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Green J, Hanckel B, Petticrew M, Paparini S, Shaw S. Case study research and causal inference. BMC Med Res Methodol 2022; 22:307. [PMID: 36456923 PMCID: PMC9714179 DOI: 10.1186/s12874-022-01790-8] [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: 08/12/2022] [Accepted: 11/10/2022] [Indexed: 12/05/2022] Open
Abstract
Case study methodology is widely used in health research, but has had a marginal role in evaluative studies, given it is often assumed that case studies offer little for making causal inferences. We undertook a narrative review of examples of case study research from public health and health services evaluations, with a focus on interventions addressing health inequalities. We identified five types of contribution these case studies made to evidence for causal relationships. These contributions relate to: (1) evidence about system actors' own theories of causality; (2) demonstrative examples of causal relationships; (3) evidence about causal mechanisms; (4) evidence about the conditions under which causal mechanisms operate; and (5) inference about causality in complex systems. Case studies can and do contribute to understanding causal relationships. More transparency in the reporting of case studies would enhance their discoverability, and aid the development of a robust and pluralistic evidence base for public health and health services interventions. To strengthen the contribution that case studies make to that evidence base, researchers could: draw on wider methods from the political and social sciences, in particular on methods for robust analysis; carefully consider what population their case is a case 'of'; and explicate the rationale used for making causal inferences.
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Affiliation(s)
- Judith Green
- grid.8391.30000 0004 1936 8024Wellcome Centre for Cultures & Environments of Health, University of Exeter, Exeter, UK
| | - Benjamin Hanckel
- grid.1029.a0000 0000 9939 5719Institute for Culture and Society, Western Sydney University, Sydney, Australia
| | - Mark Petticrew
- grid.8991.90000 0004 0425 469XDepartment of Public Health, Environments & Society, London School of Hygiene & Tropical Medicine, London, UK
| | - Sara Paparini
- grid.4868.20000 0001 2171 1133Wolfson Institute of Population Health, Queen Mary University of London, London, UK
| | - Sara Shaw
- grid.4991.50000 0004 1936 8948Nuffield Department of Primary Care Health Sciences, University of Oxford, Oxford, UK
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Zeidan A, Salhi B, Backster A, Shelton E, Valente A, Safdar B, Wong A, Porta AD, Lee S, Schneberk T, Wilson J, Westgard B, Samuels-Kalow M. A Structural Competency Framework for Emergency Medicine Research: Results from a Scoping Review and Consensus Conference. West J Emerg Med 2022; 23:650-659. [PMID: 36205664 PMCID: PMC9541992 DOI: 10.5811/westjem.2022.6.56056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2022] [Revised: 06/23/2022] [Accepted: 06/23/2022] [Indexed: 11/26/2022] Open
Abstract
INTRODUCTION The application of structural competency and structural vulnerability to emergency medicine (EM) research has not been previously described despite EM researchers routinely engaging structurally vulnerable populations. The purpose of this study was to conduct a scoping review and consensus-building process to develop a structurally competent research approach and operational framework relevant to EM research. METHODS We conducted a scoping review focused on structural competency and structural vulnerability. Results of the review informed the development of a structural competency research framework that was presented throughout a multi-step consensus process culminating in the 2021 Society for Academic Emergency Medicine Consensus Conference. Feedback to the framework was incorporated throughout the conference. RESULTS The scoping review produced 291 articles with 123 articles relevant to EM research. All 123 articles underwent full-text review and data extraction following a standardized data extraction form. Most of the articles acknowledged or described structures that lead to inequities with a variety of methodological approaches used to operationalize structural competency and/or structural vulnerability. The framework developed aligned with components of the research process, drawing upon methodologies from studies included in the scoping review. CONCLUSION The framework developed provides a starting point for EM researchers seeking to understand, acknowledge, and incorporate structural competency into EM research. By incorporating components of the framework, researchers may enhance their ability to address social, historical, political, and economic forces that lead to health inequities, reframing drivers of inequities away from individual factors and focusing on structural factors.
