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Smith J, Liu C, Beck A, Fei L, Brokamp C, Meryum S, Whaley KG, Minar P, Hellmann J, Denson LA, Margolis P, Dhaliwal J. Racial Disparities in Pediatric Inflammatory Bowel Disease Care: Differences in Outcomes and Health Service Utilization Between Black and White Children. J Pediatr 2023; 260:113522. [PMID: 37244575 PMCID: PMC10894641 DOI: 10.1016/j.jpeds.2023.113522] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 05/08/2023] [Accepted: 05/21/2023] [Indexed: 05/29/2023]
Abstract
OBJECTIVE To describe racial inequities in pediatric inflammatory bowel disease care and explore potential drivers. METHODS We undertook a single-center, comparative cohort study of newly diagnosed Black and non-Hispanic White patients with inflammatory bowel disease, aged <21 years, from January 2013 through 2020. Primary outcome was corticosteroid-free remission (CSFR) at 1 year. Other longitudinal outcomes included sustained CSFR, time to anti-tumor necrosis factor therapy, and evaluation of health service utilization. RESULTS Among 519 children (89% White, 11% Black), 73% presented with Crohn's disease and 27% with ulcerative colitis. Disease phenotype did not differ by race. More patients from Black families had public insurance (58% vs 30%, P < .001). Black patients were less likely to achieve CSFR 1-year post diagnosis (OR: 0.52, 95% CI:0.3-0.9) and less likely to achieve sustained CSFR (OR: 0.48, 95% CI: 0.25-0.92). When adjusted by insurance type, differences by race to 1-year CSFR were no longer significant (aOR: 0.58; 95% CI: 0.33, 1.04; P = .07). Black patients were more likely to transition from remission to a worsened state, and less likely to transition to remission. We found no differences in biologic therapy utilization or surgical outcomes by race. Black patients had fewer gastroenterology clinic visits and 2-fold increased odds for emergency department visits. CONCLUSIONS We observed no differences by race in phenotypic presentation and medication usage. Black patients had half the odds of achieving clinical remission, but a degree of this was mediated by insurance status. Understanding the cause of such differences will require further exploration of social determinants of health.
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Affiliation(s)
- Julia Smith
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Chunyan Liu
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Andrew Beck
- Division of Pediatrics, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Lin Fei
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Cole Brokamp
- Division of Biostatistics and Epidemiology, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Syeda Meryum
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH
| | - Kaitlin G Whaley
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Phillip Minar
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Jennifer Hellmann
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Lee A Denson
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Peter Margolis
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH
| | - Jasbir Dhaliwal
- Division of Gastroenterology, Hepatology & Nutrition, Cincinnati Children's Hospital Medical Center, Cincinnati, OH; Department of Pediatrics, University of Cincinnati, Cincinnati, OH.
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Brom H, Anusiewicz CV, Udoeyo I, Chittams J, Brooks Carthon JM. Access to post-acute care services reduces emergency department utilisation among individuals insured by Medicaid: An observational study. J Clin Nurs 2022; 31:726-732. [PMID: 34240494 PMCID: PMC8741822 DOI: 10.1111/jocn.15932] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Revised: 05/25/2021] [Accepted: 06/07/2021] [Indexed: 11/27/2022]
Abstract
AIMS AND OBJECTIVES We examined whether access to post-acute care services differed between individuals insured by Medicaid and commercial insurers and whether those differences explained emergency department utilisation 30 days post-hospitalisation. BACKGROUND Timely follow-up to community-based providers is a strategy to improve post-hospitalisation outcomes. However, little is known regarding the influence of post-acute care services on the likelihood of emergency department use post-hospitalisation for individuals insured by Medicaid. DESIGN We conducted a retrospective observational study of electronic health record data from an academic medical centre in a large northeastern urban setting. The STROBE checklist was used in reporting this observational study. METHODS Our analysis included adults insured by Medicaid or commercial insurers who were discharged from medical services between 1 August-31 October 2017 (n = 785). Logistic regression models were used to examine the effects of post-acute care services (primary care, home health, specialty care) on the odds of an emergency department visit. RESULTS Post-hospitalisation, 12% (n = 59) of individuals insured by Medicaid experienced an emergency department visit compared to 4.2% (n = 13) of individuals commercially insured. Having Medicaid insurance was associated with higher odds of emergency department visits post-hospitalisation (OR = 3.24). Having a home care visit or specialty care visit within 30 days post-discharge were significant predictors of lower odds of emergency department visits. Specific to specialty care visits, Medicaid was no longer a significant predictor of emergency department visits with specialty care being more influential (OR = 0.01). CONCLUSIONS Improving connections to appropriate post-acute care services, specifically specialty care, may improve outcomes among individuals insured by Medicaid. RELEVANCE TO CLINICAL PRACTICE Hospital-based nurses, including those in direct care, case management and discharge planning, play an important role in facilitating referrals and scheduling appointments prior to discharge. Individuals insured by Medicaid may require additional support in accessing these services and nurses are well-positioned to facilitate care continuity.
