Characteristics of Frequent Geriatric Users of an Urban Emergency Department

Estimation of racial and language disparities in pediatric emergency department triage using statistical modeling and natural language processing

OBJECTIVES

The study aims to assess racial and language disparities in pediatric emergency department (ED) triage using analytical techniques and provide insights into the extent and nature of the disparities in the ED setting.

MATERIALS AND METHODS

The study analyzed a cross-sectional dataset encompassing ED visits from January 2019 to April 2021. The study utilized analytical techniques, including K-mean clustering (KNN), multivariate adaptive regression splines (MARS), and natural language processing (NLP) embedding. NLP embedding and KNN were employed to handle the chief complaints and categorize them into clusters, while the MARS was used to identify significant interactions among the clinical features. The study also explored important variables, including age-adjusted vital signs. Multiple logistic regression models with varying specifications were developed to assess the robustness of analysis results.

RESULTS

The study consistently found that non-White children, especially African American (AA) and Hispanic, were often under-triaged, with AA children having >2 times higher odds of receiving lower acuity scores compared to White children. While the results are generally consistent, incorporating relevant variables modified the results for specific patient groups (eg, Asians).

DISCUSSION

By employing a comprehensive analysis methodology, the study checked the robustness of the analysis results on racial and language disparities in pediatric ED triage. The study also recognized the significance of analytical techniques in assessing pediatric health conditions and analyzing disparities.

CONCLUSION

The study's findings highlight the significant need for equal and fair assessment and treatment in the pediatric ED, regardless of their patients' race and language.

Association of a telephone triage service for emergency patients with better outcome: a population-based study in Osaka City, Japan

OBJECTIVE

Telephone triage service in emergency care has been introduced in many countries, and it is important to determine the effect of telephone triage service on the outcome of emergency patients. The aim of this study was to evaluate the effect of telephone triage service on the outcome of emergency patients using propensity score.

METHODS DESIGN, SETTINGS, AND PARTICIPANTS

This was a retrospective study with a study period from January 2016 to December 2019. We included all patients transported by ambulances of the Osaka Municipal Fire Department during study period.

EXPOSURE

Telephone triage service.

OUTCOME MEASURES AND ANALYSIS

The main outcome of this study was unfavorable outcome following use of the telephone triage service. In this study, unfavorable outcome was defined as patients who were admitted, transferred, or died after care in the emergency department. Propensity scores were calculated using a logistic regression model with 12 variables that were present before the telephone triage service was used or were indicative of the patient's condition. Data analyses were not only propensity score matching but also a multivariable logistic regression model and regression model with propensity score as a covariate.

MAIN RESULTS

The number of patients eligible for analyses was 707 474. Of these patients, 8008 (1.0%) used the telephone triage services and 699 466 patients (99.0%) did not use it. The number of patients with an unfavorable outcome was 407 568 (57.6%) in the total cohort. Of them, 2305 patients (28.8%) used the telephone triage service and 297 601 patients (42.5%) did not use it. For propensity score matching, 8008 patients were matched from each group. Use of the telephone triage service was inversely associated with unfavorable outcome in a multivariate logistic regression model with propensity score as a covariate [adjusted odds ratio (OR) 0.874; 95% confidence interval (CI), 0.831-0.919] and propensity score matching (crude OR, 0.875; 95% CI, 0.818-0.936).

CONCLUSIONS

This study revealed that the use of the telephone triage service in Osaka city, Japan was associated with better outcomes of patients transported by ambulance.

Analysis of Medical Management in Geriatric Patients in the Hospital Emergency Department by Example of Selected Cities with County Status in Poland: A Retrospective Cohort Study

