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Furbacher J, Fockele C, Del Buono B, Janneck L, March C, Molina M, Duber H, Doran K, Lin M, Cooper R, Modi P. 2021 SAEM Consensus Conference Proceedings: Research Priorities for Developing Emergency Department Screening Tools for Social Risks and Needs. West J Emerg Med 2022; 23:817-822. [DOI: 10.5811/westjem.2022.8.57271] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2022] [Accepted: 08/17/2022] [Indexed: 11/12/2022] Open
Abstract
Introduction: The Emergency Department (ED) acts as a safety net for our healthcare system. While studies have shown increased prevalence of social risks and needs among ED patients, there are many outstanding questions about the validity and use of social risks and needs screening tools in the ED setting.
Methods: In this paper, we present research gaps and priorities pertaining to social risks and needs screening tools used in the ED, identified through a consensus approach informed by literature review and external expert feedback as part of the 2021 SAEM Consensus Conference -- From Bedside to Policy: Advancing Social Emergency Medicine and Population Health.
Results: Four overarching research gaps were identified: (1) Defining the purpose and ethical implications of ED-based screening; (2) Identifying domains of social risks and needs; (3) Developing and validating screening tools; and (4) Defining the patient population and type of screening performed. Furthermore, the following research questions were determined to be of highest priority: (1) What screening tools should be used to identify social risks and needs? (2) Should individual EDs use a national standard screening tools or customized screening tools? (3) What are the most prevalent social risks and needs in the ED? and (4) Which social risks and needs are most amenable to intervention in the ED setting?
Conclusion: Answering these research questions will facilitate the use of evidence-based social risks and needs screening tools that address knowledge gaps and improve the health of our communities by better understanding the underlying determinants contributing to their presentation and health outcomes.
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Affiliation(s)
- Jacqueline Furbacher
- University of Massachusetts Chan Medical School, Department of Emergency Medicine, Worcester, Massachusetts
| | - Callan Fockele
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Ben Del Buono
- Virginia Commonwealth University, Department of Emergency Medicine, Richmond, Virginia
| | - Laura Janneck
- University of Oklahoma School of Community Medicine, Department of Emergency Medicine, Tulsa, Oklahoma
| | - Cooper March
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Melanie Molina
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Herbet Duber
- University of Washington, Department of Emergency Medicine, Seattle, Washington
| | - Kelly Doran
- NYU School of Medicine, Departments of Emergency Medicine and Population Health, New York, New York
| | - Michelle Lin
- Stanford University School of Medicine, Department of Emergency Medicine, Stanford, California
| | - Richelle Cooper
- UCLA School of Medicine, Department of Emergency Medicine, Los Angeles, California
| | - Payal Modi
- University of Massachusetts Chan Medical School, Department of Emergency Medicine, Worcester, Massachusetts
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D'Andrea G, Suprani F, Tolomelli E, Gennari M, Lanari M, Faldella G, Muratori R, Berardi D, Tarricone I. Childhood medical history and psychosis in adult life: Findings from the Bologna EU-GEI incidence and case-control study. Early Interv Psychiatry 2021; 15:397-401. [PMID: 32351018 DOI: 10.1111/eip.12970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Revised: 03/11/2020] [Accepted: 04/02/2020] [Indexed: 11/28/2022]
Abstract
AIM To estimate the association between the inpatient admissions and Emergency Department (ED) visits before age of 18 years and adulthood-onset first-episode psychosis (FEP). METHODS We conducted a FEP incidence and case-control study and calculated the odds ratios (ORs) for incident FEP associated with inpatient admissions and ED visits prior to age of 18 years, adjusting our results for cannabis use, parental socio-economic class and childhood trauma. RESULTS In multivariate logistic regression analysis, odds of FEP increased significantly if the participant had a history of at least one inpatient admission (OR = 3.52; 95% confidence interval [95%CI] 1.07-11.54; P = .04) or at least one ED visit (OR = 8.93; 95%CI 2.41-33.14; P = .001) before age of 18. The associations remained significant adjusting for cannabis use, education, parental socio-economic class and childhood trauma. CONCLUSION Consistently with the socio-neurodevelopmental model, we found a significant association between a positive history of hospital care in childhood and adulthood-onset psychosis.
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Affiliation(s)
- Giuseppe D'Andrea
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy
| | - Federico Suprani
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Elena Tolomelli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy
| | - Monia Gennari
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Marcello Lanari
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi University Hospital, Bologna, Italy
| | - Giacomo Faldella
- Pediatric Emergency Unit, Department of Medical and Surgical Sciences (DIMEC), St. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Domenico Berardi
- Department of Biomedical and NeuroMotor Sciences (DIBINEM), University of Bologna, Bologna, Italy.,Department of Mental Health, AUSL Bologna, Bologna, Italy
| | - Ilaria Tarricone
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Bologna, Italy.,Department of Mental Health, AUSL Bologna, Bologna, Italy
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Walter LA, Leader E, Galbraith JW. Human Papillomavirus Awareness, Vaccine Status, and Risk Factors in Female Emergency Patients. West J Emerg Med 2020; 21:203-208. [PMID: 32191177 PMCID: PMC7081844 DOI: 10.5811/westjem.2019.12.44422] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2019] [Accepted: 12/05/2019] [Indexed: 12/27/2022] Open
Abstract
Introduction A vaccine targeting high-risk human papillomavirus (HPV) strains can effectively prevent HPV-associated cervical cancer risk. However, many girls and women do not receive the vaccine, more often those impacted by health disparities associated with race and/or socioeconomic status. This same disparate population has also been shown to be at higher risk for cervical cancer. Many of these women also rely on the emergency department (ED) as a safety net for their healthcare. This study sought to gather information pertaining to HPV and cervical cancer risk factors, awareness of HPV and the vaccine, as well as HPV vaccine uptake in female patients presenting to an ED. Methods We obtained 81 surveys completed by female ED patients. Demographics included age, race, income, insurance status, primary care provider status, and known cervical-cancer risk factors. Subsequent survey questions explored respondents’ knowledge, familiarity, and attitudes regarding HPV, cervical cancer, and the HPV vaccine, including vaccination uptake rates. We analyzed data using descriptive statistics and Fisher’s exact test. Results Approximately one in seven respondents (14.8%) had never previously heard of HPV and 32.1% were unaware of the existence of a HPV vaccine. Minority patients, including those who were Black and Hispanic patients, low income patients, and uninsured and publicly insured patients were less likely to be aware of HPV and the vaccine and likewise were less likely to be offered and receive the vaccine. More than 60% of all respondents (61.3%) had never previously been offered the vaccine, and only 24.7% of all respondents had completed the vaccine series. Conclusion Female ED patients may represent an at-risk cohort with relatively low HPV awareness and low HPV vaccine uptake. The ED could represent a novel opportunity to access and engage high-risk HPV populations.
