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van Loon-van Gaalen M, Voshol IE, van der Linden MC, Gussekloo J, van der Mast RC. Frequencies and reasons for unplanned emergency department return visits by older adults: a cohort study. BMC Geriatr 2023; 23:309. [PMID: 37198554 DOI: 10.1186/s12877-023-04021-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2022] [Accepted: 05/05/2023] [Indexed: 05/19/2023] Open
Abstract
BACKGROUND As unplanned Emergency Department (ED) return visits (URVs) are associated with adverse health outcomes in older adults, many EDs have initiated post-discharge interventions to reduce URVs. Unfortunately, most interventions fail to reduce URVs, including telephone follow-up after ED discharge, investigated in a recent trial. To understand why these interventions were not effective, we analyzed patient and ED visit characteristics and reasons for URVs within 30 days for patients aged ≥ 70 years. METHODS Data was used from a randomized controlled trial, investigating whether telephone follow-up after ED discharge reduced URVs compared to a satisfaction survey call. Only observational data from control group patients were used. Patient and index ED visit characteristics were compared between patients with and without URVs. Two independent researchers determined the reasons for URVs and categorized them into: patient-related, illness-related, new complaints and other reasons. Associations were examined between the number of URVs per patient and the categories of reasons for URVs. RESULTS Of the 1659 patients, 222 (13.4%) had at least one URV within 30 days. Male sex, ED visit in the 30 days before the index ED visit, triage category "urgent", longer length of ED stay, urinary tract problems, and dyspnea were associated with URVs. Of the 222 patients with an URV, 31 (14%) returned for patient-related reasons, 95 (43%) for illness-related reasons, 76 (34%) for a new complaint and 20 (9%) for other reasons. URVs of patients who returned ≥ 3 times were mostly illness-related (72%). CONCLUSION As the majority of patients had an URV for illness-related reasons or new complaints, these data fuel the discussion as to whether URVs can or should be prevented. TRIAL REGISTRATION For this cohort study, we used data from a randomized controlled trial (RCT). This trial was pre-registered in the Netherlands Trial Register with number NTR6815 on the 7th of November 2017.
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Affiliation(s)
- Merel van Loon-van Gaalen
- Emergency Department, Haaglanden Medical Center, P.O. Box 432, 2501 CK, The Hague, The Netherlands.
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands.
| | | | | | - Jacobijn Gussekloo
- Department of Internal Medicine, Section of Gerontology and Geriatrics, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health and Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Roos C van der Mast
- Department of Psychiatry, Leiden University Medical Center, Leiden, The Netherlands
- Department of Psychiatry, CAPRI-University Antwerp, Antwerp, Belgium
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Palungwachira P, Montimanutt G, Musikatavorn K, Savatmongkorngul S. Reducing 48-h emergency department revisits and subsequent admissions: a retrospective study of increased emergency medicine resident floor coverage. Int J Emerg Med 2022; 15:66. [PMID: 36474146 PMCID: PMC9724369 DOI: 10.1186/s12245-022-00471-z] [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: 11/10/2021] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Early unexpected hospital admission after emergency department (ED) discharge is an important topic regarding effective preventive measures. Reducing avoidable return visits can improve ED effectiveness and emergency care. This study evaluated the effects of an increase in the number of physicians and the 24-h coverage of emergency physicians on 48-h ED revisits with subsequent hospital admission. The characteristics and risk factors of the patients were also investigated. RESULTS This was a retrospective analysis performed 2 years before and 2 years after the implementation of an intervention in a tertiary care hospital in Thailand. The medical records of adult patients who revisited the ED within 48 h for related complaints were reviewed. The effect of the intervention was analyzed, and a prediction model was developed based on logistic regression. After implementing the intervention, the hospital admission rate at the second ED visit decreased from 44.5 to 41.1%; no significant difference was found (95% confidence interval (CI) - 5.05 to 11.78). Patients who required hospital admission had a significantly higher comorbidity score, more ED visits, and more hospitalizations within the past 12 months. A significantly higher hospital admission rate was also observed among patients older than 60 years, those who had an initial infectious diagnosis, and those who had a higher triage severity level (ESI II) at their first visit. The odds ratio (OR) showed lower odds of hospital admission at the second visit in the postintervention period; this difference was not significant (OR 0.87; 95% CI 0.61 to 1.23). CONCLUSION Our intervention did not significantly decrease the incidence of admission at an ED revisit. However, some factors identified in this study seem to have some benefits and might be helpful for preventing errors and constructing a standard discharge care plan for patients with these risk factors.
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Affiliation(s)
- Pakhawadee Palungwachira
- grid.419934.20000 0001 1018 2627Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330 Thailand
| | - Gunnaree Montimanutt
- grid.419934.20000 0001 1018 2627Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330 Thailand
| | - Khrongwong Musikatavorn
- grid.419934.20000 0001 1018 2627Department of Emergency Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, 10330 Thailand
| | - Sorravit Savatmongkorngul
- grid.10223.320000 0004 1937 0490Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400 Thailand
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3
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Ong CEC, Phan P, Wu CX, Chen Z, Quek LS. Value-based analysis of a Singaporean post-ED discharge support program for older adults. JOURNAL OF PATIENT SAFETY AND RISK MANAGEMENT 2022. [DOI: 10.1177/25160435221113955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Objective We evaluated the effectiveness of a post emergency department (ED) discharge intervention for frail, older adult patients in reducing hospital admissions. Methods 9-month retrospective real-world evaluation of a quality improvement intervention comparing frail adults 65-years and older who received a post-ED discharge intervention program (SAFE-Lite) with those who were eligible but declined and received usual care instead. The primary outcomes were the differences in rates of first acute hospital admission at 30- and 60-days post-ED discharge. The difference in primary outcome between the two groups was compared using the Cox proportional hazards model. We report adjusted hazards ratios (HRs) with 95% CIs for age, gender, Triage Risk Screening Tool (TRST) scores, as well as baseline ED utilization and acute hospital admission rates in the past year. Results There were 66 patients in the intervention group and 46 patients in the control group. There was no significant difference in risk of acute hospital admission at both 30 days (15 vs. 13%, HR = 0.92, 95% CI: 0.35–2.41) and 60 days (21 vs. 16%, HR = 0.97, 95% CI: 0.42–2.21) for the intervention and control groups. Conclusion Compared to usual post-ED discharge care, SAFE-Lite showed no difference in reducing 30- and 60-day admissions of frail, older patients.
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Affiliation(s)
| | - Phillip Phan
- Carey Business School, Johns Hopkins University, Baltimore, MD, USA
- Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Christine Xia Wu
- Quality, Innovation & Improvement, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Zhaoqi Chen
- Quality, Innovation & Improvement, Ng Teng Fong General Hospital, Singapore, Singapore
| | - Lit Sin Quek
- Office of CEO, Ng Teng Fong General Hospital, Singapore, Singapore
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Lachs DK, Stern ME, Elman A, Gogia K, Clark S, Mulcare MR, Greenway A, Golden D, Sharma R, Bessey PQ, Rosen T. Geriatric Burn Injuries Presenting to the Emergency Department of a Major Burn Center: Clinical Characteristics and Outcomes. J Emerg Med 2022; 63:143-158. [PMID: 35637048 PMCID: PMC9489596 DOI: 10.1016/j.jemermed.2022.01.016] [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: 03/15/2021] [Revised: 01/05/2022] [Accepted: 01/25/2022] [Indexed: 11/19/2022]
Abstract
BACKGROUND Burn injuries in geriatric patients are common and may have significant associated morbidity and mortality. Most research has focused on the care of hospitalized patients after admission to burn units. Little is known about the clinical characteristics of geriatric burn victims who present to the emergency department (ED) and their ED assessment and management. OBJECTIVE Our aim was to describe the clinical characteristics and outcomes of geriatric patients presenting to the ED with burn injuries. METHODS We performed a comprehensive retrospective chart review on all patients 60 years and older with a burn injury presenting from January 2011 through September 2015 to a large, urban, academic ED in a hospital with a 20-bed burn center. RESULTS A total of 459 patients 60 years and older were treated for burn injuries during the study period. Median age of burn patients was 71 years, 23.7% were 80 years and older, and 56.6% were female. The most common burn types were hot water scalds (43.6%) and flame burns (23.1%). Median burn size was 3% total body surface area (TBSA), 17.1% had burns > 10% TBSA, and 7.8% of patients had inhalation injuries. After initial evaluation, 46.4% of patients were discharged from the ED. Among patients discharged from the ED, only 1.9% were re-admitted for any reason within 30 days. Of the patients intubated in the ED, 7.1% were extubated during the first 2 days of admission, and 64.3% contracted ventilator-associated pneumonia. CONCLUSIONS Better understanding of ED care for geriatric burn injuries may identify areas in which to improve emergency care for these vulnerable patients.