The aim of this study was to analyse medical management in geriatric patients in the Hospital Emergency Departments in the Biała Podlaska County and Chełm County (Poland) between 2016 and 2018 in a group of patients ≥65 years of age. We analysed medical records of 829 patients transported to Hospital Emergency Departments by Medical Emergency Teams. The research was conducted in the period from June 2019 to March 2020. We analysed emergency medical procedure forms and medical records of patients transported to the hospitals. Cardiovascular diseases were diagnosed in 40% of patients. Mortality cases accounted for 3.1% of the 1200 interventions analysed. Ambulance dispatch resulted in the patient being transported to the Hospital Emergency Departments in more than ²/₃ of cases. The concordance between the diagnoses made by the Medical Emergency Teams and those made at the Hospital Emergency Departments was confirmed for 78% patients admitted to the department (n = 647), whereas the concordance of classification at the group level was estimated at 71.7% (n = 594). Further in-patient treatment was initiated in some of the patients admitted to the department (n = 385). The mean time of hospital stay was 10.1 days. In conclusion, differences between the initial diagnosis made by the heads of the Medical Emergency Teams and the diagnosis made by the doctor on duty in the Hospital Emergency Departments depended on the chapter of diseases in the ICD-10 classification, but they were acceptable. The majority of the patients were transported to Hospital Emergency Departments. The most common groups of diseases that require Hospital Emergency Departments admission include cardiovascular diseases, injuries due to external causes, and respiratory diseases. A moderate percentage of patients were qualified for further specialist treatment in hospital departments.

A mixed methods evaluation of got care!

This study aimed to assess the relationship between an Interprofessional Collaborative Practice (IPCP) intervention for community-dwelling older adults, Geriatric Outreach and Training with Care! (GOT Care!), and the observed 26% reduction in Emergency Department (ED) visits for the 51 older adult participants. A convergent parallel mixed-methods design was utilized. Demographic data and ED visit data were collected and analyzed using paired-samples t-tests, poisson regression and generalized poisson regression. Stakeholder perspectives were assessed via emailed open-ended surveys and analyzed using content analysis. The quantitative results were transformed into trends that were compared and contrasted with the qualitative themes. The results were consistent with the current literature that IPCP models may have a greater impact on older adults with certain demographic characteristics such as polypharmacy, diabetes and prior ED use, while nursing was identified as an ideal leader for IPCP teams.

Statistical tools used for analyses of frequent users of emergency department: a scoping review

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.

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

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

Tracking the Rise of Geriatric Emergency Departments in the United States

The traditional model of emergency care no longer fits the growing needs of the over 20 million older adults annually seeking emergency department care. In 2007 a tailored "geriatric emergency department" model was introduced and rapidly replicated among hospitals, rising steeply over the past 5 years. This survey examined all U.S. emergency departments self-identifying themselves as Geriatric Emergency Departments (GEDs) and providing enhanced geriatric emergency care services. It was guided by the recently adopted Geriatric Emergency Department Guidelines and examined domains including, GED identity, staffing, and administration; education, equipment, and supplies; policies, procedures, and protocols; follow-up and transitions of care; and quality improvement. Results reveal a heterogeneous mix of GED staffing, procedures, physical environments and that GEDs' familiarity with the GED Guidelines is low. Findings will inform emergency departments and gerontologists nationwide about key GED model elements and will help hospitals to improve ED services for their older adult patients.

Supporting the on-call primary care physician with community paramedicine

Prior to being referred to the emergency department (ED), patients such as the frail elderly often call their primary care physician. However, the on-call primary care physician or covering provider does not always have the tools to make an accurate and safe assessment over the phone or to treat patients remotely. This often results in preventable transport to an ED, avoidable admissions and iatrogenic events. An opportunity exists to reduce unnecessary ED referrals by enhancing the capabilities of the on-call primary care physician. In this communication, we describe the development of a community paramedicine programme that supports on-call primary care providers managing a high-risk patient population with the goal of reducing avoidable ED referrals.

Predictors of Emergent Emergency Department Visits and Costs in Community-Dwelling Older Adults

BACKGROUND

The number of yearly emergency department (ED) visits by older adults in the United States has been increasing.

PURPOSE

The objectives were to (1) describe the demographics, health-related variables, and ED visit characteristics for community-dwelling older adults using an urban, safety-net ED; (2) examine the association between demographics, health-related variables, and ED visit characteristics with emergent vs nonemergent ED visits; and (3) examine the association between demographics, health-related variables, ED visit characteristics, and ED visit costs.

METHODS

A cross-sectional, retrospective analysis of administrative electronic medical record and billing information from 2010 to 2013 ED visits (n = 7805) for community-dwelling older adults (⩾65 years old) from an academic medical center in central Virginia was conducted.

