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV 89154, USA
| | - Hailey Ephrem
- School of Medicine, University of Nevada, Las Vegas, NV 89154, USA
| | - Jay J. Shen
- Department of Healthcare Administration and Policy, School of Public Health, University of Nevada, Las Vegas, NV 89154, USA
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Lippi Bruni M, Ugolini C, Verzulli R, Leucci AC. The impact of Community Health Centers on inappropriate use of emergency services. HEALTH ECONOMICS 2023; 32:375-394. [PMID: 36317315 DOI: 10.1002/hec.4625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Revised: 08/25/2022] [Accepted: 10/17/2022] [Indexed: 06/16/2023]
Abstract
Community Health Centers offer coordinated and comprehensive responses to primary care needs. Our study aims at assessing whether the introduction of such organizational model improved health outcomes measured by inappropriate emergency visits among diabetics in the Emilia-Romagna region of Italy. Using difference-in-differences methods within a staggered treatment setting, we estimate the effect of Community Health Center participation on inappropriate hospital emergency visits between year 2010 and year 2016. We distinguish between emergency department admissions for varying time spans, occurring at daytime during working days, at night-time, as well as during weekends. We show that, the causal effect of the adoption of the community care model leads to a reduction in the probability of inappropriate admissions by an amount ranging between 1.6 and 1.7% points during working days at daytime, with large facilities responsible for most gains by experiencing a decrease ranging between 4 and 3% points. Conversely, we detect no difference at night-time and during weekends. Our results point out that the coordinated care model increases appropriateness among vulnerable patients, and that extending opening hours and the range of services can further enhance such benefits.
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Affiliation(s)
- Matteo Lippi Bruni
- Department of Economics, CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Bologna, Italy
| | - Cristina Ugolini
- Department of Economics, CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Bologna, Italy
| | - Rossella Verzulli
- Department of Economics, CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Bologna, Italy
| | - Anna Caterina Leucci
- CRIFSP-School of Advanced Studies in Health Policy, University of Bologna, Bologna, Italy
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Association between acute care collaborations and health care utilization as compared to stand-alone facilities in the Netherlands: a quasi-experimental study. Eur J Emerg Med 2023; 30:15-20. [PMID: 35989654 PMCID: PMC9770117 DOI: 10.1097/mej.0000000000000969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Health systems invest in coordination and collaboration between emergency departments (ED) and after-hours primary care providers (AHPCs) to alleviate pressure on the acute care chain. There are substantial gaps in the existing evidence, limited in sample size, follow-up care, and costs. We assess whether acute care collaborations (ACCs) are associated with decreased ED utilization, hospital admission rates, and lower costs per patient journey, compared with stand-alone facilities. The design is a quasi-experimental study using claims data. The study included 610 845 patients in the Netherlands (2017). Patient visits in ACCs were compared to stand-alone EDs and AHPCs. The number of comorbidities was similar in both groups. Multiple logistic and gamma regressions were used to determine whether patient visits to ACCs were negatively associated with ED utilization, hospital admission rates, and costs. Logistic regression analysis did not find an association between patients visiting ACCs and ED utilization compared to patients visiting stand-alone facilities [odds ratio (OR), 1.01; 95% confidence interval (CI), 1.00-1.03]. However, patients in ACCs were associated with an increase in hospital admissions (OR, 1.07; 95% CI, 1.04-1.09). ACCs were associated with higher total costs incurred during the patient journey (OR, 1.02; 95% CI, 1.01-1.03). Collaboration between EDs and AHPCs was not associated with ED utilization, but was associated with increased hospital admission rates, and higher costs. These collaborations do not seem to improve health systems' financial sustainability.