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Affiliation(s)
- David K Lachs
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Michael E Stern
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Alyssa Elman
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Kriti Gogia
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Sunday Clark
- Boston Trauma Institute, Department of Surgery, Boston University School of Medicine, Boston, Massachusetts
| | - Mary R Mulcare
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Andrew Greenway
- Division of Trauma, Burns, Acute and Critical Care, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Daniel Golden
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Rahul Sharma
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Palmer Q Bessey
- Division of Trauma, Burns, Acute and Critical Care, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York
| | - Tony Rosen
- Department of Emergency Medicine, Weill Cornell Medicine, New York-Presbyterian Hospital, New York, New York.
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van Loon‐van Gaalen M, van der Linden MC, Gussekloo J, van der Mast RC. Telephone follow-up to reduce unplanned hospital returns for older emergency department patients: A randomized trial. J Am Geriatr Soc 2021; 69:3157-3166. [PMID: 34173229 PMCID: PMC9290482 DOI: 10.1111/jgs.17336] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 05/10/2021] [Accepted: 05/29/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND/OBJECTIVES Telephone follow-up calls could optimize the transition from the emergency department (ED) to home for older patients. However, the effects on hospital return rates are not clear. We investigated whether telephone follow-up reduces unplanned hospitalizations and/or unplanned ED return visits within 30 days of ED discharge. DESIGN Pragmatic randomized controlled trial with allocation by month; odd months intervention group, even months control group. SETTING Two ED locations of a non-academic teaching hospital in The Netherlands. PARTICIPANTS Community-dwelling adults aged ≥70 years, discharged home from the ED were randomized to the intervention group (N = 4732) or control group (N = 5104). INTERVENTION Intervention group patients: semi-scripted telephone call from an ED nurse within 24 h after discharge to identify post-discharge problems and review discharge instructions. Control group patients: scripted satisfaction survey telephone call. MEASUREMENTS Primary outcome: total number of unplanned hospitalizations and/or ED return visits within 30 days of ED discharge. SECONDARY OUTCOMES separate numbers of unplanned hospitalizations and ED return visits. Subgroup analysis by age, sex, living condition, and degree of crowding in the ED at discharge. RESULTS Overall, 42% were males, and median age was 78 years. In the intervention group, 1516 of 4732 patients (32%) consented, and in the control group 1659 of 5104 (33%) patients. Unplanned 30-day hospitalization and/or ED return visit was found in 16% of intervention group patients and 14% of control group patients (odds ratio 1.16; 95% confidence interval: 0.96-1.42). Also, no statistically significant differences were found in secondary outcome measures. Within the subgroups, the intervention did not have beneficial effects for the intervention group. CONCLUSION Telephone follow-up after ED discharge in older patients did not result in reduction of unplanned hospital admissions and/or ED return visits within 30 days. These results raise the question of whether other outcomes could be improved by post-discharge ED telephone follow-up.
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Affiliation(s)
| | | | - Jacobijn Gussekloo
- Department of Internal Medicine, Section of Gerontology and GeriatricsLeiden University Medical CenterLeidenThe Netherlands
- Department of Public Health and Primary CareLeiden University Medical CenterLeidenThe Netherlands
| | - Roos C. van der Mast
- Department of PsychiatryLeiden University Medical CenterLeidenThe Netherlands
- Department of PsychiatryCAPRI‐University AntwerpAntwerpBelgium
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Yau FFF, Yang Y, Cheng CY, Li CJ, Wang SH, Chiu IM. Risk Factors for Early Return Visits to the Emergency Department in Patients Presenting with Nonspecific Abdominal Pain and the Use of Computed Tomography Scan. Healthcare (Basel) 2021; 9:healthcare9111470. [PMID: 34828517 PMCID: PMC8620581 DOI: 10.3390/healthcare9111470] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Revised: 10/28/2021] [Accepted: 10/29/2021] [Indexed: 11/17/2022] Open
Abstract
Over a quarter of patients presenting with abdominal pain at emergency departments (EDs) are diagnosed with nonspecific abdominal pain (NSAP) at discharge. This study investigated the risk factors associated with return ED visits in Taiwanese patients with NSAP after discharge. We divided patients into two groups: the study group comprising patients with ED revisits after the index ED visit, and the control group comprising patients without revisits. During the study period, 10,341 patients discharged with the impression of NSAP after ED management. A regression analysis found that older age (OR [95%CI]: 1.007 [1.003–1.011], p = 0.004), male sex (OR [95%CI]: 1.307 [1.036–1.650], p = 0.024), and use of NSAIDs (OR [95%CI]: 1.563 [1.219–2.003], p < 0.001) and opioids (OR [95%CI]: 2.213 [1.643–2.930], p < 0.001) during the index visit were associated with increased return ED visits. Computed tomography (CT) scans (OR [95%CI]: 0.605 [0.390–0.937], p = 0.021) were associated with decreased ED returns, especially for those who were older than 60, who had an underlying disease, or who required pain control during the index ED visit.
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Affiliation(s)
- Fei-Fei Flora Yau
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
| | - Ying Yang
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
| | - Chi-Yung Cheng
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
| | - Chao-Jui Li
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
| | - Su-Hung Wang
- Division of Hepatogastroenterology, Department of Internal Medicine, Chi-Mei Medical Center, Tainan 710, Taiwan;
| | - I-Min Chiu
- Department of Emergency Medicine, Kaohsiung Chang Gung Memorial Hospital, Kaohsiung 833, Taiwan; (F.-F.F.Y.); (Y.Y.); (C.-Y.C.); (C.-J.L.)