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Affiliation(s)
- Amy Zeidan
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Brian Salhi
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Anika Backster
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Erica Shelton
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Alycia Valente
- University of Massachusetts, Department of Emergency Medicine, Worcester, Massachusetts
| | - Basmah Safdar
- Yale University, Department of Emergency Medicine, New Haven, Connecticut
| | - Ambrose Wong
- Yale University, Department of Emergency Medicine, New Haven, Connecticut
| | | | - Sangil Lee
- The University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - Todd Schneberk
- Los Angeles + University of Southern California, Department of Emergency Medicine, Los Angeles, California
| | - Jason Wilson
- Morsani College of Medicine, Division of Emergency Medicine, Department of Internal Medicine, Tampa, Florida
| | - Bjorn Westgard
- University of Minnesota Medical School, Department of Emergency Medicine, Minneapolis, Minnesota
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Meyer AND, Giardina TD, Khawaja L, Singh H. Patient and clinician experiences of uncertainty in the diagnostic process: Current understanding and future directions. PATIENT EDUCATION AND COUNSELING 2021; 104:2606-2615. [PMID: 34312032 DOI: 10.1016/j.pec.2021.07.028] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/13/2021] [Accepted: 07/14/2021] [Indexed: 06/13/2023]
Abstract
OBJECTIVE Uncertainty occurs throughout the diagnostic process and must be managed to facilitate accurate and timely diagnoses and treatments. Better characterization of uncertainty can inform strategies to manage it more effectively in clinical practice. We provide a comprehensive overview of current literature on diagnosis-related uncertainty describing (1) where patients and clinicians experience uncertainty within the diagnostic process, (2) how uncertainty affects the diagnostic process, (3) roots of uncertainty related to probability/risk, ambiguity, or complexity, and (4) strategies to manage uncertainty. DISCUSSION Each diagnostic process step involves uncertainty, including patient engagement with the healthcare system; information gathering, interpretation, and integration; formulating working diagnoses; and communicating diagnoses to patients. General management strategies include acknowledging uncertainty, obtaining more contextual information from patients (e.g., gathering occupations and family histories), creating diagnostic safety nets (e.g., informing patients what red flags to look for), engaging in worst case/best case scenario planning, and communicating diagnostic uncertainty to patients, families, and colleagues. Potential strategies tailored to various aspects of diagnostic uncertainty are also outlined. CONCLUSION Scientific knowledge on diagnostic uncertainty, while previously elusive, is now becoming more clearly defined. Next steps include research to evaluate relationships between management and communication of diagnostic uncertainty and improved patient outcomes.
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Affiliation(s)
- Ashley N D Meyer
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Traber D Giardina
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Lubna Khawaja
- Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
| | - Hardeep Singh
- Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, 2002 Holcombe Boulevard (152), Houston, TX 77030, USA; Department of Medicine, Baylor College of Medicine, One Baylor Plaza, Houston, TX 77030, USA.
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Sy A, Moglia B, Aragunde G, Derossi P. Emergency care under the magnifying glass: a review of ethnographic studies in the scientific literature on hospital emergency services. CAD SAUDE PUBLICA 2021; 37:e00026120. [PMID: 33503159 DOI: 10.1590/0102-311x00026120] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Accepted: 09/23/2020] [Indexed: 12/20/2022] Open
Abstract
The article presents a review of ethnographic studies in the scientific literature on hospital emergency services, with the objective of systematizing the studies and their principal findings, referring to the health-disease-healthcare process in hospital emergency services from an ethnographic perspective. An integrative literature review was performed of studies published in Argentine and international indexed journals and in the following electronic databases: PubMed, VHL, Scopus, Redalyc, and SciELO. The corpus of the analysis consisted of a total of 69 articles, which were submitted to content analysis, having identified the following analytical dimensions: quality of care, communication and bonds, subjectivity, application of information technologies, methodological reflection, patients' experiences and practices, decision-making, and violence. The results allowed identifying a process that differs from guidelines and protocols, in which healthcare workers' subjective aspects, communication and interpersonal relations, and working conditions shape, orient, and condition the treatment and care provided in the hospital. The article thus highlights the approach to subjective aspects in health studies, to understand not only health workers' perspectives and experiences but also the persistent barriers to providing better quality of care, complexifying a problem ignored by a large share of the analyses.
