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Hincapie MR, Corbera-Hincapie MA, Suresh S, Alston K, Butler G, Fabio A, Ray KN. Primary Care Enhanced Access Services and the Association With Nonurgent Pediatric Emergency Department Utilization and Child Opportunity Index. Pediatr Emerg Care 2024; 40:e209-e215. [PMID: 38718422 DOI: 10.1097/pec.0000000000003213] [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] [Indexed: 08/30/2024]
Abstract
OBJECTIVES This study aims to examine the association between primary care practice characteristics (enhanced access services) and practice-level rates of nonurgent emergency department (ED) visits using ED and practice-level data. Survey data suggest that enhanced access services within a child's primary care practice may be associated with reduced nonurgent ED visits. METHODS We performed a cross-sectional analysis of nonurgent ED visits to a tertiary pediatric hospital in Western Pennsylvania with nearly 85,000 annual ED visits. We obtained patient encounter data of all nonurgent pediatric ED (PED) visits between January 2018 and December 2019. We identified the primary care provider at the time of the study period. For each of the 42 included offices, we determined the number of unique children in the office with a nonurgent PED visit, allowing us to determine the percentage of children in the practice with such a visit during the study period. We then stratified the 42 offices into low, intermediate, and high tertiles of nonurgent PED use. Using Kruskal-Wallis tests, logistic regression, and Pearson χ 2 tests, we compared practice characteristics, enhanced access services, practice location Child Opportunity Index 2.0, and PED visit diagnoses across tertiles. RESULTS We examined 52,459 nonurgent PED encounters by 33,209 unique patients across 42 outpatient offices. Primary care practices in the lowest ED visit tertile were more likely to have 4 or more evenings with office hours (36% vs 14%, P = 0.04), 4 or more evenings of weekday extended hours (43% vs 14%, P = 0.05), and at least 1 day of any weekend hours (86% vs 29%, P = 0.01), compared with practices in other tertiles. High PED use tertile offices were also associated with lower Child Opportunity Index scores. CONCLUSIONS Primary care offices with higher nonurgent PED utilization had fewer enhanced access services and were located in neighborhood with fewer child-focused resources.
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Affiliation(s)
| | | | | | - Kaila Alston
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Gabriella Butler
- Department of Pediatrics, Division of Health Informatics, University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Anthony Fabio
- Department of Epidemiology, University of Pittsburgh School of Public Health, Pittsburgh, PA
| | - Kristin N Ray
- Department of Pediatrics, Division of General Academic Pediatrics, University of Pittsburgh, Pittsburgh, PA
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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; 40:668-673. [PMID: 38534003 DOI: 10.1097/pec.0000000000003195] [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] [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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Mahmood AUD, Adily P, Francis S, Eastwood J, Bein K, Chakar BA, Montgomery A. Understanding low acuity emergency department presentations in infancy: A cohort study. Emerg Med Australas 2024; 36:401-412. [PMID: 38239022 DOI: 10.1111/1742-6723.14364] [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: 05/22/2023] [Revised: 11/06/2023] [Accepted: 12/12/2023] [Indexed: 05/21/2024]
Abstract
OBJECTIVE Low acuity presentations (LAPs) contribute to large numbers of ED presentations and carry numerous consequences. The present study sought to improve the understanding of regional infant LAPs by analysing temporal patterns of presentation, discharge diagnoses and potential predictive factors. METHODS This retrospective observational study examined ED presentations among children less than 12 months old (infants) to the Royal Prince Alfred Hospital between 2017 and 2019. Descriptive statistics were used to identify temporal patterns of presentation and common discharge diagnoses among LAPs. Multivariable logistic regression was used to determine the association between early life, demographic and perinatal factors and low acuity presenters. RESULTS Of 6881 infant ED presentations, 19.8% were LAPs, occurring disproportionately on weekdays (82.2%) and during hours of 08.00-17.00 (69.9%). Respiratory tract infections and gastrointestinal complaints were most common overall, though non-allergic rash, feeding difficulties, eczema and developmental concerns contributed substantially among LAPs. Socio-economic status (SES) (odds ratio [OR] 1.71), overseas maternal nationality (OR 1.25) and Medicare ineligible maternal financial class (OR 0.49) were associated with low acuity presenters. Low appearance, pulse, grimace, activity and respiration score (OR 3.53), low SES (OR 3.26), complicated delivery (OR 1.64), maternal multiparity (OR 0.50), maternal partner presence (OR 0.40) and obstetric complications (OR 0.37) were associated with repeat, multi-low acuity presenters (multi-LAPs). CONCLUSION A substantial minority of infant ED presentations are LAPs. Targeted interventions may benefit from focusing on families with a background of socioeconomic disadvantage, social isolation, cultural and linguistic diversity and perinatal complications, with a view to strengthening engagement with community-based services among these groups.