- Department of Computer Science and Engineering, National Sun Yat-Sen University, Kaohsiung 804, Taiwan
- Correspondence: ; Tel.: +886-978839856
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Demir Akça AS, Kafadar D, Kahveci FO, Büyükuysal MÇ, Akca F. Performance of Identification of Seniors at Risk tool to predict unplanned revisits to the emergency department in 6 months was low in predictive accuracy: A single-center study. HONG KONG J EMERG ME 2021. [DOI: 10.1177/1024907920914811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background: Elderly people are at risk for mortality, functional decline, reattendance, and hospitalization after an emergency department visit. Objective: The aim of this study was to evaluate the performance of Identification of Seniors at Risk tool to predict unplanned readmissions after an emergency department visit. Methods: Records of patients aged ⩾65 years, who completed Identification of Seniors at Risk tool as they were being discharged from the emergency department, were analyzed. Patients were called back at 30th, 60th, 90th, 120th, and 180th days after emergency department discharge to assess their readmission to emergency department. Descriptive statistics and receiver operating characteristic curve analysis were performed. Results: This was a single-center study conducted with elderly patients with chronic diseases in a tertiary-level hospital within a period of 10 months with the follow-up calls. During the first month, 1792 patients were admitted to emergency department and 333 patients were aged ⩾65 years. Patients who completed Identification of Seniors at Risk tool as they were discharged from the emergency department were 170 out of 333. In 6 months, 71 patients out of 170, 36 men (50.7%) and 35 women (49.3%), were able to complete the follow-up. For predictive unplanned admissions, specificity and sensitivity at 1, 3, and 6 months were 40%, 40%, 38% and 69%, 78%, 67%, respectively, which demonstrates that sensitivity of Identification of Seniors at Risk tool was higher than its specificity. Although representing poor performance, Identification of Seniors at Risk tool was better at 3 months in predicting health risks for the elderly who have visited emergency department. Conclusion: Predictive ability of Identification of Seniors at Risk tool at the usual cutoff ⩾2 points to identify elderly at risk for revisiting emergency department for adverse health outcomes is limited. Multicentered studies, with standardized procedures and well-defined patient profile, are needed to improve the predictive ability of Identification of Seniors at Risk tool to screen elderly who require additional support after hospitalization.
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Affiliation(s)
- Ayse Semra Demir Akça
- Department of Family Medicine, Medical Faculty, Zonguldak Bülent Ecevit University, Zonguldak, Turkey
| | - Didem Kafadar
- Department of Family Medicine, Health Sciences University, Istanbul Bağcılar Training and Research Hospital, Istanbul, Turkey
| | - Fatih Ozan Kahveci
- Department of Emergency Medicine, Medical Faculty, Zonguldak Bülent Ecevit University, Zonguldak, Turkey
| | | | - Fatih Akca
- Zonguldak Public Health Directorate, Zonguldak, Turkey
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Benjenk I, DuGoff EH, Jacobsohn GC, Cayenne N, Jones CMC, Caprio TV, Cushman JT, Green RK, Kind AJH, Lohmeier M, Mi R, Shah MN. Predictors of Older Adult Adherence With Emergency Department Discharge Instructions. Acad Emerg Med 2021; 28:215-225. [PMID: 32767696 DOI: 10.1111/acem.14105] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Revised: 07/13/2020] [Accepted: 07/27/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Older adults discharged from the emergency department (ED) are at high risk for adverse outcomes. Adherence to ED discharge instructions is necessary to reduce those risks. The objective of this study is to determine the individual-level factors associated with adherence with ED discharge instructions among older adult ED outpatients. METHODS We performed a secondary analysis of data from the control group of a randomized controlled trial testing a care transitions intervention among older adults (age ≥ 60 years) discharged home from the ED in two states. Taking data from patient surveys and chart reviews, we used multivariable logistic regression to identify patient characteristics associated with adherence to printed discharge instructions. Outcomes were patient-reported medication adherence, provider follow-up visit adherence, and knowledge of "red flags" (signs of worsening health requiring further medical attention). RESULTS A total 824 patients were potentially eligible, and 699 had data in at least one pillar. A total of 35% adhered to medication instructions, 76% adhered to follow-up instructions, and 35% recalled at least one red flag. In the multivariate analysis, no factors were significantly associated with failure to adhere to medications. Participants with poor health status (adjusted odds ratio [AOR] = 0.55, 95% confidence interval [CI] = 0.31 to 0.98) were less likely to adhere to follow-up instructions. Participants who were older (AORs trended downward as age category increased) or depressed (AOR = 0.39, 95% CI = 0.17 to 0.85) or had one or more functional limitations (AOR = 0.62, 95% CI = 0.41 to 0.94) were less likely to recall red flags. CONCLUSION Older adults discharged home from the ED have mixed rates of adherence to discharge instructions. Although it is thought that some subgroups may be higher risk than others, given the opportunity to improve ED-to-home transitions, EDs and health systems should consider providing additional care transition support to all older adults discharged home from the ED.
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Affiliation(s)
- Ivy Benjenk
- From the Department of Health Policy and Management School of Public Health University of Maryland College Park MDUSA
| | - Eva H. DuGoff
- From the Department of Health Policy and Management School of Public Health University of Maryland College Park MDUSA
- the Department of Population Health Sciences School of Medicine and Public HealthUniversity of Wisconsin MadisonWIUSA
- the Berkeley Research Group Washington DCUSA
| | - Gwen C. Jacobsohn
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Nia Cayenne
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Courtney M. C. Jones
- the Department of Emergency MedicineUniversity of Rochester Medical Center RochesterNYUSA
| | - Thomas V. Caprio
- the Department of Public Health SciencesUniversity of Rochester Medical Center RochesterNYUSA
- the Department of Medicine Division of Geriatrics University of Rochester Medical Center Rochester NYUSA
| | - Jeremy T. Cushman
- the Department of Emergency MedicineUniversity of Rochester Medical Center RochesterNYUSA
- the Department of Public Health SciencesUniversity of Rochester Medical Center RochesterNYUSA
| | - Rebecca K. Green
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Amy J. H. Kind
- the Division of Geriatrics and Gerontology Department of Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
- and the William S. Middleton Veterans Affairs Geriatrics Research, Education, and Clinical Center Madison WIUSA
| | - Michael Lohmeier
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Ranran Mi
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
| | - Manish N. Shah
- the Department of Population Health Sciences School of Medicine and Public HealthUniversity of Wisconsin MadisonWIUSA
- and the Department of Emergency Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
- the Division of Geriatrics and Gerontology Department of Medicine School of Medicine and Public Health University of Wisconsin Madison WIUSA
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Sheikh S, Booth-Norse A, Smotherman C, Kalynych C, Lukens-Bull K, Guerrido E, Henson M, Gautam S, Hendry P. Predicting Pain-Related 30-Day Emergency Department Return Visits in Middle-Aged and Older Adults. PAIN MEDICINE (MALDEN, MASS.) 2020; 21:2748-2756. [PMID: 32875332 PMCID: PMC8557807 DOI: 10.1093/pm/pnaa213] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
OBJECTIVE The objective of this study was to determine predictive factors for pain-related emergency department returns in middle-aged and older adults. Design, Setting, and Subjects. This was a subanalysis of patients > 55 years of age enrolled in a prospective observational study of adult patients presenting within 30 days of an index visit to a large, urban, academic center. METHODS Demographic and clinical data were collected and compared to determine significant differences between patients who returned for pain and those who did not. Multiple logistic regressions were used to determine significant predictive variables for return visits. RESULTS The majority of the 130 enrolled patients > 55 years of age returned for pain (57%), were African American (78%), were younger (55-64 years old, 67%), had a high emergency department acuity level (level 1 or 2) at their index visit (56%), had low health literacy (Rapid Estimate of Adult Literacy in Medicine [REALM] score, 62%), lived in an area of extreme deprivation (69%), and were admitted (61%) during their index visit. Age (odds ratio [OR] = 0.9, 95% CI = 0.8-0.9, P = 0.047), health literacy (REALM scores; OR = 3.1, 95% CI = 1.3-7.5, P = 0.011), and index visit pain scores (OR = 1.1, 95% CI = 1.0-1.2, P = 0.004) were predictive of emergency department returns for pain in middle-aged and older adults. CONCLUSIONS The likelihood of emergency department return visits for pain in middle-aged and older adults decreased with older age, increased with higher health literacy (REALM scores), and increased with increase in pain scores.