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Affiliation(s)
- Anahi Sy
- Instituto de Salud Colectiva, Universidad Nacional de Lanús, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Brenda Moglia
- Instituto de Salud Colectiva, Universidad Nacional de Lanús, Buenos Aires, Argentina.,Consejo Nacional de Investigaciones Científicas y Técnicas, Buenos Aires, Argentina
| | - Gisele Aragunde
- Instituto de Salud Colectiva, Universidad Nacional de Lanús, Buenos Aires, Argentina
| | - Paula Derossi
- Instituto de Salud Colectiva, Universidad Nacional de Lanús, Buenos Aires, Argentina
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Schumacher JR, Lutz BJ, Hall AG, Harman JS, Turner K, Brumback BA, Hendry P, Carden DL. Impact of an Emergency Department-to-Home Transitional Care Intervention on Health Service Use in Medicare Beneficiaries: A Mixed Methods Study. Med Care 2021; 59:29-37. [PMID: 33298706 PMCID: PMC8689563 DOI: 10.1097/mlr.0000000000001452] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Hospital-based acute care [emergency department (ED) visits and hospitalizations] that is preventable with high-quality outpatient care contributes to health care system waste and patient harm. OBJECTIVE To test the hypothesis that an ED-to-home transitional care intervention reduces hospital-based acute care in chronically ill, older ED visitors. RESEARCH DESIGN Convergent, parallel, mixed-methods design including a randomized controlled trial. SETTING Two diverse Florida EDs. SUBJECTS Medicare fee-for-service beneficiaries with chronic illness presenting to the ED. INTERVENTION The Coleman Care Transition Intervention adapted for ED visitors. MEASURES The main outcome was hospital-based acute care within 60 days of index ED visit. We also assessed office-based outpatient visits during the same period. RESULTS The Intervention did not significantly reduce return ED visits or hospitalizations or increase outpatient visits. In those with return ED visits, the Intervention Group was less likely to be hospitalized than the Usual Care Group. Interview themes describe a cycle of hospital-based acute care largely outside patients' control that may be difficult to interrupt with a coaching intervention. CONCLUSIONS AND RELEVANCE Structural features of the health care system, including lack of access to timely outpatient care, funnel patients into the ED and hospital admission. Reducing hospital-based acute care requires increased focus on the health care system rather than patients' care-seeking decisions.
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Affiliation(s)
- Jessica R. Schumacher
- Department of Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison WI
| | - Barbara J. Lutz
- School of Nursing, College of Health and Human Services, University of North Carolina-Wilmington, Wilmington NC
| | - Allyson G. Hall
- Department of Health Services Administration, School of Health Professions, University of Alabama at Birmingham, Birmingham, AL
| | - Jeffrey S. Harman
- Department of Behavioral Sciences and Social Medicine, College of Medicine, Florida State University, Tallahassee FL
| | | | - Babette A. Brumback
- Department of Biostatistics, College of Public Health and Health Professions & College of Medicine, University of Florida-Gainesville, Gainesville FL
| | - Phyllis Hendry
- Department of Emergency Medicine, College of Medicine, University of Florida-Jacksonville, Jacksonville FL
| | - Donna L. Carden
- Department of Emergency Medicine, College of Medicine, University of Florida-Gainesville, Gainesville FL
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Wardrop R, Crilly J, Ranse J, Chaboyer W. Vulnerability: A concept synthesis and its application to the Emergency Department. Int Emerg Nurs 2020; 54:100936. [PMID: 33188947 DOI: 10.1016/j.ienj.2020.100936] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Revised: 07/18/2020] [Accepted: 10/01/2020] [Indexed: 11/30/2022]
Abstract
AIM The aim of this concept synthesis was to add clarity to the concept of vulnerability with application to the Emergency Department (ED) by critiquing, analysing and amalgamating published concept analyses. BACKGROUND The concept of vulnerability has been used widely, however it has various meanings. A clearer understanding of vulnerability and application to the ED may help healthcare professionals provide high quality care responsive to the needs of vulnerable individuals. METHOD Nine concept analyses of vulnerability were retrieved using Medline, CINAHL, and PsycINFO databases. After extracting data on each analysis, Walker and Avant's concept synthesis method was used to structure this synthesis, with a thematic synthesis approach used in the analysis. FINDINGS Four themes associated with vulnerability emerged from the synthesis. The first theme, vulnerability as a journey, reflected elements within an individual's life that perpetuate and exacerbate vulnerability. The second theme, vulnerability as susceptibility and risk, highlighted intrinsic and extrinsic elements that contribute to a state of risk. The third theme, positive and negative repercussions, emphasised lessons that can be learned from experience, with the fourth theme of a shared understanding indicating the importance of understanding the concept of vulnerability for patient care. CONCLUSION Findings from this synthesis highlight the multiple elements associated with a vulnerable state, evident in the context of the ED. With multiple ED-specific elements contributing to vulnerability, clarity of the term is important to inform ED-specific interventions designed to meet the needs of vulnerable populations.