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Adams U, Buckio J, Schreiber E, Cook A, Charles A. Same-Day Surgery Clinic: A model for improving access to care at academic medical centers. Am J Surg 2023; 225:374-377. [PMID: 36075762 DOI: 10.1016/j.amjsurg.2022.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Revised: 08/11/2022] [Accepted: 08/19/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Best-practice models delivering surgical care in the preoperative setting are unknown. In April 2018, we established a Same-Day Clinic (SDC) to increase the access and efficiency of general surgical care delivery. METHODS This is a single-institution retrospective cohort study. We included patients who underwent elective laparoscopic cholecystectomy, inguinal or umbilical hernia repair. 112 patients were seen in the year prior to clinic creation; 84 were seen in the year following clinic creation. RESULTS After clinic creation, the percentage of patients referred following an emergency department encounter decreased from 33.4 to 17.9%. Patients referred from primary care encounters increased from 28.6 to 44%. Patients who underwent pre-referral imaging decreased from 58.9% to 44%. The SDC cohort was seen 11 days sooner (40 vs. 29d). CONCLUSION The SDC increases access and decreases wait times to surgical treatment. It strengthens referral networks for traditionally underserved populations and reduces the burden of non-necessary preoperative imaging.
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Affiliation(s)
- Ursula Adams
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA
| | - Joellen Buckio
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA
| | - Elizabeth Schreiber
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA
| | - Audrey Cook
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA
| | - Anthony Charles
- Department of Surgery University of North Carolina, 101 Manning Drive Chapel Hill, NC, 27514, USA.
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North F, Garrison GM, Jensen TB, Pecina J, Stroebel R. Hospitalization Risk Associated With Emergency Department Reasons for Visit and Patient Age: A Retrospective Evaluation of National Emergency Department Survey Data to Help Identify Potentially Avoidable Emergency Department Visits. Health Serv Res Manag Epidemiol 2023; 10:23333928231214169. [PMID: 38023369 PMCID: PMC10664417 DOI: 10.1177/23333928231214169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/30/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Background Patients often present to emergency departments (EDs) with concerns that do not require emergency care. Self-triage and other interventions may help some patients decide whether they should be seen in the ED. Symptoms associated with low risk of hospitalization can be identified in national ED data and can inform the design of interventions to reduce avoidable ED visits. Methods We used the National Hospital Ambulatory Medical Care Survey (NHAMCS) data from the United States National Health Care Statistics (NHCS) division of the Centers for Disease Control and Prevention (CDC). The ED datasets from 2011 through 2020 were combined. Primary reasons for ED visit and the binary field for hospital admission from the ED were used to estimate the proportion of ED patients admitted to the hospital for each reason for visit and age category. Results There were 221,027 surveyed ED visits during the 10-year data collection with 736 different primary reasons for visit and 23,228 hospitalizations. There were 145 million estimated hospitalizations from 1.37 billion estimated ED visits (10.6%). Inclusion criteria for this study were reasons for visit which had at least 30 ED visits in the sample; there were 396 separate reasons for visit which met this criteria. Of these 396 reasons for visit, 97 had admission percentages less than 2% and another 52 had hospital admissions estimated between 2% and 4%. However, there was a significant increase in hospitalizations within many of the ED reasons for visit in older adults. Conclusion Reasons for visit from national ED data can be ranked by hospitalization risk. Low-risk symptoms may help healthcare institutions identify potentially avoidable ED visits. Healthcare systems can use this information to help manage potentially avoidable ED visits with interventions designed to apply to their patient population and healthcare access.
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Affiliation(s)
- Frederick North
- Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
| | | | - Teresa B Jensen
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Jennifer Pecina
- Department of Family Medicine, Mayo Clinic, Rochester, MN, USA
| | - Robert Stroebel
- Community Internal Medicine, Geriatrics, and Palliative Care, Mayo Clinic, Rochester, MN, USA
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Kleber KT, Kravitz-Wirtz N, Buggs SL, Adams CM, Sardo AC, Hoch JS, Brown IE. Emergency department visit patterns in the recently discharged, violently injured patient: Retrospective cohort review. Am J Surg 2023; 225:162-167. [PMID: 35871849 DOI: 10.1016/j.amjsurg.2022.07.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 06/21/2022] [Accepted: 07/14/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND Analysis of the costs associated with emergency department (ED) visits after discharge for violent injury could highlight subgroups for the development of cost-effective interventions to support healing and prevent treatment failures in violently injured patients. METHODS A retrospective cohort review was conducted of all patients with return ED visits within 90 days of discharge after treatment for a violent injury occurring between July 1, 2016, and June 30, 2018. Hospital costs were calculated for each incidence and analyzed against demographic and injury type variables to identify trends. RESULTS 218 return ED visits were identified. Hospital costs showed a high frequency of low-cost visits. For more complex visits, distinct cost patterns were observed for Black and LatinX males compared to White males as a function of age. CONCLUSIONS Analysis of hospital cost per visit identified trends among different subgroups. Underlying etiologies presumably vary between groups, but hypothesis-driven further investigation and needs assessment is required. Understanding the driving forces behind these cost trends may aid in developing effective interventions.