RESULTS

Most of the ED visits were by women (62%), African Americans (75%), and approximately 50% of ED visits were nonemergent (n = 3871). Men had 1.2 times the odds of an emergent ED visit (95% confidence interval [CI]: 1.02-1.37). The ED visits by white patients had 1.3 times the odds of an emergent ED visit (95% CI: 1.09-1.57) and 14% higher costs (white race: 95% CI: 1.07-1.21) compared with African American patients. Emergent ED visits were 60% more likely to have higher costs than nonemergent visits (95% CI: 1.52-1.69). White race and arrival by ambulance were associated with both emergent ED visits and higher total ED visit costs in this sample of ED visits by community-dwelling older adults.

CONCLUSIONS

Strategies to maximize opportunities for care in the primary care setting are warranted to potentially reduce nonemergent ED utilization in community-dwelling older adults.

Health related quality of life and emergency department visits in adults of age ≥ 66 years: a prospective cohort study

Background

Age increases the risk of emergency department [ED] visits. Health related quality of life (HRQoL) is often estimated as an outcome of ED visits, but it can be a risk factor of ED visits. This study aims to assess the association of HRQoL with time to first ED visit and/or frequent ED use in older adults during four-year period and if this association differs in 66–80 and 80+ age groups.

Methods

Data from the Swedish National Study on Aging and Care-Blekinge of wave 2007–2009 was used in combination with electronic health records on ED visits. The analytical sample included 673 participants of age 66 years and older with information on HRQoL. Cox proportional hazard model was used to assess the association between HRQoL and time to first ED visit. Logistic regression analysis was performed to estimate the association of HRQoL with frequent ED use.

Results

During the study period, 55.3% of older adults visited the ED and 28.8% had a frequent ED use. Poor physical HRQoL was independently associated with first ED visit both in total sample (p < 0.001) and in 66–80 (p < 0.001) and 80+ (p = 0.038) age groups. Poor mental HRQoL had no significant association with first ED visit and frequent ED use.

Conclusion

Findings suggest that poor physical HRQoL is associated with time to first ED visit in older adults. Therefore, physical HRQoL should be considered while planning interventions on the reduction of ED utilisation in older adults. Explanatory factors of frequent ED use may differ in age groups. Further studies are needed to identify associated factors of frequent ED visits in 80+ group.

Characteristics and outcomes of older emergency department patients assigned a low acuity triage score

Objective

Although older patients are a high-risk population in the emergency department (ED), little is known about those identified as “less acute” at triage. We aimed to describe the outcomes of patients ages 65 years and older who receive low acuity triage scores.

Methods

This health records review assessed ED patients who were ages 65 years and above or ages 40 to 55 years (controls) who received a Canadian Triage Acuity Scale score of 4 or 5. Data collected included patient demographics, ED management, disposition, and a return visit or hospital admission at 14 days. Data were analysed descriptively and chi-square testing performed. A pre-planned stratified analysis of patients ages 65 to 74, 75 to 84, and 85 and older was conducted.

Results

Three hundred fifty older patients with a mean age of 76.5 years and 150 control patients were included. Most patients presented with musculoskeletal or skin complaints and were triaged to the ambulatory care area. Older patients were significantly more likely than controls to be admitted on the index visit (5.0% v. 0.3%, p=0.016) and on re-presentation (4.0% v. 0.7%, p=0.045). In a subgroup analysis, patients ages 85 years and above were most likely to be admitted (8.9%, p=0.003).

Conclusions

Older patients who present to the ED with issues labelled as “less acute” at triage are 16 times more likely to be admitted than younger controls. Patients ages 85 years and up are the primary drivers of this higher admission rate. Our study indicates that even “low acuity” elders presenting to the ED are at risk for re-presentation and admission within 14 days.

Comprehensive geriatric assessment pilot of a randomized control study in a Swedish acute hospital: a feasibility study

BACKGROUND

Comprehensive geriatric assessment (CGA) represent an important component of geriatric acute hospital care for frail older people, secured by a multidisciplinary team who addresses the multiple needs of physical health, functional ability, psychological state, cognition and social status. The primary objective of the pilot study was to determine feasibility for recruitment and retention rates. Secondary objectives were to establish proof of principle that CGA has the potential to increase patient safety.