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Affiliation(s)
- Lauren A Walter
- University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama
| | - Elizabeth Leader
- University of Alabama at Birmingham, Department of Emergency Medicine, Birmingham, Alabama
| | - James W Galbraith
- University of Mississippi Medical Center, Department of Emergency Medicine, Jackson, Mississippi
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Dorsett M, Cooper RJ, Taira BR, Wilkes E, Hoffman JR. Bringing value, balance and humanity to the emergency department: The Right Care Top 10 for emergency medicine. Emerg Med J 2019; 37:240-245. [PMID: 31874920 DOI: 10.1136/emermed-2019-209031] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/25/2019] [Accepted: 12/09/2019] [Indexed: 01/29/2023]
Affiliation(s)
- Maia Dorsett
- Emergency Medicine, University of Rochester Medical Center, Rochester, New York, USA
| | - Richelle J Cooper
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Breena R Taira
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
| | - Erin Wilkes
- Kaiser Permanente LAMC, Los Angeles, California, USA
| | - Jerome R Hoffman
- Department of Emergency Medicine, University of California Los Angeles, Los Angeles, California, USA
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Jackson TS, Moran TP, Lin J, Ackerman J, Salhi BA. Homelessness Among Patients in a Southeastern Safety Net Emergency Department. South Med J 2019; 112:476-482. [PMID: 31485585 DOI: 10.14423/smj.0000000000001016] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
OBJECTIVES Emergency departments (EDs) are important providers for homeless individuals, providing vital health care and meeting the subsistence needs of many homeless patients (eg, food, water, shelter). Studies that have examined the proportion of patients in the ED setting who experience homelessness have been conducted primarily in the northeastern United States. We hypothesized that findings from prior studies, conducted primarily in the Northeast, would not generalize to other regions of the United States. We conducted a direct patient survey to describe the proportion and demographics of ED patients who have experienced homelessness within the past 12 months in an urban safety net hospital in Atlanta, Georgia. METHODS A cross-sectional survey of a convenience sample of patients presenting to the ED from September to December 2016. A team of trained research assistants administered a structured survey instrument to patients who were 18 years old, English speakers, not incarcerated, and able to provide informed consent. Questions were based on the US Department of Health and Human Services definition of homelessness. RESULTS A total of 923 ED patients (55.1% male; median age 44 years) completed the survey. Of the ED patients surveyed, 51.5% reported some measure of homelessness in the past 12 months: lived with others but did not pay rent (n = 279, 30.2%), skipped mortgage or rent payment (n = 111, 12%), experienced eviction (n = 74, 8%), lived in a hotel or motel (n = 196, 21.2%), lived in a place not meant for human habitation (n = 76, 8.2%), slept in a shelter (n = 131, 14.2%), and slept on the street (n = 115, 12.5%). Men (odds ratio [OR] 1.56, 95% confidence interval [CI] 1.17-2.09), patients who completed some school (OR 2.85, 95% CI 1.72-4.71), and patients who completed high school (OR 2.32, 95% CI 1.53-3.52) were more likely to have experienced homelessness in the 12 months preceding their ED visit. CONCLUSIONS The rate of patients experiencing homelessness at our hospital is substantially greater than those reported in prior surveys of ED patients. More research is needed on homelessness and its implications for ED patients.
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Affiliation(s)
- Toni S Jackson
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
| | - Tim P Moran
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
| | - Jonathan Lin
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
| | - Jeremy Ackerman
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
| | - Bisan A Salhi
- From the Department of Emergency Medicine, Emory University, Atlanta, Georgia, and the Georgia Institute of Technology, Atlanta
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6
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Doran KM, Ran Z, Castelblanco D, Shelley D, Padgett DK. "It Wasn't Just One Thing": A Qualitative Study of Newly Homeless Emergency Department Patients. Acad Emerg Med 2019; 26:982-993. [PMID: 31418514 DOI: 10.1111/acem.13677] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Revised: 12/17/2018] [Accepted: 12/18/2018] [Indexed: 11/28/2022]
Abstract
OBJECTIVES Emergency departments (EDs) frequently care for patients who are homeless or unstably housed. One promising approach taken by the homeless services system is to provide interventions that attempt to prevent homelessness before it occurs. Experts have suggested that health care settings may be ideal locations to identify and intervene with patients at risk for homelessness, yet little is known even about the basic characteristics of patients who might benefit from such interventions. METHODS We conducted in-depth, one-on-one qualitative interviews with ED patients who had become homeless within the past 6 months. Using a semistructured interview guide, we asked patients about their pathways into homelessness and what might have prevented them from becoming homeless. Interviews were digitally recorded and professionally transcribed. Transcripts were coded line by line by multiple investigators who then met as a group to discuss and refine codes in an iterative fashion. RESULTS Interviews were completed with 31 patients. Mean interview length was 42 minutes. Four main themes emerged: 1) unique stories yet common social and health contributors to homelessness, 2) personal agency versus larger structural forces, 3) limitations in help from family or friends, and 4) homelessness was not expected. CONCLUSIONS These findings demonstrate gaps in current homeless prevention services and can help inform future interventions for unstably housed and homeless ED patients. More immediately, the findings provide rich, unique context to the lives of a vulnerable patient population commonly seen in EDs.
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Affiliation(s)
- Kelly M. Doran
- Department of Emergency Medicine NYU School of Medicine New York NY
- Department of Population Health NYU School of Medicine New York NY
| | - Ziwei Ran
- NYU Silver School of Social Work New York NY
| | | | - Donna Shelley
- Department of Population Health NYU School of Medicine New York NY
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Lynch S, Pines J, Mutter R, Teich JL, Hendry P. Characterizing behavioral health-related emergency department utilization among children with Medicaid: Comparing high and low frequency utilizers. SOCIAL WORK IN HEALTH CARE 2019; 58:807-824. [PMID: 31422764 DOI: 10.1080/00981389.2019.1653418] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Revised: 07/23/2019] [Accepted: 08/03/2019] [Indexed: 06/10/2023]
Abstract
While the frequency of children's behavioral health (BH)-related visits to the emergency department (ED) is rising nationwide, few studies have examined predictors of high rates of ED use. This study examines Florida Medicaid claims (2011-2012) for children age 0-18 who were seen in an emergency department (ED) for behavioral health (BH) conditions. A logistic regression model was used to explore factors associated with frequent ED use and patterns of psychotropic medication utilization. The majority (95%) of patients with at least one BH-related ED visit had three or fewer of these visits, but 5% had four or more. Seventy-four percent of ED visits were not associated with psychotropic medication, including over half (54%) of visits for attention deficit hyperactivity disorder (ADHD). Frequent ED use was higher among older children and those with substance use disorders. The implementation of interventions that reduce non-emergent ED visits through the provision of care coordination, social work services, and/or the use of community health workers as care navigators may address these findings.
