ED utilization: the effect of changing demographics from 1992 to 2000

Developing a Health-Spatial Indicator System for a Healthy City in Small and Midsized Cities

A recent examination of the significant role of public health has prompted calls to re-investigate how the urban environment affects public health. A vital part of the solution includes Healthy City initiatives that have been the subject of extensive policies, implications, and practices globally. However, the existing literature mainly focuses on big cities and metropolitan areas, while investigations into small and midsized cities (SMCs) are lacking, and thus reflect the underlying issues of health inequity. This study develops an indicator system for evaluating Healthy City initiatives in SMCs, linking urban design and public health, supported by the analyzed opinions from experts collected using both questionnaires and interviews. The indicator system includes six primary dimensions and 37 variables: urban form and transportation (UFT); health-friendly service (HFS); environmental quality and governance (EQG); community and facility (CF); green and open space (GOS); and ecological construction and biodiversity (ECB). A fuzzy synthetic evaluation technique was used to assess the relative importance of factors, emphasizing the importance of UFT, HFS, and EQG, with importance indexes of 0.175, 0.174, and 0.174, respectively. This indicator system is helpful for SMCs seeking to construct a Healthy City in the future, and is based on urban design and governance inputs and for enhancing the Healthy City knowledge base of cities of varied scales.

Here one year, gone the next? Investigating persistence of frequent emergency department attendance: a retrospective study in Australia

OBJECTIVES

Patients are presenting to emergency departments (EDs) with increasing complexity at rates beyond population growth and ageing. Intervention studies target patients with 12 months or less of frequent attendance. However, these interventions are not well targeted since most patients do not remain frequent attenders. This paper quantifies temporary and ongoing frequent attendance and contrasts risk factors for each group.

DESIGN

Retrospective population-based study using 10 years of longitudinal data.

SETTING

An Australian geographic region that includes metropolitan and rural EDs.

PARTICIPANTS

332 100 residents visited any ED during the study period.

MAIN OUTCOME MEASURE

Frequent attendance was defined as seven or more visits to any ED in the region within a 12-month period. Temporary frequent attendance was defined as meeting this threshold only once, and ongoing more than once. Risk factors for temporary and ongoing frequent attenders were identified using logistic regression models for adults and children.

RESULTS

Of 8577 frequent attenders, 80.1% were temporary and 19.9% ongoing (12.9% repeat, 7.1% persistent). Among adults, ongoing were more likely than temporary frequent attenders to be young to middle aged (aged 25-64 years), and less likely to be from a high socioeconomic area or be admitted. Ongoing frequent attenders had higher rates of non-injury presentations, in particular substance-related (OR=2.5, 99% CI 1.1 to 5.6) and psychiatric illness (OR=2.9, 99% CI 1.8 to 4.6). In comparison, children who were ongoing were more likely than temporary frequent attenders to be aged 5-15 years, and were not more likely to be admitted (OR=2.7, 99% CI 0.7 to 10.9).

CONCLUSIONS

Future intervention studies should distinguish between temporary and ongoing frequent attenders, develop specific interventions for each group and include rigorous evaluation.

Demand for hospital emergency departments: a conceptual understanding

BACKGROUND

Emergency departments (EDs) are critical to the management of acute illness and injury, and the provision of health system access. However, EDs have become increasingly congested due to increased demand, increased complexity of care and blocked access to ongoing care (access block). Congestion has clinical and organisational implications. This paper aims to describe the factors that appear to influence demand for ED services, and their interrelationships as the basis for further research into the role of private hospital EDs.

DATA SOURCES

Multiple databases (PubMed, ProQuest, Academic Search Elite and Science Direct) and relevant journals were searched using terms related to EDs and emergency health needs. Literature pertaining to emergency department utilisation worldwide was identified, and articles selected for further examination on the basis of their relevance and significance to ED demand.

RESULTS

Factors influencing ED demand can be categorized into those describing the health needs of the patients, those predisposing a patient to seeking help, and those relating to policy factors such as provision of services and insurance status. This paper describes the factors influencing ED presentations, and proposes a novel conceptual map of their interrelationship.

CONCLUSION

This review has explored the factors contributing to the growing demand for ED care, the influence these factors have on ED demand, and their interrelationships depicted in the conceptual model.

Profiles of older patients in the emergency department: findings from the interRAI Multinational Emergency Department Study

STUDY OBJECTIVE

We examine functional profiles and presence of geriatric syndromes among older patients attending 13 emergency departments (EDs) in 7 nations.

METHODS

This was a prospective observational study of a convenience sample of patients, aged 75 years and older, recruited sequentially and mainly during normal working hours. Clinical observations were drawn from the interRAI Emergency Department Screener, with assessments performed by trained nurses.

RESULTS

A sample of 2,282 patients (range 98 to 549 patients across nations) was recruited. Before becoming unwell, 46% were dependent on others in one or more aspects of personal activities of daily living. This proportion increased to 67% at presentation to the ED. In the ED, 26% exhibited evidence of cognitive impairment, and 49% could not walk without supervision. Recent falls were common (37%). Overall, at least 48% had a geriatric syndrome before becoming unwell, increasing to 78% at presentation to the ED. This pattern was consistent across nations.

CONCLUSION

Functional problems and geriatric syndromes affect the majority of older patients attending the ED, which may have important implications for clinical protocols and design of EDs.

The efficacy and value of emergency medicine: a supportive literature review

Study objectives

The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established.

Methods

The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included.

Results

A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles).