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Affiliation(s)
- Rachel Wardrop
- School of Nursing and Midwifery, Griffith University, Australia.
| | - Julia Crilly
- School of Nursing and Midwifery, Griffith University, Australia; Menzies Health Institute Queensland, Griffith University, Australia; Department of Emergency Medicine, Gold Coast Hospital and Health Service, Australia.
| | - Jamie Ranse
- School of Nursing and Midwifery, Griffith University, Australia; Menzies Health Institute Queensland, Griffith University, Australia; Department of Emergency Medicine, Gold Coast Hospital and Health Service, Australia.
| | - Wendy Chaboyer
- School of Nursing and Midwifery, Griffith University, Australia; Menzies Health Institute Queensland, Griffith University, Australia.
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Sheikh S, Booth-Norse A, Smotherman C, Kalynych C, Lukens-Bull K, Guerrido E, Henson M, Gautam S, Hendry P. Predicting Pain-Related 30-Day Emergency Department Return Visits in Middle-Aged and Older Adults. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2748-2756. [PMID: 32875332 PMCID: PMC8557807 DOI: 10.1093/pm/pnaa213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objective of this study was to determine predictive factors for pain-related emergency department returns in middle-aged and older adults. Design, Setting, and Subjects. This was a subanalysis of patients > 55 years of age enrolled in a prospective observational study of adult patients presenting within 30 days of an index visit to a large, urban, academic center. METHODS Demographic and clinical data were collected and compared to determine significant differences between patients who returned for pain and those who did not. Multiple logistic regressions were used to determine significant predictive variables for return visits. RESULTS The majority of the 130 enrolled patients > 55 years of age returned for pain (57%), were African American (78%), were younger (55-64 years old, 67%), had a high emergency department acuity level (level 1 or 2) at their index visit (56%), had low health literacy (Rapid Estimate of Adult Literacy in Medicine [REALM] score, 62%), lived in an area of extreme deprivation (69%), and were admitted (61%) during their index visit. Age (odds ratio [OR] = 0.9, 95% CI = 0.8-0.9, P = 0.047), health literacy (REALM scores; OR = 3.1, 95% CI = 1.3-7.5, P = 0.011), and index visit pain scores (OR = 1.1, 95% CI = 1.0-1.2, P = 0.004) were predictive of emergency department returns for pain in middle-aged and older adults. CONCLUSIONS The likelihood of emergency department return visits for pain in middle-aged and older adults decreased with older age, increased with higher health literacy (REALM scores), and increased with increase in pain scores.
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Affiliation(s)
- Sophia Sheikh
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Ashley Booth-Norse
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Colleen Kalynych
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Katryne Lukens-Bull
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Erika Guerrido
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Shiva Gautam
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
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McKenna G, Rogers A, Walker S, Pope C. The influence of personal communities in understanding avoidable emergency department attendance: qualitative study. BMC Health Serv Res 2020; 20:887. [PMID: 32958065 PMCID: PMC7504825 DOI: 10.1186/s12913-020-05705-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Accepted: 08/31/2020] [Indexed: 11/20/2022] Open
Abstract
BACKGROUND Use of emergency department (ED) care globally seems to be increasing at a faster rate than population growth (Baker, House of Commons Library. Accident and Emergency Statistics, Demand, Performance, 2017). In the UK there has been a reported 16% rise in emergency admissions over the past 5 years. Estimates that between 11 and 40% of ED attendances are non-urgent, with 11% of patients being discharged from the ED without treatment (NHS Digital 2017), and a further 44% require no follow-up treatment (NHS Digital, Hospital Accident and Emergency Activity 2016-17, 2019) is cited as evidence that these patients did not require this level of care. The solution to not using the most appropriate point in the system has traditionally been seen as a knowledge problem, requiring, improved sign-posting and information to enable people to self-manage or use health care management for minor ailments. However research about help-seeking behaviour suggests that the problem may not be an informational one. A considerable literature points to help seeking as a social process influenced by a range of contingencies and contextual factors including the way in which lay people influence health care utilisation (Giebel et al. BMJ Open 9:1, 2019). Personal communities comprise a variety of active and significant social ties which have potential to influence individual capacity to seek help. Here we extend and unpack further influencing decisions about seeking formal health care with reference to how they are shaped and informed by and within personal social networks. METHODS We undertook a personal network mapping and qualitative interview-based study to look at, problematize and understand attendance for non-urgent problems. We used network analysis and methods to map and characterise the personal communities of people seeking help from ED for minor ailments and semi-structured interviews with 40 people attending a single ED and associated GP hub providing equivalent care. Interviews were built around an ego network mapping activity and a topic guide structured to explore attender's narratives about why they had visited the ED. This ego network activity uses a diagram consisting of three concentric circles (Fiori et al. J Gerontol B-Psychol 62: 322-30, 2007), representing closest social network members (in the centre) and those at further distance. Participants were initially presented with one of these diagrams and asked to write names of people or resources that had played a role in their attendance and the interviewer probed the interviewee to discuss the actions, input and value of the people and services that supported the visit to the ED. RESULTS We analysed number and type of network connections and undertook a thematic analysis to identify how imagined and actual network members and influences were implicated in ED attendance. The network maps created during the interviews were examined and a typology of networks was developed and used to distinguish different types of networks informed by our reading of the data, and a Network Typology Scoring Tool, a measure of frequency of contact and relationship type in networks. CONCLUSIONS Our study suggests that faced with acute minor illness or injury people's networks narrow: they do not (and perhaps cannot) mobilise their imagined care network because the resources or connections may not be there or are difficult to engage. In addition we identified important system drivers of behaviour, notably that these patients are often directed to the ED by 'professional influencers' including health services staff.