METHODS

The CGA pilot took place at a University hospital in Western Sweden, from March to November 2016, with data analyses in March 2017. Participants were frail people aged 75 and older, who required an acute admission to hospital. Participants were recruited and randomized in the emergency room. The intervention group received CGA, a person-centered multidisciplinary team addressing health, participation, and safety. The control group received usual care. The main objective measured the recruitment procedure and retention rates. Secondary objectives were also collected regarding services received on the ward including discharge plan, care plan meeting and hospital risk assessments including risk for falls, nutrition, decubitus ulcers, and activities of daily living status.

RESULT

Participants were recruited from the emergency department, over 32 weeks. Thirty participants were approached and 100% (30/30) were included and randomized, and 100% (30/30) met the inclusion criteria. Sixteen participants were included in the intervention and 14 participants were included in the control. At baseline, 100% (16/16) intervention and 100% (14/14) control completed the data collection. A positive propensity towards the secondary objectives for the intervention was also evidenced, as this group received more care assessments. There was an average difference between the intervention and control in occupational therapy assessment - 0.80 [95% CI 1.06, - 0.57], occupational therapy assistive devices - 0.73 [95% CI 1.00, - 0.47], discharge planning -0.21 [95% CI 0.43, 0.00] and care planning meeting 0.36 [95% CI-1.70, -0.02]. Controlling for documented risk assessments, the intervention had for falls - 0.94 [95% CI 1.08, - 0.08], nutrition - 0.87 [95% CI 1.06, - 0.67], decubitus ulcers - 0.94 [95% CI 1.08, - 0.80], and ADL status - 0.80 [95% CI 1.04, - 0.57].

CONCLUSION

The CGA pilot was feasible and proof that the intervention increased safety justifies carrying forward to a large-scale study.

TRIAL REGISTRATION

Clinical Trials ID: NCT02773914. Registered 16 May 2016.

Low-Income Senior Housing Residents' Emergency Department Use and Care Transition Problems

Older adults may be at risk of adverse outcomes after emergency department (ED) visits due to ineffective transitions of care. Semi-structured interviews were employed to identify and categorize reasons for ED use and problems that occur during transition from the ED back to home among 14 residents of low-income senior housing. Qualitative thematic and descriptive analyses were used. Ambulance use, timely ED use or a wait-and-see approach, and lack of health-care provider contact before ED visit were emergent themes. Delayed medication receipt, no current medication list, and medication knowledge gaps were identified. Lack of a personal health record, follow-up care instruction, and worsening symptoms education emerged as transition problems from ED to home. After an ED visit, education opportunities exist around seeing primary care providers for nonurgent conditions, follow-up care, medications, and worsening condition symptoms. Timely receipt of discharge medications and medication education may improve medication-related transition problems.

Frequent Use of Emergency Departments by the Elderly Population When Continuing Care Is Not Well Established

Introduction

The elderly, who suffer from multiple chronic diseases, represent a substantial proportion of Emergency Department (ED) frequent users, thus contributing to ED overcrowding, although they could benefit from other health care facilities, if those were available. The aim of this study was to evaluate and characterize hospital visits of older patients (age 65 or greater) to the ED of a university teaching hospital in Rome from the 1st of January to the 31st of December 2014, in order to identify clinical and social characteristics potentially associated with “elderly frequent users”.

Material and Methods

A retrospective study was performed during the calendar year 2014 (1^st January 2014 – 31^st December 2014) analyzing all ED admissions to the University Hospital of Rome Tor Vergata. Variables collected included age, triage code, arrival data, discharge diagnosis, and visit outcome. We performed a risk analysis using univariate binary logistic regression models.

Results

A total number of 38,016 patients accessed the ED, generating 46,820 accesses during the study period, with an average of 1.23 accesses for patient. The elderly population represented a quarter of the total ED population and had an increased risk of frequent use (OR 1.5: CI 1.4–1.7) and hospitalization (OR 3.8: CI 3.7–4). Moreover, they showed a greater diagnostic complexity, as demonstrated by the higher incidence of yellow and red priority codes compared to other ED populations (OR 3.1: CI 2.9–3.2).

Discussion

Older patients presented clinical and social characteristics related to the definition of “elderly frail frequent users”. The fact that a larger number of hospitalizations occurred in such patients is indirect evidence of frailty in this specific population, suggesting that hospital admissions may be an inappropriate response to frailty, especially when continued care is not established.

Conclusion

Enhancement of continuity of care, establishment of a tracking system for those who are at greater risk of visiting the ED and evaluating fragile individuals should be the highest priority in addressing ED frequent usage by the elderly.