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Affiliation(s)
- Heather Brom
- M. Louise Fitzpatrick College of Nursing, Villanova University, Villanova, PA, USA
| | - Colleen V. Anusiewicz
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Danville, PA, USA
| | | | - Jesse Chittams
- BECCA Lab, University of Pennsylvania, Philadelphia, PA, USA
| | - J. Margo Brooks Carthon
- Center for Health Outcomes and Policy Research, University of Pennsylvania School of Nursing, Philadelphia, Danville, PA, USA
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Wartelle A, Mourad-Chehade F, Yalaoui F, Questiaux H, Monneret T, Soliveau G, Chrusciel J, Duclos A, Laplanche D, Sanchez S. Multimorbidity clustering of the emergency department patient flow: Impact analysis of new unscheduled care clinics. PLoS One 2022; 17:e0262914. [PMID: 35100301 PMCID: PMC8803184 DOI: 10.1371/journal.pone.0262914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 01/07/2022] [Indexed: 11/19/2022] Open
Abstract
Background
In France, the number of emergency department (ED) admissions doubled between 1996 and 2016. To cope with the resulting crowding situation, redirecting patients to new healthcare services was considered a viable solution which would spread demand more evenly across available healthcare delivery points and render care more efficient. The objective of this study was to analyze the impact of opening new on-demand care services based on variations in patient flow at a large hospital emergency department.
Methods
We performed a before-and-after study investigating the use of unscheduled care services in the Aube region in eastern France, that focused on ED attendance at Troyes Hospital. A hierarchical clustering based on co-occurrence of diagnoses was applied which divided the population into different multimorbidity profiles. Temporal trends of the resultant clusters were also studied empirically and using regression models. A multivariate logistic regression model was constructed to adjust the periodic effect for appropriate confounders and therefore confirm its presence.
Results
In total, 120,722 visits to the ED were recorded over a 24-month period (2018–2019) and 16 clusters were identified, accounting for 94.76% of all visits. There was a decrease of 56.77 visits per week in seven specific clusters and an increase of use of unscheduled health care services by 328.12 visits per week.
Conclusions
Using an innovative and reliable methodology to evaluate changes in patient flow through the ED, these findings may help inform public health policy experts on the implementation of unscheduled care services to ease pressure on hospital EDs.
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Affiliation(s)
- Adrien Wartelle
- Computer Science and Digital Society Laboratory (LIST3N), Université de Technologie de Troyes, Troyes, France
- Public Health and Performance Department, Centre Hospitalier de Troyes, Troyes, France
- * E-mail: (SS); (AW)
| | - Farah Mourad-Chehade
- Computer Science and Digital Society Laboratory (LIST3N), Université de Technologie de Troyes, Troyes, France
| | - Farouk Yalaoui
- Computer Science and Digital Society Laboratory (LIST3N), Université de Technologie de Troyes, Troyes, France
| | - Hélène Questiaux
- Emergency Department, Centre Hospitalier de Troyes, Troyes, France
| | | | | | - Jan Chrusciel
- Public Health and Performance Department, Centre Hospitalier de Troyes, Troyes, France
| | - Antoine Duclos
- Research on Healthcare Performance Lab, INSERM U1290 RESHAPE, Université Claude Bernard Lyon 1, Villeurbanne, France
- Health Data Department, Hospices Civils de Lyon, Lyon, France
| | - David Laplanche
- Public Health and Performance Department, Centre Hospitalier de Troyes, Troyes, France
| | - Stéphane Sanchez
- Public Health and Performance Department, Centre Hospitalier de Troyes, Troyes, France
- Research on Health University Department–University of Reims Champagne Ardenne, Reims, France
- * E-mail: (SS); (AW)
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Patient Navigation to Reduce Emergency Department (ED) Utilization Among Medicaid Insured, Frequent ED Users: A Randomized Controlled Trial. J Emerg Med 2020; 58:967-977. [PMID: 32184056 DOI: 10.1016/j.jemermed.2019.12.001] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2019] [Revised: 11/26/2019] [Accepted: 12/04/2019] [Indexed: 11/22/2022]
Abstract