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Affiliation(s)
- Gemma McKenna
- Health Services Management Centre, School of Social Policy, University of Birmingham, Birmingham, B15 2RT UK
| | - Anne Rogers
- NIHR CLAHRC Wessex, University of Southampton, Southampton, SO17 1BJ UK
| | - Sandra Walker
- NIHR CLAHRC Wessex, University of Southampton, Southampton, SO17 1BJ UK
| | - Catherine Pope
- Nuffield Department of Primary Care Health Services, University of Oxford, Oxford, OX2 6GG UK
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Slovis B, McCarthy D, Nord G, Doty A, Piserchia K, Rising K. Identifying Emergency Department Symptom-Based Diagnoses with the Unified Medical Language System. West J Emerg Med 2019. [DOI: 10.5811//westjem.2019.8.44230] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022] Open
Affiliation(s)
- Benjamin Slovis
- Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Danielle McCarthy
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Garrison Nord
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amanda Doty
- Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Katherine Piserchia
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Kristin Rising
- Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
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Slovis BH, McCarthy DM, Nord G, Doty AMB, Piserchia K, Rising KL. Identifying Emergency Department Symptom-Based Diagnoses with the Unified Medical Language System. West J Emerg Med 2019; 20:910-917. [PMID: 31738718 PMCID: PMC6860381 DOI: 10.5811/westjem.2019.8.44230] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 08/24/2019] [Accepted: 08/31/2019] [Indexed: 11/18/2022] Open
Abstract
INTRODUCTION Many patients who are discharged from the emergency department (ED) with a symptom-based discharge diagnosis (SBD) have post-discharge challenges related to lack of a definitive discharge diagnosis and follow-up plan. There is no well-defined method for identifying patients with a SBD without individual chart review. We describe a method for automated identification of SBDs from ICD-10 codes using the Unified Medical Language System (UMLS) Metathesaurus. METHODS We mapped discharge diagnosis, with use of ICD-10 codes from a one-month period of ED discharges at an urban, academic ED to UMLS concepts and semantic types. Two physician reviewers independently manually identified all discharge diagnoses consistent with SBDs. We calculated inter-rater reliability for manual review and the sensitivity and specificity for our automated process for identifying SBDs against this "gold standard." RESULTS We identified 3642 ED discharges with 1382 unique discharge diagnoses that corresponded to 875 unique ICD-10 codes and 10 UMLS semantic types. Over one third (37.5%, n = 1367) of ED discharges were assigned codes that mapped to the "Sign or Symptom" semantic type. Inter-rater reliability for manual review of SBDs was very good (0.87). Sensitivity and specificity of our automated process for identifying encounters with SBDs were 84.7% and 96.3%, respectively. CONCLUSION Use of our automated process to identify ICD-10 codes that classify into the UMLS "Sign or Symptom" semantic type identified the majority of patients with a SBD. While this method needs refinement to increase sensitivity of capture, it has potential to automate an otherwise highly time-consuming process. This novel use of informatics methods can facilitate future research specific to patients with SBDs.