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Affiliation(s)
- Kara T Kleber
- Department of Surgery, University of California Davis School of Medicine, 235 Stockton Blvd, Sacramento, CA, 95817, USA.
| | - Nicole Kravitz-Wirtz
- Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, 2315 Stockton Blvd, Sacramento, CA, 95817, USA.
| | - Shani L Buggs
- Violence Prevention Research Program, Department of Emergency Medicine, University of California Davis School of Medicine, 2315 Stockton Blvd, Sacramento, CA, 95817, USA.
| | - Christy M Adams
- Trauma Prevention Program, UC Davis Health, University of California Davis, 4900 Broadway, Suite 1650, Sacramento, CA, 95820, USA.
| | - Angela C Sardo
- University of California Davis School of Medicine, 4610 X St, Sacramento, CA, 95817, USA.
| | - Jeffrey S Hoch
- Division of Health Policy and Management, Department of Public Health Sciences and Center for Healthcare Policy and Research, University of California Davis, 4900 Broadway, Suite 1430, Sacramento, CA, 95820, USA.
| | - Ian E Brown
- Division of Trauma, Acute Care Surgery, and Surgical Critical Care, Department of Surgery University of California Davis Medical Center, 2335 Stockton Blvd, Sacramento, CA, 95817, USA.
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Redirecting Nonurgent Patients From the Pediatric Emergency Department to Their Pediatrician Office for a Same-Day Visit-A Quality Improvement Initiative. Pediatr Emerg Care 2022; 38:692-696. [PMID: 36318627 DOI: 10.1097/pec.0000000000002879] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
OBJECTIVES Providing high-quality care in the appropriate setting to optimize value is a worthy goal of an efficient health system. Consequences of managing nonurgent complaints in the emergency department (ED) have been described including inefficiency, loss of the primary care-patient relationship, and delayed care for other ED patients. The purpose of this initiative was to redirect nonurgent patients arriving in the ED to their primary care office for a same-day visit, and the SMART AIM was to increase redirected patients from 0% of those eligible to 30% in a 12-month period. METHODS The setting was a pediatric ED (PED) and primary care office of a tertiary care pediatric medical system. The initiative utilized the electronic health record to identify and mediate the redirection of patients to the patient's primary care office after ED triage. The primary measurement was the percentage of eligible patients redirected. Additional measures included health benefits during the primary care visit (vaccines, well-visits) and a balancing measure of patients returned to the PED. RESULTS The SMART AIM of >30% redirection was achieved and sustained with a final redirection rate of 46%. In total, 216 of 518 eligible patients were redirected, with zero untoward outcomes. The encounter time for redirected patients was similar for those who remained in the PED, and additional health benefits were appreciated for redirected patients. CONCLUSIONS This initiative redirected nonurgent patients efficiently from a PED setting to their primary care office. The process is beneficial to patients and families and supports the patient-centered medical home. The balancing measure of no harm done to patients who accepted redirect reinforced the reliability of PED triage. The benefits achieved through the project highlight the value of the primary care-patient relationship and the continued need to improve access for patients and families.