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Affiliation(s)
- Sophia Sheikh
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Ashley Booth-Norse
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Carmen Smotherman
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Colleen Kalynych
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Katryne Lukens-Bull
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Erika Guerrido
- Center for Health Equity and Quality Research, University of Florida College of Medicine, Jacksonville, Florida
| | - Morgan Henson
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
| | - Shiva Gautam
- Department of Medicine, University of Florida College of Medicine, Jacksonville, Florida, USA
| | - Phyllis Hendry
- Department of Emergency Medicine, University of Florida College of Medicine, Jacksonville, Florida
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Magidson PD, Huang J, Levitan EB, Westfall AO, Sheehan OC, Roth DL. Prompt Outpatient Care For Older Adults Discharged From The Emergency Department Reduces Recidivism. West J Emerg Med 2020; 21:198-204. [PMID: 33207166 PMCID: PMC7673881 DOI: 10.5811/westjem.2020.8.47276] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2020] [Revised: 08/04/2020] [Accepted: 08/14/2020] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION Older adults present unique challenges to both emergency clinicians and health systems. These challenges are especially evident with respect to discharge after an emergency department (ED) visit as older adults are at risk for short-term, negative outcomes including repeat ED visits. The aim of this study was to evaluate characteristics and risk factors associated with repeat ED utilization by older adults. METHODS ED visits among participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study between 2003-2016 were examined using linked Medicare claims data to identify such visits and resulting disposition. Multilevel proportional hazards models examined associations of age, comorbidity status, race, gender, Medicaid dual eligibility status, social support characteristics (living alone or caregiver support), and use of ambulatory primary and subspecialty care with repeat ED utilization. RESULTS Older adults discharged from the ED seen by a primary care provider (hazard ratio [HR] = 0.93, confidence interval [CI], 0.87-0.98, p = 0.01) or subspecialist (HR = 0.91, CI 0.86-0.97, P <0.01) after the ED visit were less likely to return to the ED within 30 days compared to those who did not have such post-ED ambulatory visits. Additionally, comorbidity (HR =1.14, 95% CI, 1.13-1.16, P <0.01) and dual eligibility for Medicare and Medicaid (HR = 1.34, 95% CI, 1.20-1.50, p<0.01) were associated with return to the ED within 30 days. Those who were older (HR = 1.10, 95% CI, 1.05-1.15), had more comorbidities (HR = 1.17, 95% CI 1.15-1.18), Black (HR = 1.23, 95% CI, 1.14-1.33,P <0.01), and dually eligible (HR =1.23, 95% CI, 1.14-1.33, P <0.01) were more likely to return within 31-90 days after their initial presentation. The association of outpatient visits with repeat ED visits was no longer seen beyond 30 days. Patients without a caregiver or who lived alone were no more likely to return to the ED in the time periods evaluated in our study. CONCLUSION Both primary care and subspecialty care visits among older adults who are seen in the ED and discharged are associated with less frequent repeat ED visits within 30 days.
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Affiliation(s)
- Phillip D Magidson
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, Maryland
| | - Jin Huang
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, Baltimore, Maryland
| | - Emily B Levitan
- University of Alabama at Birmingham School of Public Health, Department of Epidemiology, Birmingham, Alabama
| | - Andrew O Westfall
- University of Alabama at Birmingham School of Public Health, Department of Biostatistics, Birmingham, Alabama
| | - Orla C Sheehan
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, Baltimore, Maryland
| | - David L Roth
- Johns Hopkins University School of Medicine, Division of Geriatric Medicine and Gerontology, Baltimore, Maryland
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11
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Miller TA, Paul R, Forthofer M, Wurdeman SR. The Role of Earlier Receipt of a Lower Limb Prosthesis on Emergency Department Utilization. PM R 2020; 13:819-826. [PMID: 33010182 PMCID: PMC8451817 DOI: 10.1002/pmrj.12504] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2019] [Revised: 08/14/2020] [Accepted: 08/24/2020] [Indexed: 11/23/2022]
Abstract
Introduction Adverse events after a lower limb amputation (LLA) can negatively affect the rehabilitation process and may lead to emergency department (ED) visits. Earlier receipt of a prosthesis, as compared to delayed or not receiving a prosthesis, may decrease or moderate the risk of increased ED utilization. In addition, adverse events (ie, fall‐related injury [FRI]) may be associated with increased health care utilization as measured by ED use. The implication of the timing of prosthesis provision after amputation and reduced ED use is not well established. Obtaining data about ED utilization early post‐LLA could assist the rehabilitation team in ensuring timely and appropriate access to improve outcomes. Objective To determine the role that timing of prosthesis receipt has in ED utilization and the association of fall/FRI with health care utilization. Design Retrospective observational cohort using commercial claims data. A logistic regression model was used to assess factors that influence ED utilization post‐LLA. Setting Watson/Truven administrative database 2014 to 2016. Participants The study sample consisted of 510 adults age 18 to 64 years with continuous enrollment for 3 years. Interventions Independent variables included age, sex, diabetes status, amputation level, fall diagnosis, and prosthesis receipt. Fall was defined as presence of a diagnosis code in any outpatient procedure after the amputation date. Main Outcome Measure ED use after amputation was defined as the presence of procedure codes that billed for ED services (99281 to 99285). Results Individuals who receive a prosthesis early, within 0 to 3 months, post‐LLA were 48% (odds ratio [OR] 0.52, 95% confidence interval [CI] 0.28 to 0.97) less likely to use the ED compared to those who did not receive a prosthesis. Individuals who experienced a fall/FRI had 2.8 (OR 2.86, 95% CI 1.23 to 6.66) times the odds of ED utilization. Conclusion Receipt of a prosthesis reduces the risk of ED use. The current study underscores the value of prostheses during the rehabilitation process after LLA.
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Affiliation(s)
- Taavy A Miller
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC.,Department of Clinical and Scientific Affairs, Hanger Clinic, Austin, TX
| | - Rajib Paul
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC
| | - Melinda Forthofer
- Department of Public Health Sciences, University of North Carolina at Charlotte, Charlotte, NC
| | - Shane R Wurdeman
- Department of Clinical and Scientific Affairs, Hanger Clinic, Austin, TX.,Department of Biomechanics, University of Nebraska at Omaha, Omaha, NE
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12
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Avelino-Silva TJ, Steinman MA. Diagnostic discrepancies between emergency department admissions and hospital discharges among older adults: secondary analysis on a population-based survey. SAO PAULO MED J 2020; 138:359-367. [PMID: 32935740 PMCID: PMC9673862 DOI: 10.1590/1516-3180.0471.r1.05032020] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 03/05/2020] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Older adults frequently experience nonspecific clinical features. However, there is limited evidence on how often admission diagnoses for hospitalized older patients are incorrect, potentially leading to treatment delays. OBJECTIVES To determine the consistency between hospital admission and discharge diagnoses, and identify factors associated with diagnostic discrepancies in older adults. DESIGN AND SETTING Population-based cohort study in the United States. We included adults aged ≥ 18 years who were admitted from emergency departments (EDs) to hospitals, identified using the 2005-2010 National Hospital Ambulatory Medical Survey, a nationally representative survey. METHODS Three admission diagnoses and the principal discharge diagnosis were captured and classified as discrepant if they involved considerably different conditions within the same organ system, or different organ systems altogether. RESULTS Each year, 12 million adults were hospitalized following ED visits in the United States; 45% were aged ≥ 65 years. These patients' mean age was 79 years and 58% were women. Diagnostic discrepancies between admission and discharge were more common among adults ≥ 65 years (12.5 versus 8.3%; P < 0.001). Certain admission diagnoses had particularly high rates of diagnostic discrepancies: 26-27% of patients presenting with mental disorders or with endocrine and metabolic diseases had substantial diagnostic discrepancies between admission and discharge. Substantial diagnostic discrepancy was independently associated with longer hospitalization and higher in-hospital mortality. CONCLUSION One out of eight older adults hospitalized from EDs was discharged with a principal diagnosis differing considerably from the admission diagnosis. Given that missed or delayed diagnoses are a critical safety problem, clinicians should be vigilant and frequently cogitate alternative diagnostic possibilities.