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Affiliation(s)
- Areeb-Ud-Deen Mahmood
- Community Paediatrics, Sydney Local Health District, Sydney, New South Wales, Australia
- UNSW Faculty of Medicine and Health, Sydney, New South Wales, Australia
| | - Pejman Adily
- Community Paediatrics, Sydney Local Health District, Sydney, New South Wales, Australia
- Ingham Institute of Medical Research, Sydney, New South Wales, Australia
- Database Manager for The Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia
| | - Stephanie Francis
- Royal Prince Alfred Hospital, Emergency Department, Sydney, New South Wales, Australia
- UNSW School of Women's and Children's Health, Sydney, New South Wales, Australia
| | - John Eastwood
- Community Paediatrics, Sydney Local Health District, Sydney, New South Wales, Australia
- Southern District Health Board, South Island, New Zealand
| | - Kendall Bein
- Royal Prince Alfred Hospital, Emergency Department, Sydney, New South Wales, Australia
- RPA Greenlight Institute for Emergency Care, Sydney, New South Wales, Australia
| | - Bashir A Chakar
- Royal Prince Alfred Hospital, Emergency Department, Sydney, New South Wales, Australia
- RPA Greenlight Institute for Emergency Care, Sydney, New South Wales, Australia
| | - Alicia Montgomery
- Community Paediatrics, Sydney Local Health District, Sydney, New South Wales, Australia
- Database Manager for The Sydney Institute for Women, Children and their Families, Sydney Local Health District, Sydney, Australia
- RPA Greenlight Institute for Emergency Care, Sydney, New South Wales, Australia
- UNSW School of Psychiatry, Sydney, New South Wales, Australia
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Moon SH, Kim SO. Enhancing triage accuracy in emergency nurses: The impact of a game-based triage educational app. Int Emerg Nurs 2024; 72:101398. [PMID: 38198949 DOI: 10.1016/j.ienj.2023.101398] [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: 08/25/2023] [Revised: 11/05/2023] [Accepted: 11/28/2023] [Indexed: 01/12/2024]
Abstract
INTRODUCTION Digital technology has enabled gamification methods to enhance triage education, reflecting an evolving healthcare landscape. OBJECTIVE To evaluate the effectiveness of a Gamification Triage Education App (GTEA) as a learning tool for emergency nurses, with a focus on creating an engaging and educationally effective platform for triage training. METHOD The GTEA was developed using no-code based software and expanded upon previous iterations, with added features such as points, rankings, instant feedback, and quest-based stories. From December 2021 to March 2022, 27 emergency room nurses from three hospitals in Korea were instructed to use GTEA for 100 min over the course of a week. The effects were measured before and after the intervention. RESULTS The results demonstrated a significant increase in triage accuracy from 4.3 ± 2.00 to 5.33 ± 1.47 (t = -2.18, p = 0.039), along with a substantial reduction in overtriage (t = 3.11, p = 0.004). Additionally, increases in critical thinking disposition, triage competency, and triage knowledge were observed (t = -3.11, p = 0.004; t = -2.72, p = 0.011; t = -3.14, p = 0.004, respectively). CONCLUSIONS The findings provide robust evidence for the effectiveness of gamification in triage training within emergency nursing.
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Affiliation(s)
- Sun-Hee Moon
- College of Nursing, Chonnam National University, Gwangju, South Korea.
| | - Su Ol Kim
- Department of Nursing, Kwangju Women's University, Gwangju, South Korea.