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Affiliation(s)
- Benjamin H. Slovis
- Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Danielle M. McCarthy
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Garrison Nord
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Amanda MB Doty
- Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Katherine Piserchia
- Northwestern University Feinberg School of Medicine, Department of Emergency Medicine, Chicago, Illinois
| | - Kristin L. Rising
- Sidney Kimmel Medical College at Thomas Jefferson University, Department of Emergency Medicine, Philadelphia, Pennsylvania
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Sheikh S. Risk Factors Associated with Emergency Department Recidivism in the Older Adult. West J Emerg Med 2019; 20:931-938. [PMID: 31738721 PMCID: PMC6860386 DOI: 10.5811/westjem.2019.7.43073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/29/2019] [Accepted: 07/28/2019] [Indexed: 01/09/2023] Open
Abstract
Our objective was to review risk factors predictive of older adult recidivism in the emergency department. Certain risk factors and themes commonly occurred in the literature. These recurring factors included increasing age, male gender, certain diagnoses (abdominal pain, traumatic injuries, and respiratory complaints), psychosocial factors (depression, anxiety, poor social support, and limited health literacy), and poor general health (cognitive health and physical functioning). Many of the identified risk factors are not easily modifiable posing a significant challenge in the quest to develop and implement effective intervention strategies.
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Affiliation(s)
- Sophia Sheikh
- University of Florida-Jacksonville, Department of Emergency Medicine, Jacksonville, Florida
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Moore M, Conrick KM, Reddy A, Allen A, Jaffe C. From Their Perspective: The Connection between Life Stressors and Health Care Service Use Patterns of Homeless Frequent Users of the Emergency Department. HEALTH & SOCIAL WORK 2019; 44:113-122. [PMID: 30855682 PMCID: PMC6642452 DOI: 10.1093/hsw/hlz010] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/25/2018] [Revised: 10/26/2018] [Accepted: 01/07/2019] [Indexed: 06/09/2023]
Abstract
The perspective of homeless adults on their health care service utilization is not well studied. This article describes a study that used in-depth, semistructured interviews with 18 individuals to highlight the viewpoints of homeless people who are frequent users of the emergency department (ED) about the influence of life events on service utilization. Participants reported high levels of pain and comorbid psychiatric, substance use, and medical conditions. They also reported an identifiable pattern of health care utilization, often centered on a crisis event, influenced by high perceived medical needs, inability to cope after crisis, predisposing vulnerability from social determinants of health, and health care system factors. A social work case management intervention often led to a period of stability and use of ED alternatives. Modifiable targets for intervention at the health care system and local levels include improving trust and convenience of ED alternatives, enhancing consistency of care at ED-alternative sites, and educating those at risk of frequent ED use about community alternatives.
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Affiliation(s)
- Megan Moore
- Megan Moore, PhD, MSW, is Sidney Miller endowed associate professor in direct practice, School of Social Work, and core faculty, Harborview Injury Prevention and Research Center, University of Washington, Seattle. Kelsey M. Conrick, MPH, is research coordinator, School of Social Work, University of Washington, Seattle. Ashok Reddy, MD, MSc, is assistant professor, University of Washington Division of General Medicine; physician investigator, Health Services Research and Development Service, Veteran’s Administration (VA); and primary care provider, VA Puget Sound Health Care System, Seattle. Ann Allen, LICSW, is social worker, School of Social Work, University of Washington, Seattle. Craig Jaffe, MD, is a psychiatrist, Harborview Medical Center, Psychiatry, and clinical assistant professor of psychiatry and behavioral sciences, University of Washington, Seattle. This work was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (KL2TR000421 to MM) and the Northwest Center for Public Health Practice Training Program
| | - Kelsey M Conrick
- Megan Moore, PhD, MSW, is Sidney Miller endowed associate professor in direct practice, School of Social Work, and core faculty, Harborview Injury Prevention and Research Center, University of Washington, Seattle. Kelsey M. Conrick, MPH, is research coordinator, School of Social Work, University of Washington, Seattle. Ashok Reddy, MD, MSc, is assistant professor, University of Washington Division of General Medicine; physician investigator, Health Services Research and Development Service, Veteran’s Administration (VA); and primary care provider, VA Puget Sound Health Care System, Seattle. Ann Allen, LICSW, is social worker, School of Social Work, University of Washington, Seattle. Craig Jaffe, MD, is a psychiatrist, Harborview Medical Center, Psychiatry, and clinical assistant professor of psychiatry and behavioral sciences, University of Washington, Seattle. This work was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (KL2TR000421 to MM) and the Northwest Center for Public Health Practice Training Program