Alcohol Use as Risk Factors for Older Adults' Emergency Department Visits: A Latent Class Analysis

INTRODUCTION

Late middle-aged and older adults' share of emergency department (ED) visits is increasing more than other age groups. ED visits by individuals with substance-related problems are also increasing. This paper was intended to identify subgroups of individuals aged 50+ by their risk for ED visits by examining their health/mental health status and alcohol use patterns.

METHODS

Data came from the 2013 National Health Interview Survey's Sample Adult file (n=15,713). Following descriptive analysis of sample characteristics by alcohol use patterns, latent class analysis (LCA) modeling was fit using alcohol use pattern (lifetime abstainers, ex-drinkers, current infrequent/light/moderate drinkers, and current heavy drinkers), chronic health and mental health status, and past-year ED visits as indicators.

RESULTS

LCA identified a four-class model. All members of Class 1 (35% of the sample; lowest-risk group) were infrequent/light/moderate drinkers and exhibited the lowest probabilities of chronic health/mental health problems; Class 2 (21%; low-risk group) consisted entirely of lifetime abstainers and, despite being the oldest group, exhibited low probabilities of health/mental health problems; Class 3 (37%; moderate-risk group) was evenly divided between ex-drinkers and heavy drinkers; and Class 4 (7%; high-risk group) included all four groups of drinkers but more ex-drinkers. In addition, Class 4 had the highest probabilities of chronic health/mental problems, unhealthy behaviors, and repeat ED visits, with the highest proportion of Blacks and the lowest proportions of college graduates and employed persons, indicating significant roles of these risk factors.

CONCLUSION

Alcohol nonuse/use (and quantity of use) and chronic health conditions are significant contributors to varying levels of ED visit risk. Clinicians need to help heavy-drinking older adults reduce unhealthy alcohol consumption and help both heavy drinkers and ex-drinkers improve chronic illnesses self-management.

Associations of Mental Health and Substance Use Disorders With Presenting Problems and Outcomes in Older Adults' Emergency Department Visits

OBJECTIVES

The increasing prevalence of mental health and/or substance use disorders in older adults is a significant public health issue affecting their health, health care use, and health care outcomes. These disorders are especially prevalent in emergency department (ED) visits. This study examined the effect of mental health and substance use disorders on older adults' ED presenting problems and outcomes.

METHODS

Data were from the publicly available 2012 Nationwide Emergency Department Sample data set (unweighted n = 5,344,743 visits by the 65+ years age group). We used binary logistic regression analysis to test relationships between mental health and substance use disorders and suicide attempts, falls, and other injuries and multinomial logistic regression analysis to test relationships between the disorders and ED outcomes of death, hospital admission, transfer to institutional care, home health care, leaving against medical advice (AMA), or other or unknown destinations, as opposed to routine care.

RESULTS

Of ED visits by older adults, 5.1% involved anxiety disorders, 7.1% involved mood disorders, 10.45% involved delirium/dementia, 1.4% involved alcohol use disorders, and 0.6% involved drug use disorders; 0.2% were suicide-related, 12.0% involved falls, and 10.2% involved other injuries. Mental health and substance use disorders had large-to-medium effects on suicide attempts. Both dementia and delirium and alcohol use disorders had a small effect on falls. Drug use disorders had a small effect on other injuries. Anxiety disorder had a small effect on the risk of death in the ED or in the hospital, relative to routine care. Suicide attempts and drug use disorders had a medium effect on hospital admission. Suicide attempts had a large effect, delirium and dementia and other mental disorders had medium effects, and mood disorder had a small effect on the risk of transfer to another facility. Delirium and dementia, suicide attempts, and drug use disorders had small effects on the risk of discharge with home health care. Alcohol use disorders and drug use disorders had a small effect on the risk of leaving AMA. Finally, suicide attempts had a medium effect on the risk of other outcomes and unknown destinations.

CONCLUSIONS

Late-life mental health and substance use disorders are significant risk factors for both intentional self-harm and unintentional injuries that bring older adults to the ED and contribute to ED dispositions and outcomes that involve more intensive and longer-term health care services. The findings underscore the importance of detection and treatment of these disorders among older adults before they end up in the ED.