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Osmanlliu E, Burstein B, Tamblyn R, Buckeridge DL. Assessing the potential for virtualizable care in the pediatric emergency department. J Telemed Telecare 2022:1357633X221133415. [PMID: 36408736 DOI: 10.1177/1357633x221133415] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024]
Abstract
INTRODUCTION There is increasing interest for patient-to-provider telemedicine in pediatric acute care. The suitability of telemedicine (virtualizability) for visits in this setting has not been formally assessed. We estimated the proportion of in-person pediatric emergency department (PED) visits that were potentially virtualizable, and identified factors associated with virtualizable care. METHODS This was a retrospective analysis of in-person visits at the PED of a Canadian tertiary pediatric hospital (02/2018-12/2019). Three definitions of virtualizable care were developed: (1) a definition based on "resource use" classifying visits as virtualizable if they resulted in a home discharge, no diagnostic testing, and no return visit within 72 h; (2) a "diagnostic definition" based on primary ED diagnosis; and (3) a stringent "combined definition" by which visits were classified as virtualizable if they met both the resource use and diagnostic definitions. Multivariable logistic regression was used to identify factors associated with telemedicine suitability. RESULTS There were 130,535 eligible visits from 80,727 individual patients during the study period. Using the most stringent combined definition of telemedicine suitability, 37.9% (95% confidence interval (CI) 37.6%-38.2%) of in-person visits were virtualizable. Overnight visits (adjusted odds ratio (aOR) 1.16-1.37), non-Canadian citizenship (aOR 1.10-1.18), ethnocultural vulnerability (aOR 1.14-1.22), and a consultation for head trauma (aOR 3.50-4.60) were associated with higher telemedicine suitability across definitions. DISCUSSION There is a high potential for patient-to-provider telemedicine in the PED setting. Local patient and visit-level characteristics must be considered in the design of safe and inclusive telemedicine models for pediatric acute care.
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Affiliation(s)
- Esli Osmanlliu
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- Pediatric Emergency Medicine Division, 12367McGill University Health Center, McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
| | - Brett Burstein
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- Pediatric Emergency Medicine Division, 12367McGill University Health Center, McGill University, Montréal, Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
| | - David L Buckeridge
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine and Health Sciences, 10040McGill University, Montréal, Canada
- 507266McGill Clinical & Health Informatics (MCHI) Research Group, McGill University, Montréal, Canada
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Sampietro-Colom L, Fernandez-Barcelo C, Abbas I, Valdasquin B, Rabasseda N, García-Lorenzo B, Sanchez M, Sans M, Garcia N, Granados A. WtsWrng Interim Comparative Effectiveness Evaluation and Description of the Challenges to Develop, Assess, and Introduce This Novel Digital Application in a Traditional Health System. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2022; 19:13873. [PMID: 36360756 PMCID: PMC9654177 DOI: 10.3390/ijerph192113873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 10/21/2022] [Accepted: 10/22/2022] [Indexed: 06/16/2023]
Abstract
Science and technology have evolved quickly during the two decades of the 21st century, but healthcare systems are grounded in last century's structure and processes. Changes in the way health care is provided are demanded; digital transformation is a key driver making healthcare systems more accessible, agile, efficient, and citizen-centered. Nevertheless, the way healthcare systems function challenges the development (Innovation + Development and regulatory requirements), assessment (methodological guidance weaknesses), and adoption of digital applications (DAs). WtsWrng (WW), an innovative DA which uses images to interact with citizens for symptom triage and monitoring, is used as an example to show the challenges faced in its development and clinical validation and how these are being overcome. To prove WW's value from inception, novel approaches for evidence generation that allows for an agile and patient-centered development have been applied. Early scientific advice from NICE (UK) was sought for study design, an iterative development and interim analysis was performed, and different statistical parameters (Kappa, B statistic) were explored to face development and assessment challenges. WW triage accuracy at cutoff time ranged from 0.62 to 0.94 for the most frequent symptoms attending the Emergency Department (ED), with the observed concordance for the 12 most frequent diagnostics at hospital discharge fluctuating between 0.4 to 0.97; 8 of the diagnostics had a concordance greater than 0.8. This experience should provoke reflective thinking for DA developers, digital health scientists, regulators, health technology assessors, and payers.