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Affiliation(s)
- Thiago Junqueira Avelino-Silva
- MD, PhD. Physician and Adjunct Professor, Division of Geriatrics, Department of Internal Medicine, Hospital das Clinicas (HC), Faculdade de Medicina FMUSP, Universidade de São Paulo; Vice-Director, Laboratorio de Investigacao Medica em Envelhecimento (LIM-66), Division of Geriatrics, Hospital das Clinicas, Faculdade de Medicina FMUSP, Universidade de São Paulo, São Paulo (SP), Brazil.
| | - Michael Alan Steinman
- MD. Physician and Professor of Medicine, Division of Geriatrics, Department of Medicine, University of California San Francisco (UCSF), San Francisco (CA), United States; Professor of Medicine, San Francisco Veteran Affairs Medical Center, San Francisco (CA), United States.
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13
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Dresden SM, Lo AX, Lindquist LA, Kocherginsky M, Post LA, French DD, Gray E, Heinemann AW. The impact of Geriatric Emergency Department Innovations (GEDI) on health services use, health related quality of life, and costs: Protocol for a randomized controlled trial. Contemp Clin Trials 2020; 97:106125. [PMID: 32858227 DOI: 10.1016/j.cct.2020.106125] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 08/12/2020] [Accepted: 08/18/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND AND OBJECTIVES Older adults (age 65 and older) use the emergency department (ED) at a rate of nearly 50 ED visits per 100 older adults, accounting for over 23 million ED visits in the US annually, up to 20% of all ED visits. These ED visits are sentinel health events as discharged patients often return to the ED, experience declines in health-related quality of life (HRQoL) and disability, or are later hospitalized. Those who are admitted incur increased costs and greater risk for poor outcomes including infections, delirium, and falls. The objective of this randomized controlled trial (RCT) is to evaluate the efficacy of the Geriatric Emergency Department Innovations (GEDI) program, an ED nurse-led geriatric assessment and care coordination program, in decreasing unnecessary health services use and improving Health-Related Quality-of-Life (HRQoL) for older adults in the ED. METHODS Community dwelling older adults aged 65 and older who are vulnerable or frail according to the Clinical Frailty Scale (CFS) during an ED visit will be randomized to either GEDI (n = 420) or to usual ED care (n = 420). Outcome variables will be assessed during the ED visit and at 7-11 days and 28-32 days post ED visit. PROJECTED OUTCOMES The primary outcome is hospitalization or death within 30 days of the ED visit. Secondary outcomes include health service use outcomes (ED visits and hospitalizations), healthcare costs, and HRQoL outcomes [Patient-Reported Outcomes Measurement Information System (PROMIS) scores: PROMIS-Preference, Physical Function, Ability to Participate in Social Roles and Activities, Anxiety, and Depression]. TRIAL REGISTRATION Clinicaltrials.Gov identifier NCT04115371.
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Affiliation(s)
- Scott M Dresden
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Buheler Center for Health Policy and Economics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
| | - Alexander X Lo
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lee A Lindquist
- Department of Internal Medicine, Division of General Internal Medicine and Geriatrics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Masha Kocherginsky
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Lori Ann Post
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Buheler Center for Health Policy and Economics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Dustin D French
- Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Ophthalmology, Feinberg School of Medicine, Northwestern University, USA; Department of Veterans Affairs Health Services Research and Development Service, Edward Hines, Jr. VA Hospital, Hines, IL, USA
| | - Elizabeth Gray
- Department of Preventive Medicine, Division of Biostatistics, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA
| | - Allen W Heinemann
- Department of Emergency Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Center for Health Services and Outcomes Research, Institute for Public Health and Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA; Department of Physical Medicine and Rehabilitation, Feinberg School of Medicine, Northwestern University and Center for Rehabilitation Outcomes Research, Shirley Ryan AbilityLab, USA
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14
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Shebeshi DS, Dolja‐Gore X, Byles J. Estimating unplanned and planned hospitalization incidents among older Australian women aged 75 years and over: The presence of death as a competing risk. Int J Health Plann Manage 2020; 35:1219-1231. [DOI: 10.1002/hpm.3030] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 11/21/2019] [Accepted: 06/24/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Dinberu S. Shebeshi
- Research Centre for Generational Health and Ageing (RCGHA), Faculty of Health and Medicine The University of Newcastle Callaghan NSW Australia
- Centre for Clinical Epidemiology and Biostatistics University of Newcastle Newcastle Australia
- Research Assets Division SAX Institute, Level 3, 30C Wentworth Street Glebe NSW Australia
| | - Xenia Dolja‐Gore
- Research Centre for Generational Health and Ageing (RCGHA), Faculty of Health and Medicine The University of Newcastle Callaghan NSW Australia
| | - Julie Byles
- Research Centre for Generational Health and Ageing (RCGHA), Faculty of Health and Medicine The University of Newcastle Callaghan NSW Australia
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15
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"Analysis of readmissions to the emergency department among patients presenting with abdominal pain". BMC Emerg Med 2020; 20:37. [PMID: 32398140 PMCID: PMC7216723 DOI: 10.1186/s12873-020-00334-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 05/05/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Abdominal pain is one of the most common complaints among patients admitted to the Emergency Department (ED). Diagnosis and management of abdominal pain may be a challenge and there are patients who require admission to the ED more than once in a short period of time. Our purpose was to assess the incidence of readmissions among patients treated in the ED due to abdominal pain and to investigate the impact of readmission on the further course of treatment. METHODS We conducted a prospective observational study, which included patients admitted to the ED in one academic, teaching hospital presenting with non-traumatic abdominal pain in a three-month period. Analyzed factors included demographic data, details related to first and subsequent visits in the ED and the course of hospitalization. RESULTS Overall, 928 patients were included to the study and 101 (10.88%) patients were admitted to the ED more than once during three-month period. Patients visiting ED repeatedly were older (p = 0.03) and more likely to be hospitalized (p < 0.01) compared to single-visit patients. Patients during their subsequent visits spent more time in the ED (p = 0.01), had greater chance to repeat their appointment (p = 0.04), be admitted to the hospital (p < 0.01) and were more likely diagnosed with cholelithiasis (p = 0.03) compared to patients on their initial visit. If admitted to the surgical department they were also more often qualified for surgical procedure than patients on their first visit (p < 0.01). In a group of patients admitted to the surgical department there were no significant differences in rates of conversion, postoperative complications and mortality between subgroups. CONCLUSIONS Readmissions among patients presenting with abdominal pain are a common phenomenon with prevalence of 10.88%. They are most commonly associated with cholelithiasis and occur more frequently among older patients, which suggests, that elderly require more attention during ED managements.