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Abstract
OBJECTIVES To describe the demographic, clinical, outcome, and cost differences between children with high-frequency PICU admission and those without. DESIGN Retrospective, cross-sectional cohort study. SETTING United States. PATIENTS Children less than or equal to 18 years old admitted to PICUs participating in the Pediatric Health Information System database in 2018. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We assessed survivors of PICU admissions for repeat PICU admissions within a year of their index visit. Children with greater than or equal to 3 PICU admissions within a year were classified as high-frequency PICU utilization (HFPICU). We compared demographic, clinical, outcome, and cost characteristics between children with HFPICU and those with only an index or two admissions per year (nHFPICU). Of 95,465 children who survived an index admission, 5,880 (6.2%) met HFPICU criteria. HFPICU patients were more frequently younger, technology dependent, and publicly insured. HFPICU patients had longer lengths of stay and were more frequently discharged to a rehabilitation facility or with home nursing services. HFPICU patients accounted for 24.8% of annual hospital utilization costs among patients requiring PICU admission. Time to readmission for children with HFPICU was 58% sooner (95% CI, 56-59%) than in those with nHFPICU with two admissions using an accelerated failure time model. Among demographic and clinical factors that were associated with development of HFPICU status calculated from a multivariable analysis, the greatest effect size was for time to first readmission within 82 days. CONCLUSIONS Children identified as having HFPICU account for 6.2% of children surviving an index ICU admission. They are a high-risk patient population with increased medical resource utilization during index and subsequent ICU admissions. Patients readmitted within 82 days of discharge should be considered at higher risk of HFPICU status. Further research, including validation and exploration of interventions that may be of use in this patient population, are necessary.
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Affiliation(s)
- Julia A Heneghan
- Division of Pediatric Critical Care, Department of Pediatrics, University of Minnesota Masonic Children's Hospital, University of Minnesota, Minneapolis, MN
| | - Manzilat Akande
- Division of Pediatric Critical Care, Department of Pediatrics, Oklahoma University Health Sciences Center, Oklahoma City, OK
| | - Denise M Goodman
- Division of Pediatric Critical Care, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
| | - Sriram Ramgopal
- Division of Pediatric Emergency Medicine, Department of Pediatrics, Ann & Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, IL
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Cohen JS, Berkowitz D, Nosker L, Shaukat H, Kim D, Koutroulis I, Breslin KA. Patient and Visit Characteristics of Pediatric Patients With High-frequency Low-acuity Emergency Department Visits. Pediatr Emerg Care 2022; 38:e417-e421. [PMID: 33273428 DOI: 10.1097/pec.0000000000002312] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Pediatric patients account for a disproportionate number of low-acuity emergency department (ED) visits. The aim of this study is to describe pediatric patient and visit characteristics for high-frequency users for low-acuity visits. METHODS This was a retrospective cohort study of children presenting to a tertiary care pediatric ED and an affiliated community ED, over a 2-year period, with at least 10 low-acuity visits. Twenty patients with the highest number of visits were classified as "superusers." We analyzed patient data from the larger sample of high-frequency users and visit specific data from superuser visits. IBM SPSS Statistics 25 (SPSS Inc., Chicago, IL) was used to perform descriptive statistics and to summarize demographic and visit specific variables. RESULTS We identified 181 high-frequency users with a mean number of visits of 14.3 ± 4.3 and a subpopulation of 20 superusers accounting for 434 visits. The majority of high-frequency users (89%) identified as African American and had public insurance (96.1%). Many patients received primary care affiliated with the home institution. In the first year of the study, 50.3% of high-frequency users were infants younger than 1 year at the index visit and 47.4% of superusers were infants at the index visit.Superuser visits were evenly distributed among seasons and the majority of visits occurred during the weekdays (70.7%). The majority of visits were for medical complaints (86.6%) and almost half (47.6%) resulted in some testing (24.9%) or treatment (30.6%); however, only 1.4% resulted in hospital admission. CONCLUSIONS In our sample, most high-frequency low-acuity ED patients were infants, African American and have public insurance. Many are seen during clinic hours and are paneled at affiliated clinics. Among superusers, the majority of the visits did not require any testing, intervention, or treatment.