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Affiliation(s)
- Sean Lynch
- U.S. Department of Health & Human Services, Substance Abuse & Mental Health Services Administration, Center for Behavioral Health Statistics & Quality , Rockville , MD , USA
| | - Jesse Pines
- Department of Emergency Medicine, George Washington University , Washington , DC , USA
| | - Ryan Mutter
- U.S. Department of Health & Human Services, Substance Abuse & Mental Health Services Administration, Center for Behavioral Health Statistics & Quality , Rockville , MD , USA
| | - Judith L Teich
- U.S. Department of Health & Human Services, Substance Abuse & Mental Health Services Administration, Center for Behavioral Health Statistics & Quality , Rockville , MD , USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida-Jacksonville , Jacksonville , FL , USA
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Schmiedhofer M, Inhoff T, Krobisch V, Schenk L, Rose M, Holzinger F, Keil T, Müller-Werdan U, Günster C, Möckel M. [EMANet: A regional network for health services research in emergency and acute medicine]. ZEITSCHRIFT FUR EVIDENZ FORTBILDUNG UND QUALITAET IM GESUNDHEITSWESEN 2018; 135-136:81-88. [PMID: 30122458 DOI: 10.1016/j.zefq.2018.07.009] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Revised: 07/17/2018] [Accepted: 07/18/2018] [Indexed: 11/19/2022]
Abstract
The number of patients seeking help in emergency departments is steadily increasing. In part, this is due to patients who have acute symptoms, but do not require emergency care, as well as multimorbid patients needing complex medical care. Emergency departments serve as an interface between primary care and in-patient as well as out-patient care. The ongoing public discussion about the need to readjust emergency care structures in Germany does not adequately address this aspect. The knowledge of characteristics and needs of patients seeking help in emergency departments is insufficient. In order to develop interventions matching these needs it is necessary to gain deeper insight into these characteristics and needs. EMANet is a health services research project funded by the Federal Ministry of Education and Research. Its aim is to collect representative data on the course of medical care of emergency patients with ambulatory care sensitive conditions in all eight emergency departments in Mitte, the inner city district of Berlin. The EMANet project focuses on three patient groups: a) patients with cardiac symptoms and possible psychiatric comorbidities, b) ambulatory patients with acute or chronic diseases of the respiratory tract, and c) geriatric patients with hip fractures. The collected data shall be used to gain a better understanding of health care utilization patterns, patient-perceived satisfaction and risk factors for potentially avoidable medical conditions or worsening of chronic disease. The mixed methods design of EMANet includes quantitative data of 1,650 patients at two time points and corresponding secondary (i. e. routine) data from hospital information systems. In addition, qualitative interviews with patients and health care professionals shall reveal unmet needs for medical care. The results will give us more in-depth insight into the perceived current capacity overload and help implement structural changes in the health care system.
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Affiliation(s)
- Martina Schmiedhofer
- Arbeitsbereich Notfallmedizin, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland.
| | - Tobias Inhoff
- Arbeitsbereich Notfallmedizin, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | - Verena Krobisch
- Institut für Medizinische Soziologie und Rehabilitationswissenschaft, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | - Liane Schenk
- Institut für Medizinische Soziologie und Rehabilitationswissenschaft, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | - Matthias Rose
- Medizinische Klinik mit Schwerpunkt Psychosomatik, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | - Felix Holzinger
- Institut für Allgemeinmedizin, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | - Thomas Keil
- Institut für Sozialmedizin, Epidemiologie und Gesundheitsökonomie, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | - Ursula Müller-Werdan
- Klinik für Geriatrie und Altersmedizin, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
| | | | - Martin Möckel
- Arbeitsbereich Notfallmedizin, Charite-Universitätsmedizin Berlin. Corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin and Berlin Institute of Health, Berlin, Deutschland
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Salhi BA, White MH, Pitts SR, Wright DW. Homelessness and Emergency Medicine: A Review of the Literature. Acad Emerg Med 2018; 25:577-593. [PMID: 29223132 DOI: 10.1111/acem.13358] [Citation(s) in RCA: 72] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2017] [Revised: 11/24/2017] [Accepted: 12/04/2017] [Indexed: 11/27/2022]
Abstract
OBJECTIVES We aimed to synthesize the available evidence on the demographics, prevalence, clinical characteristics, and evidence-based management of homeless persons in the emergency department (ED). Where appropriate, we highlight knowledge gaps and suggest directions for future research. METHODS We conducted a systematic literature search following databases: PubMed, Ovid, and Google Scholar for articles published between January 1, 1990, and December 31, 2016. We supplemented this search by cross-referencing bibliographies of the retrieved publications. Peer-reviewed studies written in English and conducted in the United States that examined homelessness within the ED setting were included. We used a qualitative approach to synthesize the existing literature. RESULTS Twenty-eight studies were identified that met the inclusion criteria. Based on our study objectives and the available literature, we grouped articles examining homeless populations in the ED into four broad categories: 1) prevalence and sociodemographic characteristics of homeless ED visits, 2) ED utilization by homeless adults, 3) clinical characteristics of homeless ED visits, and 4) medical education and evidence-based management of homeless ED patients. CONCLUSION Homelessness may be underrecognized in the ED setting. Homeless ED patients have distinct care needs and patterns of ED utilization that are unmet by the current disease-oriented and episodic models of emergency medicine. More research is needed to determine the prevalence and characteristics of homelessness in the ED and to develop evidence-based treatment strategies in caring for this vulnerable population.