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Hamilton T, Johnson L, Quinn BT, Coppola J, Sachs D, Migliaccio J, Phipps C, Schwartz J, Capasso M, Carpenter M, Putrino D. Telehealth Intervention Programs for Seniors: An Observational Study of a Community-Embedded Health Monitoring Initiative. Telemed J E Health 2020; 26:438-445. [DOI: 10.1089/tmj.2018.0248] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Affiliation(s)
- Taya Hamilton
- Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
| | - Liam Johnson
- Stroke Department, The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Australia
| | - Brian T Quinn
- Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
| | - Jean Coppola
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Seidenberg School of Computer Science and Information Systems, Pace University, Pleasantville, New York
| | - David Sachs
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Seidenberg School of Computer Science and Information Systems, Pace University, Pleasantville, New York
| | - John Migliaccio
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
| | - Colette Phipps
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Senior Program and Services, The Westchester County Department of Senior Programs and Services, White Plains, New York
| | - Jennifer Schwartz
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Senior Program and Services, The Westchester County Department of Senior Programs and Services, White Plains, New York
| | - Marikay Capasso
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Senior Program and Services, The Westchester County Department of Senior Programs and Services, White Plains, New York
| | - Mae Carpenter
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Senior Program and Services, The Westchester County Department of Senior Programs and Services, White Plains, New York
| | - David Putrino
- Department of Telemedicine and Virtual Rehabilitation, Burke Medical Research Institute, White Plains, New York
- Westchester Public/Private Partnership for Aging Services, White Plains, New York
- Department of Rehabilitation Medicine, Icahn School of Medicine at Mount Sinai, Manhattan, New York
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Aslaner MA. Acil Servise Geriatrik Hastaların 72 Saat İçerisindeki Tekrar Başvuruları. ACTA MEDICA ALANYA 2019. [DOI: 10.30565/medalanya.562963] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
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18
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Montoy JCC, Tamayo-Sarver J, Miller GA, Baer AE, Peabody CR. Predicting Emergency Department "Bouncebacks": A Retrospective Cohort Analysis. West J Emerg Med 2019; 20:865-874. [PMID: 31738713 PMCID: PMC6860392 DOI: 10.5811/westjem.2019.8.43221] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Accepted: 08/16/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION The short-term return visit rate among patients discharged from emergency departments (ED) is a quality metric and target for interventions. The ability to accurately identify which patients are more likely to revisit the ED could allow EDs and health systems to develop more focused interventions, but efforts to reduce revisits have not yet found success. Whether patients with a high number of ED visits are at increased risk of a return visit remains underexplored. METHODS This was a population-based, retrospective, cohort study using administrative data from a large physician partnership. We included patients discharged from EDs from 80 hospitals in seven states from July 2014 - June 2016. We performed multivariable logistic regression of short-term return visits on patient, visit, hospital, and community characteristics. The primary outcome was the proportion of patients who had a return visit within 14 days of an index ED visit. RESULTS Among 6,699,717 index visits, the overall risk of 14-day revisit was 12.6%. Frequent visitors accounted for 18.7% of all visits and 40.2% of all 14-day revisits. Frequent visitor status was associated with the highest odds of a revisit (odds ratio [OR] 3.06; 95% confidence interval [CI], 3.041 - 3.073). Other predictors of revisits were cellulitis (OR 2.131; 95% CI, 2.106 - 2.156), alcohol-related disorders (OR 1.579; 95%CI, 1.548 - 1.610), congestive heart failure (OR 1.175; 95% CI, 1.126 - 1.226), and public insurance (Medicaid OR 1.514; 95% CI, 1.501 - 1.528; Medicare OR 1.601; 95% CI, 1.583 - 1.620). CONCLUSION Previous ED use - even a single previous visit - was a stronger predictor of a return visit than any other patient, hospital, or community characteristic. Clinicians should consider previous ED use when considering treatment decisions and risk of return visit, as should stakeholders targeting patients at risk of a return visit.
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Affiliation(s)
- Juan Carlos C Montoy
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | | | | | - Amy E Baer
- Vituity Healthcare, Emeryville, California
| | - Christopher R Peabody
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
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Sheikh S. Risk Factors Associated with Emergency Department Recidivism in the Older Adult. West J Emerg Med 2019; 20:931-938. [PMID: 31738721 PMCID: PMC6860386 DOI: 10.5811/westjem.2019.7.43073] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2019] [Revised: 07/29/2019] [Accepted: 07/28/2019] [Indexed: 01/09/2023] Open
Abstract
Our objective was to review risk factors predictive of older adult recidivism in the emergency department. Certain risk factors and themes commonly occurred in the literature. These recurring factors included increasing age, male gender, certain diagnoses (abdominal pain, traumatic injuries, and respiratory complaints), psychosocial factors (depression, anxiety, poor social support, and limited health literacy), and poor general health (cognitive health and physical functioning). Many of the identified risk factors are not easily modifiable posing a significant challenge in the quest to develop and implement effective intervention strategies.
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Affiliation(s)
- Sophia Sheikh
- University of Florida-Jacksonville, Department of Emergency Medicine, Jacksonville, Florida
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20
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Naseer M, Agerholm J, Fastbom J, Schön P, Ehrenberg A, Dahlberg L. Factors associated with emergency department revisits among older adults in two Swedish regions: A prospective cohort study. Arch Gerontol Geriatr 2019; 86:103960. [PMID: 31704624 DOI: 10.1016/j.archger.2019.103960] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Revised: 09/09/2019] [Accepted: 10/01/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVES To assess the association between baseline characteristics at an index ED visit and ED revisit within 30 days among adults aged ≥ 65 years in two Swedish regions. METHODS This was a register-based prospective cohort study. The sample included (N=16 688; N=101 017) older adults who have had an index ED visit in 2014 at hospital based EDs in the regions of Dalarna and Stockholm, Sweden. Several registers were linked to obtain information on sociodemographic factors, living conditions, social care, polypharmacy and health care use. Multivariate logistic regression was used to analyse the data. RESULTS Seventeen percent of the study sample in Dalarna and 20.1% in Stockholm revisited ED within 30 days after an index ED visit. In both regions, male gender, being in the last year of life, excessive polypharmacy (≥ 10 drugs), ≥11 primary care visits and ED care utilization were positively associated with ED revisits. In Stockholm, but not in Dalarna, low level of education, polypharmacy, and institutional care was also associated with ED revisits. In contrast, home help was associated with ED revisits in Dalarna but not in Stockholm. CONCLUSION These findings call for further in-depth examinations of variations within single countries. ED revisits among older adults are driven by need of care but also by the social and care situation.
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Affiliation(s)
- Mahwish Naseer
- School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden; Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
| | - Janne Agerholm
- Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
| | - Johan Fastbom
- Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
| | - Pär Schön
- Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
| | - Anna Ehrenberg
- School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden.
| | - Lena Dahlberg
- School of Education, Health and Social Studies, Dalarna University, SE-791 88 Falun, Sweden; Aging Research Center, Karolinska Institutet & Stockholm University, Tomtebodavägen18A, SE-171 65 Solna, Sweden.
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Blakoe M, Gamst-Jensen H, von Euler-Chelpin M, Collatz Christensen H, Møller T. Sociodemographic and health-related determinants for making repeated calls to a medical helpline: a prospective cohort study. BMJ Open 2019; 9:e030173. [PMID: 31482858 PMCID: PMC6720138 DOI: 10.1136/bmjopen-2019-030173] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVES To identify sociodemographic and health-related characteristics of callers' making repeated calls within 48 hours to a medical helpline, compared with those who only call once. SETTING In the Capital Region of Denmark people with acute, non-life-threatening illnesses or injuries are triaged through a single-tier medical helpline for acute, healthcare services. PARTICIPANTS People who called the medical helpline between 18 January and 9 February 2017 were invited to participate in the survey. During the period, 38 787 calls were handled and 12 902 agreed to participate. Calls were excluded because of the temporary civil registration number (n=78), the call was not made by the patient or a close relative (n=699), or survey responses were incomplete (n=19). Hence, the analysis included 12 106 calls, representing 11.131 callers' making single calls and 464 callers' making two or more calls within 48 hours. Callers' data (age, sex and caller identification) were collected from the medical helpline's electronic records. Data were enriched using the callers' self-rated health, self-evaluated degree of worry, and registry data on income, ethnicity and comorbidities. The OR for making repeated calls was calculated in a crude, sex-adjusted and age-adjusted analysis and in a mutually adjusted analysis. RESULTS The crude logistic regression analysis showed that age, self-rated health, self-evaluated degree of worry, income, ethnicity and comorbidities were significantly associated with making repeated calls. In the mutually adjusted analysis associations decreased, however, odds ratios remained significantly decreased for callers with a household income in the middle (OR=0.71;95% CI 0.54 to 0.92) or highest (OR=0.68;95% CI 0.48 to 0.96) quartiles, whereas immigrants had borderline significantly increased OR (OR=1.34;95% CI 0.96 to 1.86) for making repeated calls. CONCLUSIONS Findings suggest that income and ethnicity are potential determinants of callers' need to make additional calls within 48 hours to a medical helpline with triage function.