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Affiliation(s)
- Laura Sampietro-Colom
- Assessment of Innovations and New Technologies Unit, Research and Innovation Directorate, Clínic Barcelona University Hospital, 08036 Barcelona, Spain
- Mangrana Ventures S.L., 08006 Barcelona, Spain
| | - Carla Fernandez-Barcelo
- Assessment of Innovations and New Technologies Unit, Research and Innovation Directorate, Clínic Barcelona University Hospital, 08036 Barcelona, Spain
| | - Ismail Abbas
- Assessment of Innovations and New Technologies Unit, Research and Innovation Directorate, Clínic Barcelona University Hospital, 08036 Barcelona, Spain
| | - Blanca Valdasquin
- Assessment of Innovations and New Technologies Unit, Research and Innovation Directorate, Clínic Barcelona University Hospital, 08036 Barcelona, Spain
| | | | - Borja García-Lorenzo
- Assessment of Innovations and New Technologies Unit, Research and Innovation Directorate, Clínic Barcelona University Hospital, 08036 Barcelona, Spain
- Kronikgune Institute for Health Sciences Research, 48902 Barakaldo, Spain
| | - Miquel Sanchez
- Emergency Department, Clínic Barcelona University Hospital, 08036 Barcelona, Spain
| | - Mireia Sans
- CAP Comte Borrell, Consorci Atenció Primaria Salut Barcelona Esquerra—CAPSBE, 08029 Barcelona, Spain
- Health 2.0 Section of the Col·Legi Oficial de Metges de Barcelona, 08017 Barcelona, Spain
| | - Noemi Garcia
- CAP Comte Borrell, Consorci Atenció Primaria Salut Barcelona Esquerra—CAPSBE, 08029 Barcelona, Spain
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Carlson LC, Pu CT, Mark E, Gao Y, Nussbaum L, Vogeli C. Applying embedded program evaluation for care delivery transformation: An analysis of a home‐based urgent care program. Health Sci Rep 2022; 5:e643. [PMID: 36051625 PMCID: PMC9412970 DOI: 10.1002/hsr2.643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 04/09/2022] [Accepted: 04/13/2022] [Indexed: 11/10/2022] Open
Abstract
Background In 2014, Mass General Brigham, formerly Partners HealthCare, launched a novel urgent home‐based medical care program to provide rapid medical evaluation and treatment to homebound patients and older adults with frailty or limited mobility named the partners mobile observation unit (PMOU) program. Methods We conducted a pragmatic, embedded evaluation assessing the impact of PMOU on postreferral utilization and total medical expenditure (TME). We used propensity weighting and logistic regression to estimate the 30‐day adjusted odds ratios (ORs) of emergency department (ED) utilization and inpatient medical hospitalization for patients enrolled in PMOU (891 episodes of care) relative to those who were referred but not enrolled in the program (57 episodes of care) during the period of April 2017 to June 2018. We additionally conducted a difference‐in‐differences analysis assessing program impact on TME, comparing claims data 30 days pre/post referral. Results Despite positive trends, there were no statistically significant differences between the two groups with regard to postreferral ED visits or hospitalizations, with an OR of 0.83 (p = 0.56) and OR of 0.64 (p = 0.21), respectively. There was no statistically significant difference in pre/post referral TME for intervention relative to control episodes (p = 0.64). In post hoc analysis of control episodes, 75% received care elsewhere within 14 days of referral. Conclusion Although the results suggested positive trends, this analysis of this relatively mature program was unable to identify statistically significant reductions in ED visits, hospitalizations, or TME associated with the PMOU program. Future efforts to build home‐based urgent care programs or related programs targeting older adults with frailty or limited mobility should aim to improve patient targeting and identify opportunities to improve program operations and generate meaningful reductions in healthcare utilization and spending.