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Affiliation(s)
| | | | - Lois Nosker
- From the Division of Emergency Medicine, Children's National Health System
| | | | - Dana Kim
- From the Division of Emergency Medicine, Children's National Health System
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Chang L, Stewart AM, Monuteaux MC, Fleegler EW. Neighborhood Conditions and Recurrent Emergency Department Utilization by Children in the United States. J Pediatr 2021; 234:115-122.e1. [PMID: 33395566 DOI: 10.1016/j.jpeds.2020.12.071] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Revised: 12/18/2020] [Accepted: 12/29/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To determine the associations of social and physical neighborhood conditions with recurrent emergency department (ED) utilization by children in the US. STUDY DESIGN This cross-sectional study was conducted with the National Survey of Children's Health from 2016 to 2018 to determine the associations of neighborhood characteristics of cohesion, safety, amenities, and detractors with the proportions of children aged 1-17 years with recurrent ED utilization, defined as 2 or more ED visits during the past 12 months. A multivariable regression model was used to determine the independent association of each neighborhood characteristic with recurrent ED utilization controlling for individual-level characteristics. RESULTS In this study of 98 711 children weighted to a population of 70 million nationally, children had significantly greater rates of recurrent ED utilization if they lived in neighborhoods that were not cohesive, were not safe, or had detractors present (all P < .001). With adjustment for individual-level covariates and the other neighborhood characteristics, only neighborhood detractors were independently associated with recurrent ED utilization (1 detractor: aOR 1.32, 95% CI 1.03-1.68; 2 or 3 detractors: aOR 1.37, 95% CI 1.04-1.81). CONCLUSIONS Among neighborhood characteristics, the presence of physical detractors such as rundown housing and vandalism was most strongly associated with recurrent ED utilization by children. Negative attributes of the built environment may be a potential target for neighborhood-level, place-based interventions to alleviate disparities in child healthcare utilization.
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Affiliation(s)
- Lawrence Chang
- Department of Pediatrics, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA; Department of Pediatrics, Boston Medical Center, Boston, MA.
| | - Amanda M Stewart
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
| | - Eric W Fleegler
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA; Department of Pediatrics, Harvard Medical School, Boston, MA
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Ravi N, Gitz KM, Burton DR, Ray KN. Pediatric non-urgent emergency department visits and prior care-seeking at primary care. BMC Health Serv Res 2021; 21:466. [PMID: 34001093 PMCID: PMC8128083 DOI: 10.1186/s12913-021-06480-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Accepted: 05/06/2021] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND We aimed to examine how caregiver perceptions of primary care affects care-seeking prior to pediatric non-urgent ED visits. METHODS We performed a cross-sectional survey of caregivers of children presenting to a pediatric ED during weekday business hours and triaged as low acuity. We first compared caregiver sociodemographic characteristics, perceptions of primary care, and stated preference in care sites (ED vs PCP) for caregivers who had sought care from their child's PCP office versus had not sought care from their child's PCP office prior to their ED visit. We then examined odds of having sought care from their PCP office prior to their ED visit using multivariable logistic regression models sequentially including caregiver primary care perceptions and stated care site preferences along with caregiver sociodemographic characteristics. RESULTS Of 140 respondents, 64 (46%) sought care from their child's PCP office prior to presenting to the ED. In unadjusted analysis, children insured by Medicaid or CHIP, caregivers identifying as Black, and caregivers with lower educational attainment were less likely to have sought PCP care before presenting to the ED (p < 0.005, each). Caregivers who had sought PCP care were more likely to prefer their PCP relative to the ED in terms of ease of travel, cost, and wait times (p < 0.001, all). When including these stated preferences in a multivariable model, child insurance, caregiver race, and caregiver education were no longer significantly associated with odds of having sought PCP care prior to their ED visit. CONCLUSIONS Differential access to primary care may underlie observed demographic differences in non-urgent pediatric ED utilization.