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Affiliation(s)
- Mitti Blakoe
- Emergency Medical Services Copenhagen, Emergency Medical Services Copenhagen, Ballerup, Denmark
- University of Copenhagen Faculty of Health Sciences, Copenhagen, Denmark
| | - Hejdi Gamst-Jensen
- Emergency Medical Services Copenhagen, Emergency Medical Services Copenhagen, Ballerup, Denmark
| | - My von Euler-Chelpin
- Department of Public Health, University of Copenhagen Faculty of Health Sciences, Copenhagen, Denmark
| | | | - Tom Møller
- University of Copenhagen Faculty of Health Sciences, Copenhagen, Denmark
- The University Hospitals Centre for Health Research, Copenhagen, Denmark
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Factors associated with frequent use of emergency-department services in a geriatric population: a systematic review. BMC Geriatr 2019; 19:185. [PMID: 31277582 PMCID: PMC6610907 DOI: 10.1186/s12877-019-1197-9] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Accepted: 06/24/2019] [Indexed: 12/31/2022] Open
Abstract
BACKGROUND Frequent geriatric users of emergency departments (EDs) constitute a small group of individuals accounting for a disproportionately high number of ED visits. In addition to overcrowding, this situation might result in a less appropriate response to health needs and negative health impacts. Geriatric patients turn to EDs for a variety of reasons. A better understanding of the variables associated with frequent ED use will help implement interventions best suited for their needs. OBJECTIVE This review aimed at identifying variables associated with frequent ED use by older adults. METHODS For this systematic review, we searched Medline, CINAHL, Healthstar, and PsyINFO (before June 2018). Articles written in English or French meeting these criteria were included: targeting a population aged 65 years or older, reporting on frequent ED use, using an observational study design and multivariate regression analysis. The search was supplemented by manually examining the reference lists of relevant studies. Independent reviewers identified articles for inclusion, extracted data, and assessed quality with the JBI Critical Appraisal Checklist for Studies Reporting Prevalence. A narrative synthesis was done to combine the study results. A sensitivity analysis was performed to evaluate the effect of removing the studies not meeting the quality criteria. RESULTS Out of 5096 references, 8 met our inclusion criteria. A high number of past hospital and ED admissions, living in a rural area adjacent to an urban center, low income, a high number of prescribed drugs, and a history of heart disease were associated with frequent ED use among older adults. In addition, having a principal-care physician and living in a remote rural area were associated with fewer ED visits. Some variables recognized in the literature as influencing ED use among older adults received scant consideration, such as comorbidity, dementia, and considerations related to primary-care and community settings. CONCLUSION Further studies should bridge the gap in understanding and give a more global portrait by adding important personal variables such as dementia, organizational variables such as use of community and primary care, and contextual variables such as social and economic frailty.
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Fox GWC, Rodriguez S, Rivera-Reyes L, Loo G, Hazan A, Hwang U. PROMIS Physical Function 10-Item Short Form for Older Adults in an Emergency Setting. J Gerontol A Biol Sci Med Sci 2019; 75:1418-1423. [DOI: 10.1093/gerona/glz163] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Indexed: 11/13/2022] Open
Abstract
Abstract
Background
Functional status in older adults predicts hospital use and mortality, and offers insight into independence and quality of life. The Patient-Reported Outcome Measurement Information System (PROMIS) was developed to improve and standardize patient-reported outcomes measurements. The PROMIS Physical Function (PROMIS PF) 10-Item Short Form was not created specifically for older adults. By comparing PROMIS with the Katz Index of Activities of Daily Living (Katz), we evaluated PROMIS for measurement of physical function versus general function in an older adult population seen in the ED.
Methods
A prospective, convenience sample of ED patients 65 years and older (from January 1, 2015 to June 30, 2015) completed Katz and PROMIS PF. Both were compared for scoring distributions and conventional scoring thresholds for severity of impairment (eg, minimal, moderate, severe). We assessed convergence through Spearman correlations, equivalents of conventional thresholds and ranges of physical function, and item-response frequencies.
Results
A total of 357 completed both function surveys. PROMIS PF and Katz have a modest positive correlation (r = .50, p < .01). Mean PROMIS PF scores within Katz scoring ranges for minimal (43, SD = 10), moderate (32, SD = 7), and severe (24, SD = 7) impairment fell within respective PROMIS PF scoring ranges (severe = 14–29, moderate = 30–39, mild = 40–45), indicating convergence. PROMIS identified impairment in 3× as many patients as did Katz, as PROMIS assesses vigorous physical function (eg, running, heavy lifting) not queried by Katz. However, PROMIS does not assess select activities of daily living (ADLs; eg, feeding, continence) important for assessment of function in older adults.
Conclusions
There is a modest correlation between PROMIS and Katz. PROMIS may better assess physical function than Katz, but is not an adequate replacement for assessment of general functional status in older adults.
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Affiliation(s)
- G W Conner Fox
- Department of Emergency Medicine and Brookdale, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (ISMMS), New York
| | - Sandra Rodriguez
- Department of Emergency Medicine and Brookdale, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (ISMMS), New York
| | - Laura Rivera-Reyes
- Department of Emergency Medicine and Brookdale, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (ISMMS), New York
| | - George Loo
- Department of Emergency Medicine and Brookdale, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (ISMMS), New York
| | - Ariela Hazan
- Department of Emergency Medicine and Brookdale, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (ISMMS), New York
| | - Ula Hwang
- Department of Emergency Medicine and Brookdale, Department of Geriatrics and Palliative Medicine, Icahn School of Medicine at Mount Sinai (ISMMS), New York
- Geriatric Research, Education and Clinical Center, James J. Peters Veterans Affairs Medical Center, Bronx, New York
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Social factors in frequent callers: a description of isolation, poverty and quality of life in those calling emergency medical services frequently. BMC Public Health 2019; 19:684. [PMID: 31159766 PMCID: PMC6547509 DOI: 10.1186/s12889-019-6964-1] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 05/13/2019] [Indexed: 11/21/2022] Open
Abstract
Background Frequent users of emergency medical services (EMS) comprise a disproportionate percentage of emergency department (ED) visits. EDs are becoming increasingly overwhelmed and a portion of use by frequent callers of EMS is potentially avoidable. Social factors contribute to frequent use however few studies have examined their prevalence. This study aims to describe social isolation/loneliness, poverty, and quality of life in a sample of frequent callers of EMS in the Hamilton region, a southern Ontario mid-sized Canadian city. Study design Cross-sectional quantitative study. Methods We surveyed people who called EMS five or more times within 12 months. A mailed self-administered survey with validated tools, and focused on four major measures: demographic information, social isolation, poverty, and quality of life. Results Sixty-seven frequent EMS callers revealed that 37–49% were lonely, 14% had gone hungry in the preceding month, and 43% had difficulties making ends meet at the end of the month. For quality of life, 78% had mobility problems, 55% had difficulty with self-care, 78% had difficulty with usual activities, 87% experienced pain/discomfort, and 67% had anxiety/depression. Overall quality adjusted life years value was 0.53 on a scale of 0 to 1. The response rate was 41.1%. Conclusions Loneliness in our participants was more common than Hamilton and Canadian rates. Frequent EMS callers had higher rates of poverty and food insecurity than average Ontario citizens, which may also act as a barrier to accessing preventative health services. Lower quality of life may indicate chronic illness, and users who cannot access ambulatory care services consistently may call EMS more frequently. Frequent callers of EMS had high rates of social loneliness and poverty, and low quality of life, indicating a need for health service optimization for this vulnerable population.
