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Bastholm-Rahmner P, Bergqvist M, Modig K, Gustafsson LL, Schmidt-Mende K. Homecare workers - an untapped resource in preventing emergency department visits among older individuals? A qualitative interview study from Sweden. BMC Geriatr 2024; 24:350. [PMID: 38637752 PMCID: PMC11027288 DOI: 10.1186/s12877-024-04906-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 03/20/2024] [Indexed: 04/20/2024] Open
Abstract
BACKGROUND Older individuals with functional decline and homecare are frequent visitors to emergency departments (ED). Homecare workers (HCWs) interact regularly with their clients and may play a crucial role in their well-being. Therefore, this study explores if and how HCWs perceive they may contribute to the prevention of ED visits among their clients. METHODS In this qualitative study, 12 semi-structured interviews were conducted with HCWs from Sweden between July and November 2022. Inductive thematic analysis was used to identify barriers and facilitators to prevent ED visits in older home-dwelling individuals. RESULTS HCWs want to actively contribute to the prevention of ED visits among clients but observe many barriers that hinder them from doing so. Barriers refer to care organisation such as availability to primary care staff and information transfer; perceived attitudes towards HCWs as co-workers; and client-related factors. Participants suggest that improved communication and collaboration with primary care and discharge information from the ED to homecare services could overcome barriers. Furthermore, they ask for support and geriatric education from primary care nurses which may result in increased respect towards them as competent staff members. CONCLUSIONS HCWs feel that they have an important role in the health management of older individuals living at home. Still, they feel as an untapped resource in the prevention of ED visits. They deem that improved coordination and communication between primary care, ED, and homecare organisations as well as proactive care would enable them to add significantly to the prevention of ED visits.
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Affiliation(s)
- Pia Bastholm-Rahmner
- Academic Primary Healthcare Center, Region Stockholm, Sweden.
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska Institutet, Stockholm, Sweden.
| | - Monica Bergqvist
- Academic Primary Healthcare Center, Region Stockholm, Sweden
- Department of Neurobiology, Care Sciences and Society, Division of Nursing, Karolinska Institutet, Stockholm, Sweden
| | - Karin Modig
- Institute of Environmental Medicine, Unit of Epidemiology, Karolinska Institutet, Stockholm, Sweden
| | - Lars L Gustafsson
- Department of Laboratory Medicine, Division of Clinical Pharmacology, Karolinska Institutet, Karolinska Institutet, Stockholm, Sweden
| | - Katharina Schmidt-Mende
- Academic Primary Healthcare Center, Region Stockholm, Sweden
- Department of Neurobiology and Care Sciences and Society, Division of Family Medicine and Primary Care, Karolinska Institutet, Stockholm, Sweden
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Strum RP, Mondoux S, Mowbray FI, Griffith LE, Worster A, Tavares W, Miller P, Aryal K, Sivakumaran R, Costa AP. Validating the Emergency Department Avoidability Classification (EDAC): A cluster randomized single-blinded agreement study. PLoS One 2024; 19:e0297689. [PMID: 38261589 PMCID: PMC10805301 DOI: 10.1371/journal.pone.0297689] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Accepted: 01/10/2024] [Indexed: 01/25/2024] Open
Abstract
INTRODUCTION The Emergency Department Avoidability Classification (EDAC) retrospectively classifies emergency department (ED) visits that could have been safely managed in subacute primary care settings, but has not been validated against a criterion standard. A validated EDAC could enable accurate and reliable quantification of avoidable ED visits. We compared agreement between the EDAC and ED physician judgements to specify avoidable ED visits. MATERIALS AND METHODS We conducted a cluster randomized, single-blinded agreement study in an academic hospital in Hamilton, Canada. ED visits between January 1, 2019, and December 31, 2019 were clustered based on EDAC classes and randomly sampled evenly. A total of 160 ED visit charts were randomly assigned to ten participating ED physicians at the academic hospital for evaluation. Physicians judged if the ED visit could have been managed appropriately in subacute primary care (an avoidable visit); each ED visit was evaluated by two physicians independently. We measured interrater agreement between physicians with a Cohen's kappa and 95% confidence intervals (CI). We evaluated the correlation between the EDAC and physician judgements using a Spearman rank correlation and ordinal logistic regression with odds ratios (ORs) and 95% CIs. We examined the EDAC's precision to identify avoidable ED visits using accuracy, sensitivity and specificity. RESULTS ED physicians agreed on 139 visits (86.9%) with a kappa of 0.69 (95% CI 0.59-0.79), indicating substantial agreement. Physicians judged 96.2% of ED visits classified as avoidable by the EDAC as suitable for management in subacute primary care. We found a high correlation between the EDAC and physician judgements (0.64), as well as a very strong association to classify avoidable ED visits (OR 80.0, 95% CI 17.1-374.9). The EDACs avoidable and potentially avoidable classes demonstrated strong accuracy to identify ED visits suitable for management in subacute care (82.8%, 95% CI 78.2-86.8). DISCUSSION The EDAC demonstrated strong evidence of criterion validity to classify avoidable ED visits. This classification has important potential for accurately monitoring trends in avoidable ED utilization, measuring proportions of ED volume attributed to avoidable visits and informing interventions intended at reducing ED use by patients who do not require emergency or life-saving healthcare.