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Affiliation(s)
- Bisan A. Salhi
- Department of Emergency Medicine Emory University Atlanta GA
- Department of Anthropology Emory University Atlanta GA
| | | | | | - David W. Wright
- Department of Emergency Medicine Emory University Atlanta GA
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Komenda P, Tangri N, Klajncar E, Eng A, Di Nella M, Hiebert B, Strome T, Lobato de Faria R, Zacharias JM, Verrelli M, Sood MM, Rigatto C. Patterns of emergency department utilization by patients on chronic dialysis: A population-based study. PLoS One 2018; 13:e0195323. [PMID: 29664922 PMCID: PMC5903639 DOI: 10.1371/journal.pone.0195323] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 03/20/2018] [Indexed: 11/18/2022] Open
Abstract
Importance Patients on dialysis are often elderly and frail, with multiple comorbid conditions, and are heavy users of Emergency Department (ED) services. However, objective data on the frequency and pattern of ED utilization by dialysis patients are sparse. Such data could identify periods of highest risk for ED visits and inform health systems interventions to mitigate these risks and improve outcomes Objective To describe the pattern and frequency of presentation to ER by dialysis patients Design Retrospective cohort study using administrative data collected over ten years (2000–2009) in the Province of Manitoba, Canada. Setting Patients presenting to any of 9 ED’s in Winnipeg and Brandon Manitoba. These departments serve >90% of the population of Manitoba, Canada (population 1.2 million). Participants All patients presenting to an ED in any of 9 emergency departments in Manitoba, Canada. Exposure Dialysis status Main outcomes Presentation to the ED Results Over 2.1 million ED visits by more than 1.2 million non-dialysis patients and 17,782 ED visits by 3257 dialysis patients were included. Dialysis patients presented 8.5 times more frequently to the ED than the general population (age and sex adjusted, p<0.001). For dialysis patients, ED utilization was significantly higher following the long interdialytic interval (33.6% higher Mondays and 19.5% higher Tuesdays vs. other days of the week, p<0.001) and was 10-fold higher in the 7 days before and after the initiation of dialysis. Conclusion and relevance The heavy use of ED services by dialysis patients spikes upward following the long interdialytic interval and also in the week before and after dialysis initiation. The relative risks associated with these vulnerable periods were much higher than those reported for clinical patient characteristics. We propose that intrinsic gaps in the structure of care delivery (e.g. 3 times a week dialysis, imperfect surveillance and clinical monitoring of patients with low GFR) may be the fundamental drivers of this periodicity. Strategies to mitigate this excess health risk are needed.
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Affiliation(s)
- Paul Komenda
- Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Navdeep Tangri
- Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Evan Klajncar
- Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Amanda Eng
- Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Michelle Di Nella
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Brett Hiebert
- Cardiac Sciences Program, St. Boniface General Hospital, Winnipeg, MB, Canada
| | - Trevor Strome
- Winnipeg Regional Health Authority, Emergency Department Program, Winnipeg, MB, Canada
| | | | - James M. Zacharias
- Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
| | - Mauro Verrelli
- Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
| | - Manish M. Sood
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- University of Ottawa, Ottawa, ON, Canada
| | - Claudio Rigatto
- Faculty of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Manitoba Renal Program, Winnipeg, MB, Canada
- Chronic Disease Innovation Centre, Seven Oaks General Hospital, Winnipeg, MB, Canada
- * E-mail:
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11
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Are acute care settings amenable to addressing patient social needs: A sub-group analysis. Am J Emerg Med 2018; 36:2108-2109. [PMID: 29576258 DOI: 10.1016/j.ajem.2018.03.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 03/15/2018] [Accepted: 03/15/2018] [Indexed: 11/22/2022] Open
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12
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Malecha PW, Williams JH, Kunzler NM, Goldfrank LR, Alter HJ, Doran KM. Material Needs of Emergency Department Patients: A Systematic Review. Acad Emerg Med 2018; 25:330-359. [PMID: 29266523 DOI: 10.1111/acem.13370] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Revised: 12/08/2017] [Accepted: 12/12/2017] [Indexed: 12/01/2022]
Abstract
BACKGROUND Interest in social determinants of health (SDOH) has expanded in recent years, driven by a recognition that such factors may influence health outcomes, services use, and health care costs. One subset of SDOH is material needs such as housing and food. We conducted a systematic review of the literature on material needs among emergency department (ED) patients in the United States. METHODS We followed PRISMA guidelines for systematic review methodology. With the assistance of a research librarian, four databases were searched for studies examining material needs among ED patients. Two reviewers independently screened titles, abstracts, and full text to identify eligible articles. Information was abstracted systematically from eligible articles. RESULTS Forty-three articles were eligible for inclusion. There was heterogeneity in study methods; single-center, cross-sectional studies were most common. Specific material needs examined included homelessness, poverty, housing insecurity, housing quality, food insecurity, unemployment, difficulty paying for health care, and difficulty affording basic expenses. Studies overwhelmingly supported the notion that ED patients have a high prevalence of a number of material needs. CONCLUSIONS Despite some limitations in the individual studies examined in this review, the plurality of prior research confirms that the ED serves a vulnerable population with high rates of material needs. Future research is needed to better understand the role these needs play for ED patients and how to best address them.
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Affiliation(s)
| | - James H. Williams
- Department of Emergency Medicine Harbor–UCLA Medical Center TorranceCA
| | - Nathan M. Kunzler
- Brigham and Women's/Massachusetts General Hospital Harvard Affiliated Emergency Medicine Boston MA
| | - Lewis R. Goldfrank
- Ronald O. Perelman Department of Emergency Medicine NYU School of Medicine New York NY
| | - Harrison J. Alter
- Department of Emergency Medicine Highland Hospital–Alameda Health System Oakland CA
| | - Kelly M. Doran
- Ronald O. Perelman Department of Emergency Medicine NYU School of Medicine New York NY
- Department of Population Health NYU School of Medicine New York NY
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13
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Huynh C, Ferland F, Blanchette-Martin N, Ménard JM, Fleury MJ. Factors Influencing the Frequency of Emergency Department Utilization by Individuals with Substance Use Disorders. Psychiatr Q 2016; 87:713-728. [PMID: 26875101 DOI: 10.1007/s11126-016-9422-6] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
This study assessed the characteristics of individuals with substance use disorders (ISUDs) according to their frequency of emergency department (ED) utilization, and examined which variables were associated with an increase in ED visits using Andersen's model. Data linkage of administrative databanks from three sources [addiction rehabilitation centre registry, physician billing systems, and hospital discharge databank] for 4526 ISUDs was performed. Predisposing, enabling and need factors associated with number of ED visits were determined using a negative binomial regression model and generalised estimating equations. The rate of ED utilization for this population was 9.6 %. Increased number of ED visits was associated with the following variables: older age, social fragmentation, number of consultations with general practitioners, number of consultations with psychiatrists, number of consultations with other types of physicians, alcohol abuse, drug abuse, schizophrenia, anxiety disorders, personality disorders, co-occurring substance dependence and mental disorders, co-occurring substance dependence and chronic physical disorders, and co-occurring mental health disorders and chronic physical disorders. By contrast, a diagnosis of substance dependence, co-occurring drug and alcohol abuse, and a co-occurring diagnosis of substance dependence with mental health and chronic physical disorders decreased ED visits. Efforts to reduce avoidable use of EDs should focus on chronic-disease management and other related strategies aimed at reinforcing services to ISUDs in the community, especially for ISUDs with a co-occurring diagnosis of either mental health disorders or chronic physical disorders.