| | - Ashok Reddy
- Megan Moore, PhD, MSW, is Sidney Miller endowed associate professor in direct practice, School of Social Work, and core faculty, Harborview Injury Prevention and Research Center, University of Washington, Seattle. Kelsey M. Conrick, MPH, is research coordinator, School of Social Work, University of Washington, Seattle. Ashok Reddy, MD, MSc, is assistant professor, University of Washington Division of General Medicine; physician investigator, Health Services Research and Development Service, Veteran’s Administration (VA); and primary care provider, VA Puget Sound Health Care System, Seattle. Ann Allen, LICSW, is social worker, School of Social Work, University of Washington, Seattle. Craig Jaffe, MD, is a psychiatrist, Harborview Medical Center, Psychiatry, and clinical assistant professor of psychiatry and behavioral sciences, University of Washington, Seattle. This work was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (KL2TR000421 to MM) and the Northwest Center for Public Health Practice Training Program
| | - Ann Allen
- Megan Moore, PhD, MSW, is Sidney Miller endowed associate professor in direct practice, School of Social Work, and core faculty, Harborview Injury Prevention and Research Center, University of Washington, Seattle. Kelsey M. Conrick, MPH, is research coordinator, School of Social Work, University of Washington, Seattle. Ashok Reddy, MD, MSc, is assistant professor, University of Washington Division of General Medicine; physician investigator, Health Services Research and Development Service, Veteran’s Administration (VA); and primary care provider, VA Puget Sound Health Care System, Seattle. Ann Allen, LICSW, is social worker, School of Social Work, University of Washington, Seattle. Craig Jaffe, MD, is a psychiatrist, Harborview Medical Center, Psychiatry, and clinical assistant professor of psychiatry and behavioral sciences, University of Washington, Seattle. This work was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (KL2TR000421 to MM) and the Northwest Center for Public Health Practice Training Program
| | - Craig Jaffe
- Megan Moore, PhD, MSW, is Sidney Miller endowed associate professor in direct practice, School of Social Work, and core faculty, Harborview Injury Prevention and Research Center, University of Washington, Seattle. Kelsey M. Conrick, MPH, is research coordinator, School of Social Work, University of Washington, Seattle. Ashok Reddy, MD, MSc, is assistant professor, University of Washington Division of General Medicine; physician investigator, Health Services Research and Development Service, Veteran’s Administration (VA); and primary care provider, VA Puget Sound Health Care System, Seattle. Ann Allen, LICSW, is social worker, School of Social Work, University of Washington, Seattle. Craig Jaffe, MD, is a psychiatrist, Harborview Medical Center, Psychiatry, and clinical assistant professor of psychiatry and behavioral sciences, University of Washington, Seattle. This work was supported by the National Center for Advancing Translational Sciences of the National Institutes of Health (KL2TR000421 to MM) and the Northwest Center for Public Health Practice Training Program
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Rising KL, LaNoue MD, Gerolamo AM, Doty AM, Gentsch AT, Powell RE. Patient Uncertainty as a Predictor of 30-day Return Emergency Department Visits: An Observational Study. Acad Emerg Med 2019; 26:501-509. [PMID: 30246487 DOI: 10.1111/acem.13621] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Revised: 09/18/2018] [Accepted: 09/18/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The objective was to examine the relationship between patient uncertainty at the time of emergency department (ED) discharge as measured by the "Uncertainty Scale" (U-Scale) and 30-day return ED visits. We hypothesized that a higher score on the U-Scale predicts a higher likelihood of a 30-day return ED visit. METHODS This was a cross-sectional single-site pilot study performed with adult patients discharged from an urban academic ED to assess the relationship of U-Scale total and subscale scores with 30-day return ED visits. We collected demographic and U-Scale scores at the time of ED discharge and subsequent 30-day ED utilization data by follow-up telephone call. RESULTS No association was found between the total U-Scale score and subsequent ED utilization. Patients with higher uncertainty on the Treatment Quality subscale of the U-Scale had higher odds of a 30-day return ED visit (adjusted odds ratio [AOR] = 1.16), while patients with lower uncertainty on the Decision to Seek Care subscale had higher odds of a 30-day return ED visit (AOR = 0.68). CONCLUSION Patient uncertainty as measured by the U-Scale total score was not predictive of subsequent ED utilization. However, uncertainty related to treatment quality and the decision to seek care as measured by the U-Scale subscales may be important in predicting repeat ED utilization. Unlike individual patient factors such as age and race that have been associated with frequent ED visits in prior studies, these domains of uncertainty are potentially modifiable. Providers and health systems may successfully prevent recurrent acute care encounters through implementation of interventions designed to address patient uncertainty. Further work is needed to refine the U-Scale and test its predictive utility among a larger patient cohort.