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Affiliation(s)
- Ryan P. Strum
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Shawn Mondoux
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
- Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
| | - Fabrice I. Mowbray
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- College of Nursing, Michigan State University, East Lansing, Michigan, United States of America
| | - Lauren E. Griffith
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- McMaster Institute for Research and Aging, McMaster University, Hamilton, Ontario, Canada
| | - Andrew Worster
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Walter Tavares
- The Wilson Centre, University of Toronto, Toronto, Ontario, Canada
| | - Paul Miller
- Department of Medicine, Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada
- Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Komal Aryal
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ravi Sivakumaran
- Health Information Management Department, St. Joseph’s Healthcare Hamilton, Hamilton, Ontario, Canada
| | - Andrew P. Costa
- Department of Health Research Methods, Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
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Benning L, Kleinekort J, Röttger MC, Köhne N, Wehrle J, Blum M, Busch HJ, Hans FP. Factors influencing the occurrence of ambulatory care sensitive conditions in the emergency department - a single-center cross-sectional study. Front Med (Lausanne) 2023; 10:1256447. [PMID: 38020113 PMCID: PMC10665907 DOI: 10.3389/fmed.2023.1256447] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 10/16/2023] [Indexed: 12/01/2023] Open
Abstract
Background and importance The differentiation between patients who require urgent care and those who could receive adequate care through ambulatory services remains a challenge in managing patient volumes in emergency departments (ED). Different approaches were pursued to characterize patients that could safely divert to ambulatory care. However, this characterization remains challenging as the urgency upon presentation is assessed based on immediately available characteristics of the patients rather than on subsequent diagnoses. This work employs a core set of Ambulatory Care Sensitive Conditions (core-ACSCs) in an ED to describe conditions that do not require inpatient care if treated adequately in the ambulatory care sector. It subsequently analyzes the corresponding triage levels and admission status to determine whether core-ACSCs relevantly contribute to patient volumes in an ED. Settings and participants Single center cross-sectional analysis of routine data of a tertiary ED in 2019. Outcome measures and analysis The proportion of core-ACSCs among all presentations was assessed. Triage levels were binarily classified as "urgent" and "non-urgent," and the distribution of core-ACSCs in both categories was studied. Additionally, the patients presenting with core-ACSCs requiring inpatient care were assessed based on adjusted residuals and logistic regression. The proportion being discharged home underwent further investigation. Main results This study analyzed 43,382 cases of which 10.79% (n = 4,683) fell under the definition of core-ACSC categories. 65.2% of all core-ACSCs were urgent and received inpatient care in 62.8% of the urgent cases. 34.8% of the core-ACSCs were categorized as non-urgent, 92.4% of wich were discharged home. Age, triage level and sex significantly affected the odds of requiring hospital admission after presenting with core-ACSCs. The two core-ACSCs that mainly contributed to non-urgent cases discharged home after the presentation were "back pain" and "soft tissue disorders." Discussion Core-ACSCs contribute relevantly to overall ED patient volume but cannot be considered the primary drivers of crowding. However, once patients presented to the ED with what was later confirmed as a core-ACSC, they required urgent care in 65.2%. This finding highlights the importance of effective ambulatory care to avoid emergency presentations. Additionally, the core-ACSC categories "back pain" and "soft tissue disorders" were often found to be non-urgent and discharged home. Although further research is required, these core-ACSCs could be considered potentially avoidable ED presentations. Clinical trial registration The study was registered in the German trials register (DRKS-ID: DRKS00029751) on 2022-07-22.
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Affiliation(s)
- Leo Benning
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Jan Kleinekort
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Michael Clemens Röttger
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Nora Köhne
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Julius Wehrle
- Data Integration Center, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Marco Blum
- Data Integration Center, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Hans-Jörg Busch
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
| | - Felix Patricius Hans
- University Emergency Department, University Medical Center Freiburg, Albert-Ludwigs-University Freiburg, Freiburg, Germany
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Cutter CM, Tran LD, Wu S, Urech TH, Seidenfeld J, Kocher KE, Vashi AA. Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans. Acad Emerg Med 2023; 30:299-309. [PMID: 36762877 DOI: 10.1111/acem.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs. METHODS Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC-specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition-specific multivariable models. RESULTS The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs-chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition-specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition-specific age subgroups. CONCLUSIONS We identified unexplained facility-level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems-based levers to improve value in VA emergency care.
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Affiliation(s)
- Christina M Cutter
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Linda D Tran
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, California, USA
| | - Siqi Wu
- Stanford Primary Care and Population Health, Stanford University, Stanford, California, USA
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, California, USA
| | - Tracy H Urech
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, California, USA
| | - Justine Seidenfeld
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
- Department of Veterans Affairs Health Services Research & Development, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Anita A Vashi
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Emergency Medicine (Affiliated), Stanford University, Stanford, California, USA
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