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Affiliation(s)
- Lucas C. Carlson
- Population Health Management, Mass General Brigham Boston Massachusetts USA
- Department of Emergency Medicine Brigham and Women's Hospital Boston Massachusetts USA
| | - Charles T. Pu
- Population Health Management, Mass General Brigham Boston Massachusetts USA
- Department of Medicine Division of Palliative Care and Geriatric Medicine, Massachusetts General Hospital Boston Massachusetts USA
| | - Eden Mark
- Population Health Management, Mass General Brigham Boston Massachusetts USA
| | - Ya Gao
- Population Health Management, Mass General Brigham Boston Massachusetts USA
| | - Lisa Nussbaum
- Population Health Management, Mass General Brigham Boston Massachusetts USA
| | - Christine Vogeli
- Population Health Management, Mass General Brigham Boston Massachusetts USA
- The Mongan Institute, Massachusetts General Hospital Boston Massachusetts USA
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Shetty PN, Guarino GM, Zhang G, Sanghavi KK, Giladi AM. Risk Factors for Preventable Emergency Department Use After Outpatient Hand Surgery. J Hand Surg Am 2022; 47:855-864. [PMID: 35843760 DOI: 10.1016/j.jhsa.2022.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2021] [Revised: 03/30/2022] [Accepted: 05/18/2022] [Indexed: 02/02/2023]
Abstract
PURPOSE Emergency department (ED) visits for postoperative concerns that could be safely addressed in outpatient clinics have an impact on cost, quality measures, and care workflows. Patient-reported data (PRD) may give unique insights into individual-level factors that predict overuse of health care resources, and guide opportunities for intervention and prevention. We investigated the relationship between preoperative PRD and preventable ED use after outpatient hand surgery to determine whether the preoperative PRD can be used to identify patients at higher odds of having preventable ED visits. METHODS All adult patients undergoing outpatient surgery at our hand center between January 1, 2018, and December 31, 2019, were included. Questionnaires, including the Patient-Reported Outcomes Measurement Information System (PROMIS) upper extremity (UE) and pain interference (PI) scales, were completed before surgery. We used our regional health information exchange to identify ED visits within 90 days of surgery. RESULTS Our cohort included 2,819 patients. Within 90 days after surgery, 106 (3.8%) had preventable ED visits. Race, insurance status, and transportation issues increased odds of a preventable ED visit. Multivariable models found that each 1-point increase in the preoperative PROMIS UE score was associated with 4% decreased odds of ED presentation (odds ratio, 0.96; 95% confidence interval, 0.94-0.99), and each 1-point increase in the preoperative PROMIS PI score was associated with 4% increased odds of ED presentation (odds ratio, 1.04; 95% confidence interval, 1.0-1.1). Any PROMIS UE or PI scores ≥1SDs worse than population norms increased the probability of a preventable ED visit, independent of other factors. CONCLUSIONS Worse preoperative PROMIS UE and PI scores were associated with increased odds of preventable ED visits. Preoperative PRD may allow for identification of outliers at higher risk for preventable ED use, and facilitate preventative interventions. TYPE OF STUDY/LEVEL OF EVIDENCE Prognostic IV.
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Affiliation(s)
- Pragna N Shetty
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Gianna M Guarino
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD
| | - Gongliang Zhang
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Health Research Institute, Hyattsville, MD
| | - Kavya K Sanghavi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD; MedStar Health Research Institute, Hyattsville, MD
| | - Aviram M Giladi
- The Curtis National Hand Center, MedStar Union Memorial Hospital, Baltimore, MD.
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Melnick G, O'Leary JF, Zaniello BA, Abrishamian L. COVID-19 driven decline in emergency visits: Has it continued, is it permanent, and what does it mean for emergency physicians? Am J Emerg Med 2022; 61:64-67. [PMID: 36057210 PMCID: PMC9387065 DOI: 10.1016/j.ajem.2022.08.031] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 08/08/2022] [Accepted: 08/14/2022] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Hospital-based emergency departments have been a sustained source of overall hospital utilization in the United States. In 2019, an estimated 150 million hospital-based emergency department (ED) visits occurred in the United States, up from 90 million in 1993, 108 million in 2000 and 137 million in 2015. This study analyzes hospital ED visit registration data pre and post to the COVID-19 pandemic describe the impact of on hospital ED utilization and to assess long-term implications of COVID and other factors on the utilization of hospital-based emergency services. METHODS We analyze real-time hospital ED visit registration data from a large sample of US hospitals to document changes in ED visits from January 2020 through March 2022 relative to 2019 (pre-COVID baseline) to describe the impact of the COVID-19 pandemic on EDs and assess long-term implications. RESULTS Our data show an initial steep reduction in ED visits during the first half of 2020 (compared to 2019 levels) with rebounding occurring in 2021, but never reaching pre-pandemic levels. Overall, ED visit volumes across the study states declined in each year since 2019: 2020 declined by -18%, 2021 by -10% and the first quarter of 2022 is -12% below 2019 levels. CONCLUSIONS There is a wide range of potential long-term implications of the observed reduction in the demand for hospital-based emergency services not only for emergency physicians, but for hospitals, health plans and consumers.