Pre-emergency-department care-seeking patterns are associated with the severity of presenting condition for emergency department visit and subsequent adverse events: a timeframe episode analysis

Background

Many patients treated in Emergency Department (ED) visits can be treated at primary or urgent care sectors, despite the fact that a number of ED visitors seek other forms of care prior to an ED visit. However, little is known regarding how the pre-ED activity episodes affect ED visits.

Objectives

We investigated whether care-seeking patterns involve the use of health care services of various types prior to ED visits and examined the associations of these patterns with the severity of the presenting condition for the ED visit (EDVS) and subsequent events.

Methods

This retrospective observational study used administrative data on beneficiaries of the universal health care insurance program in Taiwan. The service type, treatment capacity, and relative diagnosis were used to classify pre-ED visits into 8 care types. Frequent pattern analysis was used to identify sequential care-seeking patterns and to classify 667,183 eligible pre-ED episodes into patterns. Generalized linear models were developed using generalized estimating equations to examine the associations of these patterns with EDVS and subsequent events.

Results

The results revealed 17 care-seeking patterns. The EDVS and likelihood of subsequent events significantly differed among patterns. The ED severity index of patterns differ from patterns seeking directly ED care (coefficients ranged from -0.05 to 0.13), and the odds-ratios for the likelihood of subsequent ED visits and hospitalization ranged from 1.18 to 1.86 and 1.16 to 2.84, respectively.

Conclusions

The pre-ED care-seeking patterns differ in severity of presenting condition and subsequent events that may represent different causes of ED visit. Future health policy maker may adopt different intervention strategies for targeted population to reduce unnecessary ED visit effectively.

Travel distances, socioeconomic characteristics, and health disparities in nonurgent and frequent use of Hospital Emergency Departments in South Carolina: a population-based observational study

BACKGROUND

Nonurgent use of hospital emergency departments (ED) is a controversial topic. It is thought to increase healthcare costs and reduce quality, but is also considered a symptom of unequal access to health care. In this article, we investigate whether convenience (as proxied by travel distances to the hospital ED and to the closest federally qualified health center) is associated with nonurgent ED use, and whether evidence of health disparities exist in the way vulnerable populations use the hospital ED for medical care in South Carolina.

METHODS

Our data includes 6,592,501 ED visits in South Carolina between 2005 and 2010 from the South Carolina Budget Control Board and Office of Research and Statistics. All ED visits by South Carolina residents with unmasked variables and nonmissing urgency measures, or approximately 76% of all ED visits, are used in the analysis. We perform multivariable linear regressions to estimate correlations between (1) travel distances and observable sociodemographic characteristics and (2) measures of nonurgent ED use or frequent nonurgent ED use, as defined by the New York University ED Algorithm.

RESULTS

Patients with commercial private insurance, self-pay patients, and patients with other payment sources have lower measures of nonurgent ED use the further away the ED facility is from the patients' home address. Vulnerable populations, particularly African American and Medicaid patients, have higher measures of nonurgent ED scores, and are more frequent users of the ED for both nonurgent and urgent reasons in South Carolina. At the same time, African Americans visit the hospital ED for medical conditions with higher primary care-preventable scores.

CONCLUSIONS

Contrary to popular belief, convenient access (in terms of travel distances) to hospital ED is correlated with less-urgent ED use among privately insured patients and self-pay patients in South Carolina, but not publicly insured patients. Unequal access to primary care appears to exist, as suggested by African American patients' use of the hospital ED for primary care-treatable conditions while experiencing more frequent and more severe primary care-preventable conditions.

Mortality, admission rates and outpatient use among frequent users of emergency departments: a systematic review

OBJECTIVE

This systematic review examines whether frequent emergency department (ED) users experience higher mortality, hospital admissions and outpatient visits than non-frequent ED users.

DESIGN

We published an a priori study protocol in PROSPERO. Our search strategy combined terms for 'frequent users' and 'emergency department'. At least two independent reviewers screened, selected, assessed quality and extracted data. Third-party adjudication resolved conflicts. Results were synthesised based on median effect sizes.

DATA SOURCES

We searched seven electronic databases with no limits and performed an extensive grey literature search.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES

We included observational analytical studies that focused on adult patients, had a comparison group of non-frequent ED users and reported deaths, admissions and/or outpatient outcomes.