BACKGROUND Some Medicaid enrollees frequently utilize the emergency department (ED) due to barriers accessing health care services in other settings. OBJECTIVES To determine whether an ED-initiated Patient Navigation program (ED-PN) designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs. METHODS We conducted a prospective, randomized controlled trial comparing ED-PN with usual care (UC) among 100 Medicaid-enrolled frequent ED users (defined as 4-18 ED visits in the prior year), assessing ED utilization during the 12 months pre- and post-enrollment. Secondary outcomes included hospitalizations, outpatient utilization, hospital costs, and Medicaid costs. We also compared characteristics between ED-PN patients with and without reduced ED utilization. RESULTS Of 214 eligible patients approached, 100 (47%) consented to participate. Forty-nine were randomized to ED-PN and 51 to UC. Sociodemographic characteristics and prior utilization were similar between groups. ED-PN participants had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with UC, averaging 1.4 fewer ED visits per patient (p = 0.01) and 1.0 fewer hospitalizations per patient (p = 0.001). Both groups increased outpatient utilization. ED-PN patients showed a trend toward reduced per-patient hospital costs (-$10,201, p = 0.10); Medicaid costs were unchanged (-$5,765, p = 0.26). Patients who demonstrated a reduction in ED usage were older (mean age 42 vs. 33 years, p = 0.03) and had lower health literacy (78% low health literacy vs. 40%, p = 0.02). CONCLUSION An ED-PN program targeting Medicaid-insured high ED utilizers demonstrated significant reductions in ED visits and hospitalizations in the 12 months after enrollment.
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Abstract
OBJECTIVE Conceptually, access to primary care (through insurance) should reduce emergency department (ED) visits for primary care sensitive (PCS) conditions. We sought to identify characteristics of insured Massachusetts residents associated with PCS ED use, and compare such use for public versus private insurees. POPULATION AND SETTING People under age 65 in the Massachusetts All-Payer Claims Data, 2011-2012. STUDY DESIGN Retrospective, observational analysis of PCS ED use with nonurgent, urgent/primary care treatable, and urgent/potentially avoidable visits being considered PCS. We predicted utilization in 2012 using multivariable regression models and data available in 2011 administrative records. PRINCIPAL FINDINGS Among 2,269,475 nonelderly Massachusetts residents, 40% had public insurance. Among public insurees, PCS ED use was higher than for private (mean, 36.5 vs. 9.0 per 100 persons; adjusted risk ratio, 2.53; 95% confidence limits, 2.49-2.56), while having any primary care visit was less common (70% vs. 83%), as was having any visit to one's own (attributed) primary care provider (38% vs. 44%). CONCLUSIONS Public insurance was associated with less access to primary care and more PCS ED use; statewide labor shortages and low reimbursement rates from public insurance may have provided inadequate access to care that might otherwise have helped reduce PCS ED use.
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Osteguin V, Cheng TW, Farber A, Eslami MH, Kalish JA, Jones DW, Rybin D, Raulli SJ, Siracuse JJ. Emergency Department Utilization after Lower Extremity Bypass for Critical Limb Ischemia. Ann Vasc Surg 2019; 54:134-143. [DOI: 10.1016/j.avsg.2018.03.028] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2018] [Revised: 03/07/2018] [Accepted: 03/08/2018] [Indexed: 01/10/2023]
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Segaloff HE, Evans R, Arshad S, Zervos MJ, Archer C, Kaye KS, Martin ET. The impact of obesity and timely antiviral administration on severe influenza outcomes among hospitalized adults. J Med Virol 2017; 90:212-218. [DOI: 10.1002/jmv.24946] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2017] [Revised: 08/29/2017] [Accepted: 08/30/2017] [Indexed: 11/10/2022]
Affiliation(s)
- Hannah E. Segaloff
- Department of Epidemiology; University of Michigan School of Public Health; Ann Arbor Michigan
| | - Richard Evans
- Department of Epidemiology; University of Michigan School of Public Health; Ann Arbor Michigan
| | - Samia Arshad
- Division of Infectious Diseases; Henry Ford Health System; Detroit Michigan
| | - Marcus J. Zervos
- Division of Infectious Diseases; Henry Ford Health System; Detroit Michigan
| | - Carolyn Archer
- Department of Pharmacy Practice; Wayne State University; Detroit Michigan
| | - Keith S. Kaye
- Division of Infectious Diseases; Department of Internal Medicine, University of Michigan Health System; Ann Arbor Michigan
| | - Emily T. Martin
- Department of Epidemiology; University of Michigan School of Public Health; Ann Arbor Michigan