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Affiliation(s)
- Glenn Melnick
- Center for Health Financing, Policy and Management, Price School of Public Policy, University of Southern California, Los Angeles, CA, USA.
| | - June F O'Leary
- Center for Health Financing, Policy and Management, Price School of Public Policy, University of Southern California, Los Angeles, CA, USA
| | | | - Luis Abrishamian
- Emergency Department, Providence Little Company of Mary Medical Center, Torrance, CA, USA
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Virji AZ, Cheloff AZ, Ghoshal S, Nagle B, Guo TZ, Lev MH, Raja AS, Gee MS, Succi MD. Analysis of self-initiated visits for cervical trauma at urgent care centers and subsequent emergency department referral. Clin Imaging 2022; 91:14-18. [PMID: 35973271 DOI: 10.1016/j.clinimag.2022.08.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/20/2022] [Accepted: 08/08/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Following trauma involving the cervical spine (c-spine), patients often seek care at urgent care centers (UCCs) or emergency departments (EDs). PURPOSE The purpose was to assess whether UCCs could effectively image acute self-selected c-spine trauma without referral to the ED as well as to estimate costs differences between UCC and ED imaging assessment. MATERIALS AND METHODS This retrospective study identified patients receiving c-spine imaging at UCCs affiliated with a large academic hospital system from 5/1/-8/31/2021. Patients receiving c-spine X-rays with an indication of trauma following low acuity injury, at UCCs were compared to patients receiving any c-spine imaging in the main campus ED. Medical record numbers were cross-referenced to identify patients receiving imaging at both a UCC and ED within 24 h and within 7 days. Work relative value units (wRVUs) for each UCC and ED imaging type were calculated. For the hypothetical scenario of patients presenting to the ED in the absence of UCC, patients were assumed to receive c-spine computed tomography (CT) without contrast per "usually appropriate" designation by the American College of Radiology Appropriateness Criteria®. RESULTS Among 143 self-selected, low acuity, patients who received c-spine X-rays at UCCs with an indication of trauma, one required referral to the ED within 24 h and two required referrals to the ED within 7 days. During the 4-month study period, 105.94 wRVUs ($3696.25) were saved by performing a c-spine X-ray in an UCC instead of a CT in the ED, extrapolated to 317.82 wRVUs ($11,088.74) per year. Using the average total costs of an UCC visit versus an ED visit, a total $145,976 was estimated to be saved during the study period or $437,928 per year. CONCLUSION Offering access for patient-initiated visits at UCCs for low-acuity c-spine trauma may help reduce the need for an ED visit, reducing imaging and healthcare visit costs. SUMMARY STATEMENT Urgent Care Centers (UCCs) reduced the need for an Emergency Department (ED) referral visit in nearly 100% of self-selected, low acuity, patients with cervical trauma. KEY RESULTS
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Affiliation(s)
- Azan Z Virji
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Abraham Z Cheloff
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Soham Ghoshal
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Baily Nagle
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Teddy Z Guo
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Michael H Lev
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Ali S Raja
- Harvard Medical School, Boston, MA, United States; Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Michael S Gee
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States
| | - Marc D Succi
- Harvard Medical School, Boston, MA, United States; Department of Radiology, Massachusetts General Hospital, Boston, MA, United States; Medically Engineered Solutions in Healthcare Incubator, Innovation in Operations Research Center (MESH IO), Massachusetts General Hospital, Boston, MA, United States.