RESULTS

The search strategy identified 4004 citations; 374 were screened by full text and 31 cohort and cross-sectional studies were included. Authors used many different definitions to describe frequent users; the overall quality of the included studies was moderate. Across seven studies examining mortality, frequent users had a median 2.2-fold increased odds of mortality compared with non-frequent users. Twenty-eight studies assessing hospital admissions found a median increased odds of admissions per visit at 1.16 and of admissions per patient at 2.58. Ten studies reported outpatient visits with a median 2.65-fold increased risk of having at least one outpatient encounter post-ED visit.

CONCLUSIONS

Frequent ED users appear to experience higher mortality, hospital admissions and outpatient visits compared with non-frequent users, and may benefit from targeted interventions. Standardised definitions to facilitate comparable research are urgently needed.

REVIEW REGISTRATION NUMBER

PROSPERO (CRD42013005855).

Travel distance and sociodemographic correlates of potentially avoidable emergency department visits in California, 2006-2010: an observational study

INTRODUCTION

Use of the hospital emergency department (ED) for medical conditions not likely to require immediate treatment is a controversial topic. It has been faulted for ED overcrowding, increased expenditures, and decreased quality of care. On the other hand, such avoidable ED utilization may be a manifestation of barriers to primary care access.

METHODS

A random 10% subsample of all ED visits with unmasked variables, or approximately 7.2% of all ED visits in California between 2006 and 2010 are used in the analysis. Using panel data methods, we employ linear probability and fractional probit models with hospital fixed effects to analyze the associations between avoidable ED utilization in California and observable patient characteristics. We also test whether shorter estimated road distances to the hospital ED are correlated with non-urgent ED utilization, as defined by the New York University ED Algorithm. We then investigate whether proximity of a Federally Qualified Health Center (FQHC) is correlated with reductions in non-urgent ED utilization among Medicaid patients.

RESULTS

We find that relative to the reference group of adults aged 35-64, younger patients generally have higher scores for non-urgent conditions and lower scores for urgent conditions. However, elderly patients (≥65) use the ED for conditions more likely to be urgent. Relative to male and white patients, respectively, female patients and all identified racial and ethnic minorities use the ED for conditions more likely to be non-urgent. Patients with non-commercial insurance coverage also use the ED for conditions more likely to be non-urgent. Medicare and Medicaid patients who live closer to the hospital ED have higher probability scores for non-emergent visits. However, among Medicaid enrollees, those who live in zip codes with an FQHC within 0.5 mile of the zip code population centroid visit the ED for medical conditions less likely to be non-emergent.

CONCLUSIONS

These patterns of ED utilization point to potential barriers to care among historically vulnerable groups, observable even when using rough estimates of travel distances and avoidable ED utilization.

Rate, characteristics, and factors associated with high emergency department utilization

Background

Patients with high emergency department (ED) utilization account for a disproportionate number of ED visits. The existing research on high ED utilization has raised doubts about the homogeneity of the frequent ED user. Attention to differences among the subgroups of frequent visitors (FV) and highly frequent visitors (HFV) is necessary in order to plan more effective interventions.

In the Netherlands, the incidence of high ED utilization is unknown. The purpose of this study was to investigate if the well-documented international high ED utilization also exists in the Netherlands and if so, to characterize these patients. Therefore, we assessed the proportion of FV and HFV; compared age, sex, and visit outcomes between patients with high ED utilization and patients with single ED visits; and explored the factors associated with high ED utilization.

Methods

A 1-year retrospective descriptive correlational study was performed in two Dutch EDs, using thresholds of 7 to 17 visits for frequent ED use, and greater than or equal to 18 visits for highly frequent ED use.

Results

FV and HFV (together accounting for 0.5% of total ED patients) attended the ED 2,338 times (3.3% of the total number of ED visits). FV and HFV were equally likely to be male or female, were less likely to be self-referred, and they suffered from urgent complaints more often compared to patients with single visits. FV were significantly older than patients with single visits and more often admitted than patients with single visits. Several chief complaints were indicative for frequent and highly frequent ED use, such as shortness of breath and a psychiatric disorder.

Conclusions

Based on this study, high ED utilization in the Netherlands seems to be less a problem than outlined in international literature. No major differences were found between FV and HFV, they presented with the same, often serious, problems. Our study supports the notion that most patients with high ED utilization visit the ED for significant medical problems.