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Affiliation(s)
- Nithin Ravi
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA.
| | - Katherine M Gitz
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA
- Children's Hospital of Los Angeles Medical Group, Los Angeles, USA
| | - Danielle R Burton
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Kristin N Ray
- UPMC Children's Hospital of Pittsburgh, 4401 Penn Avenue,AOB - Suite 5400, Pittsburgh, PA, 15224, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Ray KN, Yahner KA, Bey J, Martin KC, Planey AM, Culyba AJ, Miller E. Understanding Variation In Nonurgent Pediatric Emergency Department Use In Communities With Concentrated Disadvantage. Health Aff (Millwood) 2021; 40:156-164. [PMID: 33400581 DOI: 10.1377/hlthaff.2020.00675] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Children in communities with concentrated socioeconomic and structural disadvantage tend to have elevated rates of nonurgent visits to emergency departments (EDs). Using a spatial regression model of 264 census block groups in Pittsburgh, Pennsylvania, we investigated sociodemographic and structural factors associated with lower-than-expected ("low utilization") versus higher-than-expected ("high utilization") nonurgent ED visit rates among children in block groups with concentrated disadvantage. Compared with high-utilization block groups, low-utilization block groups had higher percentages of households with two adults, high school graduates, access to vehicles, sound housing quality, and owner-occupied housing. Notably, low-utilization block groups did not differ significantly from high-utilization block groups either in the percentage of households located within very close proximity to public transit or primary care or in children's health insurance coverage rates. Stakeholders wishing to reduce pediatric nonurgent ED visits among families in communities of concentrated disadvantage should consider strategies to mitigate financial, time, transportation, and health literacy constraints that may affect families' access to primary care.
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Affiliation(s)
- Kristin N Ray
- Kristin N. Ray is an associate professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh, in Pittsburgh, Pennsylvania
| | - Kristin A Yahner
- Kristin A. Yahner is the General Academic Pediatrics Division data center coordinator, Department of Pediatrics, University of Pittsburgh School of Medicine
| | - Jamil Bey
- Jamil Bey is the president and CEO of the UrbanKind Institute, in Pittsburgh, Pennsylvania
| | - Katherine C Martin
- Katherine C. Martin is a fourth-year medical student at the University of Pittsburgh School of Medicine
| | - Arrianna M Planey
- Arrianna M. Planey is an assistant professor in the Department of Health Policy and Management at the Gillings School of Global Public Health, University of North Carolina at Chapel Hill, in Chapel Hill, North Carolina
| | - Alison J Culyba
- Alison J. Culyba is an assistant professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh
| | - Elizabeth Miller
- Elizabeth Miller is a professor in the Department of Pediatrics, University of Pittsburgh School of Medicine and UPMC Children's Hospital of Pittsburgh
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Beyond Access Block: Understanding the Role of Health Literacy and Self-Efficacy in Low-Acuity Emergency Department Patients. Ochsner J 2020; 20:161-169. [PMID: 32612470 PMCID: PMC7310186 DOI: 10.31486/toj.19.0047] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Abstract
Background: Health literacy, self-efficacy, and patient satisfaction are factors associated with healthcare utilization. The relationships among these factors and their combined impact on patients’ self-rated health have historically been studied in chronic disease populations. This study assessed low-acuity emergency department (ED) patients’ ratings of these factors, the relationships among these factors, and their effect on re-presentation rates to the ED. Methods: In this single-arm cohort survey, patients provided demographic data, completed health literacy and self-efficacy assessments prior to being seen by a physician, and completed a discharge perceptions questionnaire that included a global satisfaction question at the time of departure. Three months later, patients answered a telephone survey to measure post-ED visit health outcomes. Results: Health literacy (r=0.114, P=0.023) and self-efficacy (r=0.469, P<0.001) were both independently and positively associated with self-rated health. Neither factor was associated with patient satisfaction. Self-rated health was negatively associated with return ED visits (r=–0.137, P=0.011). Conclusion: Existing research shows that health literacy has a linear association with self-efficacy and self-rated health. The results of this study suggest that in the context of low-acuity ED patients, health literacy and self-efficacy affect patients’ understanding of their health status (self-rated health) but do not lead to better utilization of healthcare resources. Improvement of health literacy and self-efficacy, specifically to increase self-rated health, may provide a future avenue of intervention to reduce low-acuity ED patient re-presentation.