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Affiliation(s)
- Christophe Huynh
- Centre de réadaptation en dépendance de Montréal - Institut universitaire, 950, rue de Louvain Est, Montreal, QC, H2M 2E8, Canada.
| | - Francine Ferland
- Centre de réadaptation en dépendance de Québec, 2525, chemin de la Canardière, Quebec, QC, G1J 2G3, Canada.,Centre de réadaptation en dépendance de Chaudière-Appalaches, 419, Dorimène-Desjardins, Lévis, QC, G6V 5V3, Canada
| | - Nadine Blanchette-Martin
- Centre de réadaptation en dépendance de Québec, 2525, chemin de la Canardière, Quebec, QC, G1J 2G3, Canada.,Centre de réadaptation en dépendance de Chaudière-Appalaches, 419, Dorimène-Desjardins, Lévis, QC, G6V 5V3, Canada
| | - Jean-Marc Ménard
- Centre de réadaptation en dépendance Domrémy-de-la-Mauricie-Centre-du-Québec, 440 rue des Forges, Trois-Rivières, QC, G9A 2H5, Canada
| | - Marie-Josée Fleury
- Centre de réadaptation en dépendance de Montréal - Institut universitaire, 950, rue de Louvain Est, Montreal, QC, H2M 2E8, Canada.,Department of Psychiatry, McGill University, Douglas Mental Health University Institute Research Centre, Quebec, Canada
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14
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Doran KM, McCormack RP, Johns EL, Carr BG, Smith SW, Goldfrank LR, Lee DC. Emergency Department Visits for Homelessness or Inadequate Housing in New York City before and after Hurricane Sandy. J Urban Health 2016; 93:331-44. [PMID: 26979519 PMCID: PMC4835349 DOI: 10.1007/s11524-016-0035-z] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.
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Affiliation(s)
- Kelly M Doran
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA.,Department of Population Health, New York University School of Medicine, New York, NY, USA
| | - Ryan P McCormack
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA
| | - Eileen L Johns
- New York City Center for Innovation through Data Intelligence, New York, NY, USA
| | - Brendan G Carr
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.,Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC, USA
| | - Silas W Smith
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA
| | - Lewis R Goldfrank
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA
| | - David C Lee
- Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA. .,Department of Population Health, New York University School of Medicine, New York, NY, USA.
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15
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Hill M, Okugo G. Emergency medicine physician attitudes toward HPV vaccine uptake in an emergency department setting. Hum Vaccin Immunother 2014; 10:2551-6. [PMID: 25483493 PMCID: PMC4977447 DOI: 10.4161/21645515.2014.970933] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2014] [Revised: 06/02/2014] [Accepted: 06/18/2014] [Indexed: 11/19/2022] Open
Abstract
A physician's recommendation is the most effective published method of motivating HPV vaccination initiation. The emergency department (ED) is the 'public health safety net', and often the only access to care for underserved populations. Recommendation of the HPV vaccine in the ED is a potential avenue to improve vaccination rates among sub-populations who do not have access to routine medical care. We assessed willingness of EM physicians to recommend the vaccine, target high-risk women, and disclose perceived barriers to vaccination in the ED. A cross sectional study using an 11-item survey, was used to assess physician attitudes toward recommending the HPV vaccine in an ED setting to age eligible patients. 67.4% stated they would recommend the vaccine, 23.9% were neutral, and 8.7% would not recommend the vaccine to age eligible patients in the ED. 41% noted lack of adequate reimbursement for vaccination as a barrier to vaccination in the ED (P<0.05). Physicians were comfortable targeting women at high risk for cervical cancer for vaccination (P<0.05). EM physicians are comfortable targeting high-risk women for HPV vaccination in an ED setting. Support of EM physicians in the national effort to improve HPV vaccine uptake is an important step in eradicating a largely preventable yet lethal cancer.
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Affiliation(s)
- Mandy Hill
- The University of Texas Health Science Center at Houston; Department of Emergency Medicine; School of Medicine; Houston, TX USA
| | - Glory Okugo
- The University of Texas Health Science Center at Houston; Department of Emergency Medicine; School of Medicine; Houston, TX USA
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16
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Tricco AC, Antony J, Ivers NM, Ashoor HM, Khan PA, Blondal E, Ghassemi M, MacDonald H, Chen MH, Ezer LK, Straus SE. Effectiveness of quality improvement strategies for coordination of care to reduce use of health care services: a systematic review and meta-analysis. CMAJ 2014; 186:E568-78. [PMID: 25225226 DOI: 10.1503/cmaj.140289] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Frequent users of health care services are a relatively small group of patients who account for a disproportionately large amount of health care utilization. We conducted a meta-analysis of the effectiveness of interventions to improve the coordination of care to reduce health care utilization in this patient group. METHODS We searched MEDLINE, Embase and the Cochrane Library from inception until May 2014 for randomized clinical trials (RCTs) assessing quality improvement strategies for the coordination of care of frequent users of the health care system. Articles were screened, and data abstracted and appraised for quality by 2 reviewers, independently. Random effects meta-analyses were conducted. RESULTS We identified 36 RCTs and 14 companion reports (total 7494 patients). Significantly fewer patients in the intervention group than in the control group were admitted to hospital (relative risk [RR] 0.81, 95% confidence interval [CI] 0.72-0.91). In subgroup analyses, a similar effect was observed among patients with chronic medical conditions other than mental illness, but not among patients with mental illness. In addition, significantly fewer patients 65 years and older in the intervention group than in the control group visited emergency departments (RR 0.69, 95% CI 0.54-0.89). INTERPRETATION We found that quality improvement strategies for coordination of care reduced hospital admissions among patients with chronic conditions other than mental illness and reduced emergency department visits among older patients. Our results may help clinicians and policy-makers reduce utilization through the use of strategies that target the system (team changes, case management) and the patient (promotion of self-management).
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Affiliation(s)
- Andrea C Tricco
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Jesmin Antony
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Noah M Ivers
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Huda M Ashoor
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Paul A Khan
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Erik Blondal
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Marco Ghassemi
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Heather MacDonald
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Maggie H Chen
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Lianne Kark Ezer
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont
| | - Sharon E Straus
- Li Ka Shing Knowledge Institute (Tricco, Antony, Ashoor, Khan, Blondal, Ghassemi, MacDonald, Chen, Ezer, Straus), St. Michael's Hospital, Toronto, Ont.; Division of Epidemiology (Tricco), Dalla Lana School of Public Health, University of Toronto, Toronto, Ont.; Women's College Hospital (Ivers), Toronto, Ont.; Departments of Family and Community Medicine (Ivers) and of Geriatric Medicine (Straus), University of Toronto, Toronto, Ont.