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Affiliation(s)
| | | | | | | | | | - Rhea E. Powell
- Department of Internal Medicine Thomas Jefferson University Philadelphia PA
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Willging C, Gunderson L, Shattuck D, Sturm R, Lawyer A, Crandall C. Structural competency in emergency medicine services for transgender and gender non-conforming patients. Soc Sci Med 2018; 222:67-75. [PMID: 30605801 DOI: 10.1016/j.socscimed.2018.12.031] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2018] [Revised: 12/20/2018] [Accepted: 12/22/2018] [Indexed: 11/19/2022]
Abstract
In this formative qualitative research, we draw upon the concepts of structural vulnerability and structural competency to examine how transgender and gender non-conforming (TGGNC) patients and healthcare personnel experience service delivery in Emergency Departments (EDs), and how this experience can be improved upon. Between October 2016 and June 2017, we undertook 31 semi-structured interviews with TGGNC patients (n = 11) and physicians (n = 6), nurses (n = 7), and non-clinical staff (n = 7) in four community-based EDs in New Mexico. Our iterative coding and analysis process resulted in eight sets of findings: (1) reasons why TGGNC patients seek care from EDs; (2) perceptions about and experiences of TGGNC patients; (3) relevance of gender identity and sex at birth; (4) bureaucracy and communication; (5) spatial considerations; (6) preparing providers and staff to care for TGGNC patients; (7) the lack of resources for structural prescriptions; and (8) respect, humanity, and sameness. Findings suggest that structural issues adversely impact the health and wellbeing of TGGNC patients and service-delivery practices in the ED. We describe study implications for training ED personnel and modifying this practice setting to prevent delayed care and ensure appropriate services for TGGNC patients in need of structurally competent emergency medicine.
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Affiliation(s)
- Cathleen Willging
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, UNM Science and Technology Park, 851 University Boulevard, SE, Suite 101, Albuquerque, NM, 87106, USA; Department of Anthropology, University of New Mexico, MSC01-1040, 1 University of New, Mexico, Albuquerque, NM, 87131, USA.
| | - Lara Gunderson
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, UNM Science and Technology Park, 851 University Boulevard, SE, Suite 101, Albuquerque, NM, 87106, USA; Department of Anthropology, University of New Mexico, MSC01-1040, 1 University of New, Mexico, Albuquerque, NM, 87131, USA.
| | - Daniel Shattuck
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, UNM Science and Technology Park, 851 University Boulevard, SE, Suite 101, Albuquerque, NM, 87106, USA; Department of Anthropology, University of New Mexico, MSC01-1040, 1 University of New, Mexico, Albuquerque, NM, 87131, USA.
| | - Robert Sturm
- Behavioral Health Research Center of the Southwest, Pacific Institute for Research and Evaluation, UNM Science and Technology Park, 851 University Boulevard, SE, Suite 101, Albuquerque, NM, 87106, USA; New Mexico Community AIDS Partnership, 903 West Alameda #764, Santa Fe, NM, 87501, USA.
| | - Adrien Lawyer
- Transgender Resource Center of New Mexico, 149 Jackson Street, NE, Albuquerque, NM, 87108, USA.
| | - Cameron Crandall
- Department of Emergency Medicine, University of New Mexico, MSC11-6025, 700 Camino de Salud, Albuquerque, NM, 87131, USA.
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15
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LaNoue MD, Gerolamo AM, Powell R, Nord G, Doty AMB, Rising KL. Development and preliminary validation of a scale to measure patient uncertainty: The “Uncertainty Scale”. J Health Psychol 2018; 25:1248-1258. [DOI: 10.1177/1359105317752827] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Research suggests that patient uncertainty related to experiencing symptoms may drive decisions to seek care. The only validated measure of patient uncertainty assesses uncertainty related to defined illness. In prior work, we engaged patients to describe uncertainty related to symptoms and used findings to develop the ‘U-Scale’ scale. In this work, we present results from preliminary scale reliability and validity testing. Psychometric testing demonstrated content validity, high internal consistency, and evidence for concurrent validity. Next steps include administration in diverse populations for continued refinement and validation, and exploration of the potential contribution of uncertainty to healthcare utilization.
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