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Enard KR, Ganelin DM. Exploring the Value Proposition of Primary Care for Safety-Net Patients Who Utilize Emergency Departments to Address Unmet Needs. J Prim Care Community Health 2017; 8:285-293. [PMID: 28745137 PMCID: PMC5739963 DOI: 10.1177/2150131917721652] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Background: An underlying assumption of strategies intended to promote appropriate primary care over emergency department (ED) use for ongoing health care needs is that patients will understand the “value proposition” of primary care: that they will receive specific benefits from primary care providers over and above what they receive from EDs. However, there is evidence that this value proposition may be unclear to safety-net patients. The goals of this study are to describe factors motivating ED use for low-acuity conditions; describe similarities and differences in usual source of care (USOC) experiences, by ED versus non-ED setting; and assess awareness and perceptions of the patient-centered medical home (PCMH) concept among safety-net patients. Methods: We conducted a cross-sectional descriptive study of adult patients (n = 329) at 3 safety-net hospitals in the Southwest. Results: Key reasons for ED use were perceived urgency, lack of awareness about other options for care, payment flexibility, and perceived quality and convenience. Approximately half of participants indicated they would seek treatment in non-ED settings, if available, but agreement differed by group (non-ED USOC, 60.2%; ED USOC, 50.7%; no USOC, 45.3%; P = .025). Agreement that providers coordinated access to needed medical services was significantly higher among patients with non-ED USOCs; agreement that providers coordinated non-medical services that facilitate access to care was similar (approximately 45%) for patients with ED and non-ED USOCs. Approximately 70% of participants in both groups agreed that every person should have a medical home. Conclusions: Perceived experiences of care in ED and non-ED USOC settings suggest challenges and opportunities for increasing the value proposition of primary care for safety-net patients. Although patients are receptive to the PCMH concept, effective strategies to better highlight the value of primary care in coordinating both medical and related nonmedical services and other PCMH benefits warrant further investigation.
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Abstract
Over the past 10 years, postdischarge clinics have been introduced in response to various health system pressures, including the focus on rehospitalizations and the challenges of primary care access. Often ignored in the discussion are questions of the effect of postdischarge physician visits on readmissions. In addition, little attention has been given to other clinical outcomes, such as reducing preventable harm and mortality. A review of dedicated, hospitalist-led postdischarge clinics, of the data supporting postdischarge physician visits, and of the role of hospitalists in these clinics may be instructive for hospitalists and health systems considering the postdischarge clinic environment. Journal of Hospital Medicine 2017;12:467-471.
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Affiliation(s)
- Lauren Doctoroff
- Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts
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Kim H, McConnell KJ, Sun BC. Comparing Emergency Department Use Among Medicaid and Commercial Patients Using All-Payer All-Claims Data. Popul Health Manag 2017; 20:271-277. [PMID: 28075692 DOI: 10.1089/pop.2016.0075] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
The high rate of emergency department (ED) use by Medicaid patients is not fully understood. The objective of this paper is (1) to provide context for ED service use by comparing Medicaid and commercial patients' differences across ED and non-ED health service use, and (2) to assess the extent to which Medicaid-commercial differences in ED use can be explained by observable factors in administrative data. Statistical decomposition methods were applied to ED, mental health, and inpatient care using 2011-2013 Medicaid and commercial insurance claims from the Oregon All Payer All Claims database. Demographics, comorbidities, health services use, and neighborhood characteristics accounted for 44% of the Medicaid-commercial difference in ED use, compared to 83% for mental health care and 75% for inpatient care. This suggests that relative to mental health and inpatient care, a large portion of ED use cannot be explained by administrative data. Models that further accounted for patient access to different primary care physicians explained an additional 8% of the Medicaid-commercial difference in ED use, suggesting that the quality of primary care may influence ED use. The remaining unexplained difference suggests that appropriately reducing ED use remains a credible target for policy makers, although success may require knowledge about patients' perceptions and behaviors as well as social determinants of health.
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Affiliation(s)
- Hyunjee Kim
- 1 Center for Health Systems Effectiveness, Oregon Health & Science University , Portland, Oregon
| | - K John McConnell
- 1 Center for Health Systems Effectiveness, Oregon Health & Science University , Portland, Oregon
| | - Benjamin C Sun
- 2 Department of Emergency Medicine, Center of Policy Research-Emergency Medicine, Oregon Health & Science University , Portland, Oregon
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