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17
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Hill M, Okugo G. Emergency Medicine Physician Attitudes toward HPV vaccine uptake in an Emergency Department Setting. Hum Vaccin Immunother 2014. [DOI: 10.4161/hv.29634] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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18
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Doran KM, Vashi AA, Platis S, Curry LA, Rowe M, Gang M, Vaca FE. Navigating the boundaries of emergency department care: addressing the medical and social needs of patients who are homeless. Am J Public Health 2013; 103 Suppl 2:S355-60. [PMID: 24148054 DOI: 10.2105/ajph.2013.301540] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We sought to understand interpersonal and systems-level factors relevant to delivering health care to emergency department (ED) patients who are homeless. METHODS We conducted semistructured interviews with emergency medicine residents from 2 residency programs, 1 in New York City and 1 in a medium-sized northeastern city, from February to September 2012. A team of researchers reviewed transcripts independently and coded text segments using a grounded theory approach. They reconciled differences in code interpretations and generated themes inductively. Data collection and analysis occurred iteratively, and interviews continued until theoretical saturation was achieved. RESULTS From 23 interviews, 3 key themes emerged: (1) use of pattern recognition in identifying and treating patients who are homeless, (2) variations from standard ED care for patients who are homeless, and (3) tensions in navigating the boundaries of ED social care. CONCLUSIONS Our study revealed practical and philosophical tensions in providing social care to patients in the ED who are homeless. Screening for homelessness in the ED and admission practices for patients who are homeless are important areas for future research and intervention with implications for health care costs and patient outcomes.
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Affiliation(s)
- Kelly M Doran
- At the time of the study, Kelly M. Doran and Anita A. Vashi were with the Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine/US Department of Veterans Affairs, New Haven, CT, and Department of Emergency Medicine, Yale School of Medicine, New Haven. At the time of the study, Stephanie Platis was with the Yale School of Public Health, New Haven. Leslie A. Curry is with the Yale School of Public Health and the Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven. Michael Rowe is with the Department of Psychiatry, Yale School of Medicine, New Haven. Maureen Gang is with the Department of Emergency Medicine, Bellevue Hospital Center/New York University School of Medicine, New York, NY. Federico E. Vaca is with the Department of Emergency Medicine, Yale School of Medicine, New Haven
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19
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Willems S, Peersman W, De Maeyer P, Buylaert W, De Maeseneer J, De Paepe P. The impact of neighborhood deprivation on patients' unscheduled out-of-hours healthcare seeking behavior: a cross-sectional study. BMC FAMILY PRACTICE 2013; 14:136. [PMID: 24034177 PMCID: PMC3847678 DOI: 10.1186/1471-2296-14-136] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/14/2013] [Accepted: 09/11/2013] [Indexed: 11/18/2022]
Abstract
BACKGROUND The use of unscheduled out of hours medical care is related to the social status of the patient. However, the social variance in the patient's preference for a hospital based versus a primary care based facility, and the impact of specific patient characteristics such as the travel distance to both types of facilities is unclear. This study aims to determine the social gradient in emergency care seeking behavior (consulting the emergency department (ED) in a hospital or the community-based Primary Care Center (PCC)) taking into account patient characteristics including the geographical distance from the patient's home to both services. METHODS A cross-sectional study, including 7,723 patients seeking out-of-hours care during 16 weekends and 2 public holidays was set up in all EDs and PCCs in Ghent, Belgium. Information on the consulted type of service, and neighborhood deprivation level was collected, but also the exact geographical distance from the patient's home to both types of services, and if the patient has a regular GP. RESULTS Patients living in a socially deprived area have a higher propensity to choose a hospital-based ED than their counterparts living in more affluent neighborhoods. This social difference persists when taking into account distance to both services, having a regular GP, and being hospitalized or not. The impact of the distance between the patient's home address and the location of both types of services on the patient's choice of service is rather small. CONCLUSIONS Initiatives aiming to lead patients more to PCC by penalizing inappropriate ED use might increase health inequity when they are not twinned with interventions improving the access to primary care services and tackling the underlying mechanisms of patients' emergency care seeking behavior. Further research exploring the impact of out-of-hours care organization (gatekeeping, payment systems, …) and the patient's perspectives on out-of-hours care services is needed.
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Affiliation(s)
- Sara Willems
- Department of Family Medicine and Primary Health Care, Ghent University, 9000 Ghent, Belgium
| | - Wim Peersman
- Department of Family Medicine and Primary Health Care, Ghent University, 9000 Ghent, Belgium
| | | | - Walter Buylaert
- Department of Internal Medicine, Ghent University, 9000 Ghent, Belgium
| | - Jan De Maeseneer
- Department of Family Medicine and Primary Health Care, Ghent University, 9000 Ghent, Belgium
| | - Peter De Paepe
- Heymans Institute of Pharmacology, Ghent University, 9000 Ghent, Belgium
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20
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Anders ME, Sheffer CE, Barone CP, Holmes TM, Simpson DD, Duncan AM. Emergency department-initiated tobacco dependence treatment. Am J Health Behav 2011; 35:546-56. [PMID: 22040616 PMCID: PMC3716374 DOI: 10.5993/ajhb.35.5.4] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To examine the feasibility of a fax referral program to increase enrollment in tobacco dependence treatment in emergency department (ED) patients. METHODS The control group received quit advice and printed information; the intervention group also received a faxed referral that generated telephone contacts. RESULTS Treatment enrollment was higher in the intervention group (13.5% vs 2.7%). Only the faxed referral was associated with treatment enrollment. CONCLUSIONS An ED intervention is feasible. Faxed referral resulted in a 5-fold increase in tobacco treatment enrollment. The ED may be an opportune setting to facilitate smoking-cessation behavior change among lower income, underserved patients.
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Affiliation(s)
- Michael E Anders
- Department of Respiratory and Surgical Technology, College of Health Related Professions, University of Arkansas for Medical Sciences, Little Rock, USA.