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Chiu Y, Racine-Hemmings F, Dufour I, Vanasse A, Chouinard MC, Bisson M, Hudon C. Statistical tools used for analyses of frequent users of emergency department: a scoping review. BMJ Open 2019; 9:e027750. [PMID: 31129592 PMCID: PMC6537981 DOI: 10.1136/bmjopen-2018-027750] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVE Frequent users represent a small proportion of emergency department users, but they account for a disproportionately large number of visits. Their use of emergency departments is often considered suboptimal. It would be more efficient to identify and treat those patients earlier in their health problem trajectory. It is therefore essential to describe their characteristics and to predict their emergency department use. In order to do so, adequate statistical tools are needed. The objective of this study was to determine the statistical tools used in identifying variables associated with frequent use or predicting the risk of becoming a frequent user. METHODS We performed a scoping review following an established 5-stage methodological framework. We searched PubMed, Scopus and CINAHL databases in February 2019 using search strategies defined with the help of an information specialist. Out of 4534 potential abstracts, we selected 114 articles based on defined criteria and presented in a content analysis. RESULTS We identified four classes of statistical tools. Regression models were found to be the most common practice, followed by hypothesis testing. The logistic regression was found to be the most used statistical tool, followed by χ2 test and t-test of associations between variables. Other tools were marginally used. CONCLUSIONS This scoping review lists common statistical tools used for analysing frequent users in emergency departments. It highlights the fact that some are well established while others are much less so. More research is needed to apply appropriate techniques to health data or to diversify statistical point of views.
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Affiliation(s)
- Yohann Chiu
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - François Racine-Hemmings
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Isabelle Dufour
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Alain Vanasse
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | | | - Mathieu Bisson
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
| | - Catherine Hudon
- Department of Family Medicine and Emergency Medicine, Université de Sherbrooke, Sherbrooke, Quebec, Canada
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Cabey WV, Shea JA, Kangovi S, Kennedy D, Onwuzulike C, Fein J. Understanding Pediatric Caretakers' Views on Obtaining Medical Care for Low-acuity Illness. Acad Emerg Med 2018; 25:1004-1013. [PMID: 29741232 DOI: 10.1111/acem.13436] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2018] [Revised: 04/07/2018] [Accepted: 04/09/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND A significant proportion of low-acuity emergency department (ED) visits are by patients under 18 years of age. Results from prior interventions designed to reduce low-acuity pediatric ED use have been mixed or poorly sustained, perhaps because they were not informed by patient and caretakers' perspectives. The objective of this study was to explore caretaker decision-making processes, values, and priorities when deciding to seek care. METHODS We conducted semistructured interviews of caretakers in both emergency and primary care settings, incorporating stimulated recall methodology. We also explored receptiveness to two care delivery innovations: use of community health workers (CHWs) and video teleconferencing. RESULTS Interviews of 57 caretakers identified multiple barriers to accessing primary care for their children's acute illness, including transportation, work constraints, and childcare. Frequent ED users lacked reliable social supports to overcome barriers. Fear of unforeseen health outcomes and a lack of trust in unfamiliar providers also influenced decision-making, rather than lack of general knowledge about minor illness. Receptiveness to CHWs was mixed, reflecting concerns for privacy and level of expertise. The option of video teleconferencing for low-acuity care was well received by caretakers. CONCLUSIONS Caretakers who used the ED frequently had limited social support and reported difficulty accessing care when compared to other caretakers. Fear also motivated care seeking and a desire for immediate medical care. Teleconferencing for low-acuity visits may be a useful health care delivery tool to reduce access barriers and provide rapid reassurance without engaging the ED.