Conclusion

There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.

[Characteristics of the emergency health service demand in Southern Brazil]

This study evaluated the demand of emergency health service. It was performed a descriptive analyses of 1647 adults that consulted at emergency public service of Pelotas, Brazil. Older subjects, non white skin color, lower schooling, without partner, and smokers presented higher prevalence of consultations at this service when compared with the general population. Individuals waited, on average, 15 minutes to have their consultations, exams were requested in more than 40% of the visits, and intravenous medication were administered in one third of the visits. Elderly waited longer before searching the service, but they had lowest awaiting time after arriving at emergency service and had higher percentage of regular doctor and social support. Elderly had more diagnosis related to circulatory system, while among the youngest, external causes were the most frequent. The low waiting average for consultation suggest this service provide an immediate care while the great number of ill-defined signs or symptoms indicate that the provided care is provisional. It is necessary to train emergency professionals to reduce the number of tests requested and to assure that either professional as the population is conscious about the importance of a continuity of care.

Frequent use of emergency medical services by the elderly: a case-control study using paramedic records

OBJECTIVE

To identify the factors that lead to increased use of emergency medical services (EMS) by patients 65 years of age and older in an urban EMS system.

METHODS

Retrospective, case-control study of frequent EMS use among elderly patients transported during one year in an urban EMS system. Three distinct groups were examined for transports that took place in 1999: (1) 1-3 transports per year (low use); (2) 4-9 times per year (high use); and (3) those transported 10+ times (very high use). This frequency-use indicator variable is the primary outcome measurement. Predictors included age, gender, preexisting medical diseases, ethnicity, number of medications, number of medical problems, primary physician, psychiatric diagnosis, and homelessness. Analysis of predictors was done using ordinal logistic regression model, and a global test of interaction terms.

RESULTS

Male gender, black ethnicity, homelessness, and a variety of types of medical problems were associated with increased use of EMS resources. The strongest single predictor of case status remained homelessness, which was nearly eight times as commonly associated with frequent EMS use than for the controls. The number of medical problems and medications also were significantly associated with EMS use in this patient population. There was a lack of association of alcohol, substance abuse, and psychiatric disorders with EMS use. Patients with asthma who did not have a primary care physician were more likely to use EMS services than were those who had a physician.

CONCLUSIONS

This analysis highlights homelessness as being strongly associated with frequent EMS use among the elderly and downplays other associated factors, such as psychiatric disease and substance use. Medical illness severity, particularly asthma when no primary care physician is available, also appears to drive frequent EMS use. Both findings have implications in terms of targeting of public resources; providing housing to medically ill elderly and primary care to asthmatics in particular, may provide dividends not only in terms of social welfare and medical care, but in preventing frequent EMS use by the elderly.

Emergency department utilization in the United States and Ontario, Canada

OBJECTIVES

The current crisis in the emergency care system is characterized by worsening emergency department (ED) overcrowding. Lack of health insurance is widely perceived to be a major contributing factor to ED overcrowding in the United States. This study aimed to compare ED visit rates in the United States and Ontario, Canada, according to demographic and clinical characteristics.

METHODS

This was a cross sectional study consisting of a nationally representative sample of 40,253 ED visits included in the 2003 National Hospital Ambulatory Medical Care Survey in the United States, and all ED visits recorded during 2003 by the National Ambulatory Care Reporting System in Ontario, Canada. The main outcome was the number of ED visits per 100 population per year.

RESULTS

The annual ED visit rate in the United States was 39.9 visits (95% confidence interval = 37.2 to 42.6) per 100 population, virtually identical to the rate in Ontario, Canada (39.7 visits per 100 population). In both the United States and Ontario, Canada, those aged 75 years and older had the highest ED visit rate and women had a slightly higher ED visit rate than men. The most common discharge diagnosis was injury/poisoning, accounting for 25.6% of all ED visits in the United States and 24.7% in Ontario, Canada. Overall, 13.9% of ED patients in the United States were admitted to hospitals, compared with 10.5% in Ontario, Canada.

CONCLUSIONS

ED visit rates and patterns are similar in the United States and Ontario, Canada. Differences in health insurance coverage may not have a substantial impact on the overall utilization of emergency care.

Modeling crisis decision-making for children in state custody

We studied 1492 children in state custody over a 6-month period to investigate the relationship between children's hospital admissions and the crisis workers' clinical assessment. A 27-item standardized decision-support tool [the Childhood Severity of Psychiatric Illness (CSPI)] was used to evaluate the symptoms, risk factors, functioning, comorbidity, and system characteristics. The CSPI has been shown to have a reliability range from 0.70 to 0.80 using intraclass correlations. Logistic regression was used to calculate age-adjusted odds ratios (AOR) of hospitalization, their 95% confidence intervals, and corresponding P values. The results showed that risk factors, symptoms, functioning, comorbidities, and system characteristics were all associated with hospital admissions. Children with a recent suicide attempt, severe danger to others, or history of running away from home/treatment settings were more likely to be hospitalized (respective AOR=12.7, P<.0001; AOR=32.3, P<.0001; AOR=3.0, P=.001). In addition, hospitalization was inversely associated with caregiver knowledge of children (AOR=0.2, P=.01) and multisystem needs (AOR=0.3, P=.04). The decision to hospitalize children psychiatrically appears to be complex. As predicted, risk behaviors and severe symptoms were independent predictors of children's hospital admissions. Interestingly, the capacity of the caregiver and the children's involvement in multiple systems also predict children's hospital admissions.