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21
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Food, shelter and safety needs motivating homeless persons' visits to an urban emergency department. Ann Emerg Med 2008; 53:598-602. [PMID: 18838193 DOI: 10.1016/j.annemergmed.2008.07.046] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2008] [Revised: 07/16/2008] [Accepted: 07/23/2008] [Indexed: 11/23/2022]
Abstract
STUDY OBJECTIVES We determine whether homeless persons present to the emergency department (ED) for food, shelter, and safety and whether the availability of alternative sites for provision of these needs might decrease their ED presentations. METHODS In July to August 2006 and February to March 2007, adult homeless and control (not homeless) patients, who self-presented (nonambulance) to an urban county ED, were interviewed with a structured instrument. RESULTS One hundred ninety-one homeless and 63 control subjects were enrolled. Homeless persons spent a mean (standard deviation [SD]) of 3.5 (3.0) nights/week sleeping without shelter and ate a mean (SD) of 2.1 (1.1) meals per day; 51% stated they had been assaulted on the street. On an analog scale, in which 0=no problem and 10=worst possible problem in their daily lives, the mean (SD) homeless subject responses for hunger, lack of shelter, and safety were 4.8 (3.7), 6.1 (4.2), and 5.1 (4.0), respectively. More homeless (29% [55/189]) than not homeless (10% [6/63]) persons replied that hunger, safety concerns, and lack of shelter were reasons they came to the ED (Delta=20%; 95% confidence interval 10% to 29%). If offered a place that would provide food, shelter, and safety at all times, 24% of homeless subjects stated they would not have come to the ED. CONCLUSION Homeless persons commonly come to the ED for food, shelter, and safety. Provision of these subsistence needs at all times at another site may decrease their ED presentations.
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22
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Shumway M, Boccellari A, O'Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008; 26:155-64. [PMID: 18272094 DOI: 10.1016/j.ajem.2007.04.021] [Citation(s) in RCA: 155] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2007] [Revised: 04/07/2007] [Accepted: 04/11/2007] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE The objective of the study was to test the hypothesis that clinical case management is more cost-effective than usual care for frequent users of the emergency department (ED). METHODS The study is a 24-month randomized trial obtaining data on psychosocial problems through interviews and service usage and cost data from administrative records. RESULTS Two-hundred fifty-two frequent users were randomized (167 to case management, 85 to usual care). Case management was associated with statistically significant reductions in psychosocial problems common among ED frequent users, including homelessness, alcohol use, lack of health insurance and social security income, and financial need. Case management was associated with statistically significant reductions in ED use and cost. Case management and usual care patients did not differ in use or cost of other hospital services. CONCLUSIONS Case management appears cost-effective for ED frequent users because it yields statistically and clinically significant reductions in psychosocial problems at a cost similar to that of usual care.
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Affiliation(s)
- Martha Shumway
- Department of Psychiatry, San Francisco General Hospital, University of California, San Francisco, CA, USA.
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23
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Bernstein SL, Boudreaux ED, Cydulka RK, Rhodes KV, Lettman NA, Almeida SL, McCullough LB, Mizouni S, Kellermann AL. Tobacco control interventions in the emergency department: a joint statement of emergency medicine organizations. J Emerg Nurs 2007; 32:370-81. [PMID: 16997023 DOI: 10.1016/j.jen.2006.06.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Revised: 02/08/2006] [Accepted: 02/14/2006] [Indexed: 11/30/2022]
Abstract
Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.
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Affiliation(s)
- Steven L Bernstein
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
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24
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Morris DM, Gordon JA. The role of the emergency department in the care of homeless and disadvantaged populations. Emerg Med Clin North Am 2006; 24:839-48. [PMID: 16982342 DOI: 10.1016/j.emc.2006.06.011] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
This article provides an overview of the role of the emergency department (ED) in the care of homeless and disadvantaged populations. It suggests that organized emergency medicine can have a significant impact on total community health by maintaining a universal "safety net" for the delivery of integrated health and human services. The epidemiology of social deprivation among ED patients is examined, with a particular focus on homelessness. Current research on the value of socio-medical integration in the ED setting is discussed, with emphasis on selected initiatives that have demonstrated feasibility, cost-effectiveness, and impact.
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Affiliation(s)
- David M Morris
- Department of Emergency Medicine, MetroWest Medical Center, Framingham Union Hospital, Framingham, MA 01702, USA.
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Bernstein SL, Boudreaux ED, Cydulka RK, Rhodes KV, Lettman NA, Almeida SL, McCullough LB, Mizouni S, Kellermann AL. Tobacco Control Interventions in the Emergency Department: A Joint Statement of Emergency Medicine Organizations. Ann Emerg Med 2006; 48:e417-26. [PMID: 16997678 DOI: 10.1016/j.annemergmed.2006.02.018] [Citation(s) in RCA: 72] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2005] [Revised: 02/08/2006] [Accepted: 02/14/2006] [Indexed: 11/25/2022]
Abstract
Smoking is the leading cause of preventable death and illness in the United States. National practice guidelines call for all health care providers to "ask" all patients about tobacco use, and to "advise, assess, assist, arrange" when smokers want to quit smoking (the "5 As"). Emergency departments (EDs) have not been an important locus of tobacco control efforts, although ED patients typically smoke at rates exceeding that of the general population, are interested in quitting, and often have limited access to primary care. To address the role of emergency medicine in tobacco control, the American College of Emergency Physicians convened a task force of representatives of major emergency medicine professional organizations. Funded by the Robert Wood Johnson Foundation, the group met in 2004 and 2005. This article represents a summary of the task force's recommendations for tobacco control practice, training, and research. We call on emergency care providers to routinely assess patients' smoking status, offer brief advice to quit, and refer patients to the national smokers' Quitline (800-QUIT-NOW) or a locally available program. Given the global burden of tobacco-related illness, the task force considers it essential for emergency physicians to conduct research into the efficacy of ED-based interventions and to place tobacco control into the training curriculum for emergency medicine residencies. Tobacco control fits within the traditions of other ED-based public health practices, such as injury control. ED-based tobacco control would allow the specialty to help fulfill the Healthy People 2010 mandate to reduce the prevalence of smoking among US citizens.
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Affiliation(s)
- Steven L Bernstein
- Department of Emergency Medicine, Albert Einstein College of Medicine, Bronx, NY, USA.