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Affiliation(s)
| | - Judy A. Shea
- Department of Medicine Division of General Internal Medicine Philadelphia PA
| | - Shreya Kangovi
- Department of Medicine Division of General Internal Medicine Philadelphia PA
| | | | | | - Joel Fein
- Department of Pediatrics Perelman School of Medicine The Children's Hospital of Philadelphia Philadelphia PA
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Riney LC, Brokamp C, Beck AF, Pomerantz WJ, Schwartz HP, Florin TA. Emergency Medical Services Utilization Is Associated With Community Deprivation in Children. PREHOSP EMERG CARE 2018; 23:225-232. [PMID: 30118621 DOI: 10.1080/10903127.2018.1501124] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pediatric emergency medical services (EMS) utilization is costly and resource intensive; significant variation exists across large-scale geographies. Less is known about variation at smaller geographic levels where factors including lack of transportation, low health literacy, and decreased access to medical homes may be more relevant. Our objective was to determine whether pediatric EMS utilization varied across Hamilton County, Ohio, census tracts and whether such utilization was associated with socioeconomic deprivation. METHODS This was a retrospective analysis of children living in Hamilton County, Ohio, transported by EMS to the Cincinnati Children's emergency department between July 1, 2014, and July 31, 2016. Participants' addresses were assigned to census tracts and an EMS utilization rate and deprivation index were calculated for each. Pearson's correlation coefficients evaluated relationships between tract-level EMS utilization and deprivation. Tract-level deprivation was used as a predictor in patient-level evaluations of acuity. RESULTS During the study period, there were 4,877 pediatric EMS transports from 219 of the 222 county census tracts. The county EMS utilization rate during the study period was 2.4 transports per 100 children (range 0.2-11). EMS utilization rates were positively correlated with increasing deprivation (r = 0.72, 95% confidence interval [CI], 0.65-0.77). Deprivation was associated with lower illness severity at triage, fewer transports resulting in resuscitation suite use, and fewer transports resulting in hospitalizations (all p < 0.05). CONCLUSIONS EMS utilization varied substantially across census tracts in Hamilton County, Ohio. A deeper understanding into why certain socioeconomically deprived areas contribute to disproportionately high rates of EMS utilization could support development of targeted interventions to improve use.
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Samuels-Kalow M, Peltz A, Rodean J, Hall M, Alpern ER, Aronson PL, Berry JG, Shaw KN, Morse RB, Freedman SB, Cohen E, Simon HK, Shah SS, Katsogridakis Y, Neuman MI. Predicting Low-Resource-Intensity Emergency Department Visits in Children. Acad Pediatr 2018; 18:297-304. [PMID: 29331346 DOI: 10.1016/j.acap.2017.12.012] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2017] [Revised: 12/15/2017] [Accepted: 12/30/2017] [Indexed: 12/23/2022]
Abstract
OBJECTIVES Interventions to reduce frequent emergency department (ED) use in children are often limited by the inability to predict future risk. We sought to develop a population-based model for predicting Medicaid-insured children at risk for high frequency (HF) of low-resource-intensity (LRI) ED visits. METHODS We conducted a retrospective cohort analysis of Medicaid-insured children (aged 1-18 years) included in the MarketScan Medicaid database with ≥1 ED visit in 2013. LRI visits were defined as ED encounters with no laboratory testing, imaging, procedures, or hospitalization; and HF as ≥3 LRI ED visits within 365 days of the initial encounter. A generalized linear regression model was derived and validated using a split-sample approach. Validity testing was conducted examining model performance using 3 alternative definitions of LRI. RESULTS Among 743,016 children with ≥1 ED visit in 2013, 5% experienced high-frequency LRI ED use, accounting for 21% of all LRI visits. Prior LRI ED use (2 visits: adjusted odds ratio = 3.5; 95% confidence interval, 3.3, 3.7; and ≥3 visits: adjusted odds ratio = 7.7; 95% confidence interval, 7.3, 8.1) and presence of ≥3 chronic conditions (adjusted odds ratio = 1.7; 95% confidence interval, 1.6, 1.8) were strongly associated with future HF-LRI ED use. A model incorporating patient characteristics and prior ED use predicted future HF-LRI ED utilization with an area under the curve of 0.74. CONCLUSIONS Demographic characteristics and patterns of prior ED use can predict future risk of HF-LRI ED use in the following year. Interventions for reducing low-value ED use in these high-risk children should be considered.