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Cost effects of nurse led triage at an emergency department with the advice to consult the adjacent general practice cooperative for low-risk patients, a cluster randomised trial. Health Policy 2022; 126:980-987. [DOI: 10.1016/j.healthpol.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 06/20/2022] [Accepted: 08/02/2022] [Indexed: 11/19/2022]
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Types of usual sources of care and their association with healthcare outcomes among cancer survivors: a Medical Expenditure Panel Survey (MEPS) study. J Cancer Surviv 2022; 17:748-758. [PMID: 35687273 PMCID: PMC10016387 DOI: 10.1007/s11764-022-01221-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 05/21/2022] [Indexed: 10/18/2022]
Abstract
PURPOSE To assess associations between usual source of care (USC) type and health status, healthcare access, utilization, and expenses among adult cancer survivors. METHODS This retrospective cross-sectional analysis using 2013-2018 Medical Expenditure Panel Survey included 2690 observations representing 31,953,477 adult cancer survivors who were currently experiencing cancer and reporting one of five USC types: solo practicing physician (SPP), a specific person in a non-hospital facility, a specific person in a hospital-based facility, a non-hospital facility, and a hospital-based facility. We used logistic regressions and generalized linear models to determine associations of USC type with health status, healthcare access, utilization, and expenses, adjusting for patient demographic and clinical characteristics. RESULTS All non-SPP USC types were associated with reporting more difficulties contacting USC by telephone during business hours (p < 0.05). Compared to SPP, non-hospital facility was associated with more difficulty getting needed prescriptions (OR: 1.81, p = 0.036) and higher annual expenses ($5225, p = 0.028), and hospital-based facility was associated with longer travel time (OR: 1.61, p = 048), more ED visits (0.13, p = 0.049), higher expenses ($6028, p = 0.014), and worse self-reported health status (OR: 1.93, p = 0.001), although both were more likely to open on nights/weekends (p < 0.05). Cancer survivors with a specific person in a hospital-based facility (vs. SPP) as USC were > twofold as likely (p < 0.05) to report difficulty getting needed prescriptions and contacting USC afterhours. CONCLUSIONS Among adult cancer survivors who were currently experiencing cancer, having a non-SPP type of UCS was associated with reporting more difficulties accessing care, worse health, more ED visits, and higher total expenses. IMPLICATIONS FOR CANCER SURVIVORS Transitioning to SPP type of USC may result in better healthcare outcomes.
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Chen AT, Muralidharan M, Friedman AB. Algorithms Identifying Low Acuity Emergency Department Visits: A Review and Validation Study. Health Serv Res 2022; 57:979-989. [PMID: 35619335 PMCID: PMC9264468 DOI: 10.1111/1475-6773.14011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVE To characterize and validate the landscape of algorithms that use International Classification of Disease (ICD) codes to identify low acuity emergency department (ED) visits. DATA SOURCES Publicly available ED data from the National Hospital Ambulatory Medical Care Survey (NHAMCS). STUDY DESIGN We systematically searched for studies that specify algorithms consisting of ICD codes that identify preventable or low acuity ED visits. We classified ED visits in NHAMCS according to these algorithms and compared agreement using the Jaccard index. We then evaluated the performance of each algorithm using positive predictive value (PPV) and sensitivity, with the reference group specified using low acuity composite (LAC) criteria consisting of both triage and clinical components. In sensitivity analyses, we repeated our primary analysis using only triage or only clinical criteria for reference. DATA COLLECTION We used 2011-2017 NHAMCS data, totaling 163,576 observations before survey weighting and after dropping observations missing a primary diagnosis. We translated ICD-9 codes (years 2011-2015) to ICD-10 using a standard crosswalk. PRINCIPAL FINDINGS We identified 15 papers with an original list of ICD codes used to identify preventable or low acuity ED presentations. These papers were published between 1992 and 2020, cited an average of 310 (SD 360) times, and included 968 (SD 1175) codes. Pairwise Jaccard similarity indices (0 = no overlap, 1 = perfect congruence) ranged from 0.01 to 0.82, with mean 0.20 (SD 0.13). When validated against the LAC reference group, the algorithms had an average PPV of 0.308 (95% CI [0.253, 0.364]) and sensitivity of 0.183 (95% CI [0.111, 0.256]). Overall, 2.1% of visits identified as low acuity by the algorithms died prehospital or in the ED, or needed surgery, critical care, or cardiac catheterization. CONCLUSIONS Existing algorithms that identify low acuity ED visits lack congruence and are imperfect predictors of visit acuity.
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Affiliation(s)
- Angela T Chen
- Health Care Management Department, The Wharton School, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.,Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Madhavi Muralidharan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Ari B Friedman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
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