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Gordon JA, Emond JA, Camargo CA. The State Children's Health Insurance Program: a multicenter trial of outreach through the emergency department. Am J Public Health 2005; 95:250-3. [PMID: 15671460 PMCID: PMC1449162 DOI: 10.2105/ajph.2003.037242] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
OBJECTIVES We evaluated emergency department (ED)-based outreach for the State Children's Health Insurance Program (SCHIP). METHODS We conducted a multicenter trial among uninsured children (< or = 18 years) who presented to 5 EDs in 2001 and 2002. On-site staff enrolled consecutive subjects for a control period followed by an intervention period during which staff handed out SCHIP applications to the uninsured. The primary outcome was state-level confirmation of insured status at 90 days. RESULTS We followed 223 subjects (108 control, 115 intervention) by both phone interview and state records. Compared to control subjects, those receiving a SCHIP application were more likely to have state health insurance at 90 days (42% vs 28%; P<.05; odds ratio [OR]=3.8; 95% confidence interval [CI]=1.7, 8.6). Although the intervention effect was prominent among 118 African Americans (50% insured after intervention vs 31% of controls, P<.05), lack of family enrollment in other public assistance programs was the primary predictor of intervention success (OR=3.7; 95% CI=1.6, 8.4). CONCLUSIONS Handing out insurance applications in the ED can be an effective SCHIP enrollment strategy, particularly among minority children without connections to the social welfare system. Adopted nationwide, this simple strategy could initiate insurance coverage for more than a quarter million additional children each year.
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Affiliation(s)
- James A Gordon
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St, Clinics 115, Boston, MA 02114, USA.
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Mahajan P, Stanley R, Ross KW, Clark L, Sandberg K, Lichtenstein R. Evaluation of an Emergency Department–Based Enrollment Program for Uninsured Children. Ann Emerg Med 2005; 45:245-50. [PMID: 15726045 DOI: 10.1016/j.annemergmed.2004.06.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
STUDY OBJECTIVE We evaluate the effectiveness of an emergency department (ED)-based outreach program in increasing the enrollment of uninsured children. METHODS The study involved placing a full-time worker trained to enroll uninsured children into Medicaid or the State Children's Health Insurance Program in an inner-city academic children's hospital ED. Analysis was carried out for outpatient ED visits by insurance status, average revenue per patient from uninsured and insured children, proportion of patients enrolled in Medicaid and State Children's Health Insurance Program through this program, estimated incremental revenue from new enrollees, and program-specific incremental costs. A cost-benefit analysis and breakeven analysis was conducted to determine the impact of this intervention on ED revenues. RESULTS Five thousand ninety-four uninsured children were treated during the 10 consecutive months assessed, and 4,667 were treated during program hours. One thousand eight hundred and three applications were filed, giving a program penetration rate of 39%. Eighty-four percent of applications filed were resolved (67% of these were Medicaid). Average revenue from each outpatient ED visit for Medicaid was US135.68 dollars, other insurance was US210.43 dollars, and uninsured was US15.03 dollars. Estimated incremental revenue for each uninsured patient converted to Medicaid was US120.65 dollars. Total annualized incremental revenue was US224,474 dollars, and the net incremental revenue, after accounting for program costs, was US157,414 dollars per year. CONCLUSION A program enrolling uninsured children at an inner-city pediatric ED into government insurance was effective and generated revenue that paid for program costs.
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Abstract
Emergency departments (EDs) are a vital component in our health care safety net, available 24 hours a day, 7 days a week, for all who require care. There has been a steady increase in the volume and acuity of patient visits to EDs, now with well over 100 million Americans (30 million children) receiving emergency care annually. This rise in ED utilization has effectively saturated the capacity of EDs and emergency medical services in many communities. The resulting phenomenon, commonly referred to as ED overcrowding, now threatens access to emergency services for those who need them the most. As managers of the pediatric medical home and advocates for children and optimal pediatric health care, there is a very important role for pediatricians and the American Academy of Pediatrics in guiding health policy decision-makers toward effective solutions that promote the medical home and timely access to emergency care.
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Abstract
Mainly in response to the policy drive to avoid unnecessary acute hospital admissions and delayed discharge on social grounds, there has been a gradual development of social work services attached to emergency departments (EDs) in the UK. In the absence of a clearly articulated evidence base or debate about the roles of ED attached social workers, a model of ED based social work practice and indicative supporting evidence is presented. It is argued that social workers may be able to contribute to the efficiency and effectiveness of hospital services while providing a key point of access to social care services. A number of obstacles remain to the implementation of this model of service, including the narrow focus of current social care practice, the hours that a social work service is normally provided, chronic under-funding, and continuing perverse incentives in the health and social care system. More systematic evidence in the UK context is needed to support the case for change.
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Affiliation(s)
- P Bywaters
- Centre for Social Justice, Coventry University, Priory Street, Coventry CV15FB, UK.
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Abstract
UNLABELLED In 1997 the U.S. government funded the Children's Health Insurance Program (CHIP), but the 48 billion dollars initiative has had limited success in finding and enrolling uninsured children. While such children are more likely to receive care in emergency departments (EDs), no national initiative has targeted EDs for child health insurance outreach. OBJECTIVE As a pilot study for a national multicenter study, this study evaluated the effectiveness of child health insurance outreach in an ED setting. METHODS This was a prospective observational study of the outreach efforts of a single case manager from August 1998 to July 1999, performed at Foote Hospital ED in Jackson, Michigan (45,000 visits/year). All patients <or=18 years old presenting during the duty-hours of the intervention worker were eligible. The case manager approached the parent of all uninsured children and provided information and an application for government-sponsored health insurance. She followed up with a brief phone interview of each parent to determine whether the targeted child had received the insurance, and whether the new coverage was due to the ED referral. Missing information was confirmed from state insurance records. Data were analyzed with frequency tabulations and 95% confidence intervals. RESULTS Seventy-eight children participated (median age 7 years; 55% male; 87% white). Forty-four percent (95% CI = 32% to 55%) of families referred for government-sponsored child health insurance successfully obtained it; 31% (95% CI = 21% to 42%) could be traced directly to intervention efforts by interview (n = 17) or by state records (n = 7). Nineteen percent (95% CI = 11% to 30%) got other private insurance. Of those who got government-sponsored insurance due to the intervention, all but one were covered by Medicaid. CONCLUSIONS The ED may be an important outreach site for child health insurance programs. National efforts to address the lack of insurance among children should include partnerships with the ED.
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Affiliation(s)
- J A Gordon
- Department of Emergency Medicine, Massachusetts General Hospital, Institute for Health Policy, Partners HealthCare System, Division of Emergency Medicine, Harvard Medical School, Boston, MA 02114-2696, USA.
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Gordon JA, Billings J, Asplin BR, Rhodes KV. Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net". Acad Emerg Med 2001; 8:1024-9. [PMID: 11691663 DOI: 10.1111/j.1553-2712.2001.tb01110.x] [Citation(s) in RCA: 79] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.
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Affiliation(s)
- J A Gordon
- Department of Emergency Medicine, Massachusetts General Hospital, Division of Emergency Medicine, Harvard Medical School, Institute for Health Policy, Massachusetts General Hospital/Partners HealthCare System, Boston, MA 02114, USA.
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