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Affiliation(s)
| | - Alon Peltz
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, Conn
| | | | | | - Elizabeth R Alpern
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Paul L Aronson
- Section of Pediatric Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Yale School of Medicine, New Haven, Conn
| | - Jay G Berry
- Division of General Pediatrics, Department of Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
| | - Kathy N Shaw
- Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, The Children's Hospital of Philadelphia, Philadelphia, Pa
| | - Rustin B Morse
- Children's Health System of Texas, Dallas, Tex; Department of Pediatrics, University of Texas Southwestern, Dallas, Tex
| | - Stephen B Freedman
- Sections of Pediatric Emergency Medicine and Gastroenterology, Department of Pediatrics, Alberta Children's Hospital, Alberta Children's Hospital Research Institute, Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harold K Simon
- Division of Emergency Medicine, Departments of Pediatrics and Emergency Medicine, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, Ga
| | - Samir S Shah
- Divisions of Hospital Medicine and Infectious Diseases, Department of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Department of Pediatrics, Ann and Robert H. Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Harvard Medical School, Boston, Mass
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15
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Peltz A, Samuels-Kalow ME, Rodean J, Hall M, Alpern ER, Aronson PL, Berry JG, Shaw KN, Morse RB, Freedman SB, Cohen E, Simon HK, Shah SS, Katsogridakis Y, Neuman MI. Characteristics of Children Enrolled in Medicaid With High-Frequency Emergency Department Use. Pediatrics 2017; 140:peds.2017-0962. [PMID: 28765381 PMCID: PMC5574719 DOI: 10.1542/peds.2017-0962] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/20/2017] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Some children repeatedly use the emergency department (ED) at high levels. Among Medicaid-insured children with high-frequency ED use in 1 year, we sought to describe the characteristics of children who sustain high-frequency ED use over the following 2 years. METHODS Retrospective longitudinal cohort study of 470 449 Medicaid-insured children appearing in the MarketScan Medicaid database, aged 1-16 years, with ≥1 ED discharges in 2012. Children with high ED use in 2012 (≥4 ED discharges) were followed through 2014 to identify characteristics associated with sustained high ED use (≥8 ED discharges in 2013-2014 combined). A generalized linear model was used to identify patient characteristics associated with sustained high ED use. RESULTS A total of 39 945 children (8.5%) experienced high ED use in 2012, accounting for 25% of total ED visits in 2012. Sixteen percent of these children experienced sustained high ED use in the following 2 years. Adolescents (adjusted odds ratio [aOR]: 1.4 [95% confidence interval: 1.3-1.5]), disabled children (aOR: 1.3 [95% confidence interval: 1.1-1.5]), and children with 3 or more chronic conditions (aOR: 2.1, [95% confidence interval: 1.9-2.3]) experienced the highest likelihood for sustaining high ED use. CONCLUSIONS One in 6 Medicaid-insured children with high ED use in a single year experienced sustained high levels of ED use over the next 2 years. Adolescents and individuals with multiple chronic conditions were most likely to have sustained high rates of ED use. Targeted interventions may be indicated to help reduce ED use among children at high risk.
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Affiliation(s)
- Alon Peltz
- Robert Wood Johnson Foundation Clinical Scholars Program and .,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | | | | | | | - Elizabeth R. Alpern
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Paul L. Aronson
- Section of Pediatric Emergency Medicine, Department of Pediatrics and of Emergency Medicine, Yale School of Medicine, New Haven, Connecticut
| | | | - Kathy N. Shaw
- Departments of Pediatrics and,Emergency Medicine, Perelman School of Medicine, University of Pennsylvania and Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
| | - Rustin B. Morse
- Children’s Health System of Texas, and Department of Pediatrics, University of Texas Southwestern, Dallas, Texas
| | - Stephen B. Freedman
- Sections of Pediatric Emergency Medicine and,Gastroenterology, Department of Pediatrics, Alberta Children’s Hospital, Alberta Children’s Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Eyal Cohen
- Division of Pediatric Medicine, Department of Pediatrics, The Hospital for Sick Children, University of Toronto, Toronto, Ontario, Canada
| | - Harold K. Simon
- Division of Emergency Medicine, Department of Pediatrics and Emergency Medicine, School of Medicine, Emory University and Children’s Healthcare of Atlanta, Atlanta, Georgia; and
| | - Samir S. Shah
- Divisions of Hospital Medicine and,Infectious Diseases, Department of Pediatrics, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio
| | - Yiannis Katsogridakis
- Division of Emergency Medicine, Ann and Robert H. Lurie Children’s Hospital of Chicago, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Mark I. Neuman
- Emergency Medicine, Department of Medicine, Boston Children’s Hospital, Harvard Medical School, Harvard University, Boston, Massachusetts
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