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Effectiveness of a post-emergency department discharge multidisciplinary bundle in reducing acute hospital admissions for the elderly. Eur J Emerg Med 2019; 26:94-99. [DOI: 10.1097/mej.0000000000000504] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Ko MC, Lien HY, Woung LC, Chen CY, Chen YL, Chen CC. Difference in frequency and outcome of geriatric emergency department utilization between urban and rural areas. J Chin Med Assoc 2019; 82:282-288. [PMID: 30893267 DOI: 10.1097/jcma.0000000000000053] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Elderly people are susceptible to develop multiple chronic diseases and are thus likely to utilize the emergency department (ED). Access to health care and health outcomes may differ between rural and urban areas. This study aims to compare the frequency and outcome of geriatric ED utilization between urban and rural areas. METHODS This population-based study obtained information from the health insurance database. The frequency and outcome of ED utilization in 2013 were compared among people aged ≥65 years living in urban and rural areas. The independent effect of various characteristics on the frequency and outcome of ED utilization was evaluated using multivariate logistic regression analysis. RESULTS Of the 6695 people living in urban areas, 1879 (28.07%) utilized the ED and accounted for 3859 ED visits. Meanwhile, 908 (29.75%) of the 3052 people living in rural areas utilized the ED and accounted for 1820 ED visits. No difference in the prevalence of ED utilization was found between the urban and rural areas. Urbanization did not affect the risk of frequent ED utilization among ED users. People living in rural areas had an increased risk of ED visits with a high acuity (adjusted odds ratio: 1.40, 95% CI: 1.12-1.75). Urbanization did not affect the risk of hospitalization or immediate death after ED visits. CONCLUSION The frequency of ED utilization showed no urban-rural difference. Elderly people living in rural areas had an increased risk of visiting the ED with a high acuity.
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Affiliation(s)
- Ming-Chung Ko
- Department of Urology, Taipei City Hospital, Taipei, Taiwan, ROC
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC
- School of Medicine, Fu-Jen Catholic University, New Taipei City, Taiwan, ROC
| | - Hsin-Yi Lien
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC
- Cross-Strait Medical and Management Communication Center, Taipei City Hospital, Taipei, Taiwan, ROC
- Superintendent Office, Taipei City Hospital, Taipei, Taiwan, ROC
| | - Lin-Chung Woung
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC
- Superintendent Office, Taipei City Hospital, Taipei, Taiwan, ROC
| | - Chin-Yi Chen
- Auditing and Advising Division, Trust Association of Republic of China, Taipei, Taiwan, ROC
| | - Yu-Ling Chen
- Center for Big Data Analytics and Statistics, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan, ROC
| | - Chu-Chieh Chen
- Department of Health Care Management, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan, ROC
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Slankamenac K, Zehnder M, Langner TO, Krähenmann K, Keller DI. Recurrent Emergency Department Users: Two Categories with Different Risk Profiles. J Clin Med 2019; 8:E333. [PMID: 30857294 PMCID: PMC6463097 DOI: 10.3390/jcm8030333] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2019] [Revised: 03/04/2019] [Accepted: 03/05/2019] [Indexed: 11/16/2022] Open
Abstract
Recurrent emergency department (ED) visits are responsible for an increasing proportion of overcrowding. Therefore, our aim was to investigate the characteristics and prevalence of recurrent ED visitors as well as to determine risk factors associated with multiple ED visits. ED patients visiting the ED of a tertiary care hospital at least four times consecutively in 2015 were enrolled. Of 33,335 primary ED visits, 1921 ED visits (5.8%) were performed by 372 ED patients who presented in the ED at least four times within the one-year period. Two different categories of recurrent ED patients were identified: repeated ED users presenting always with the same symptoms and frequent ED visitors who were suffering from different symptoms on each ED visit. Repeated ED users had more ED visits (p < 0.001) and needed more hospital admissions (p < 0.010) compared to frequent ED users. Repeated ED users visited the ED more likely due to symptoms from chronic obstructive pulmonary diseases (p < 0.001) and mental disorders (p < 0.001). In contrast, frequent ED patients showed to be at risk for multiple ED visits when being disabled (p = 0.001), had an increased Charlson co-morbidity index (p = 0.004) or suffering from rheumatic diseases (p < 0.001). A small number of recurrent ED visitors determines a relevant number of ED visits with a relevance for and impact on patient centred care and emergency services. There are two categories of recurrent ED users with different risk factors for multiple ED visits: repeated and frequent. Therefore, multi-professional follow-up care models for recurrent ED patients are needed to improve patients' needs, quality of life as well as emergency services.
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Affiliation(s)
- Ksenija Slankamenac
- Emergency Department, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
| | - Meret Zehnder
- Emergency Department, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
| | - Tim O Langner
- Emergency Department, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
| | - Kathrin Krähenmann
- Emergency Department, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
| | - Dagmar I Keller
- Emergency Department, University Hospital Zurich, Raemistrasse 100, CH-8091 Zurich, Switzerland.
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Gabayan GZ, Gould MK, Weiss RE, Chiu VY, Sarkisian CA. A Risk Score to Predict Short-term Outcomes Following Emergency Department Discharge. West J Emerg Med 2018; 19:842-848. [PMID: 30202497 PMCID: PMC6123082 DOI: 10.5811/westjem.2018.7.37945] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2018] [Revised: 06/06/2018] [Accepted: 07/20/2018] [Indexed: 11/25/2022] Open
Abstract
Introduction The emergency department (ED) is an inherently high-risk setting. Risk scores can help practitioners understand the risk of ED patients for developing poor outcomes after discharge. Our objective was to develop two risk scores that predict either general inpatient admission or death/intensive care unit (ICU) admission within seven days of ED discharge. Methods We conducted a retrospective cohort study of patients age > 65 years using clinical data from a regional, integrated health system for years 2009–2010 to create risk scores to predict two outcomes, a general inpatient admission or death/ICU admission. We used logistic regression to predict the two outcomes based on age, body mass index, vital signs, Charlson comorbidity index (CCI), ED length of stay (LOS), and prior inpatient admission. Results Of 104,025 ED visit discharges, 4,638 (4.5%) experienced a general inpatient admission and 531 (0.5%) death or ICU admission within seven days of discharge. Risk factors with the greatest point value for either outcome were high CCI score and a prolonged ED LOS. The C-statistic was 0.68 and 0.76 for the two models. Conclusion Risk scores were successfully created for both outcomes from an integrated health system, inpatient admission or death/ICU admission. Patients who accrued the highest number of points and greatest risk present to the ED with a high number of comorbidities and require prolonged ED evaluations.
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Affiliation(s)
- Gelareh Z Gabayan
- University of California, Los Angeles, Department of Emergency Medicine, Los Angeles, California
| | - Michael K Gould
- Kaiser Permanente Southern California, Department of Research and Evaluation, Pasadena, California
| | - Robert E Weiss
- University of California, Los Angeles, Fielding School of Public Health, Department of Biostatistics, Los Angeles, California
| | - Vicki Y Chiu
- Kaiser Permanente Southern California, Department of Research and Evaluation, Pasadena, California
| | - Catherine A Sarkisian
- University of California, Los Angeles, Department of Medicine, Los Angeles, California.,Greater Los Angeles Veterans Affairs Healthcare System, Department of Medicine, Los Angeles, California
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Barbic D, Kim B, Salehmohamed Q, Kemplin K, Carpenter CR, Barbic SP. Diagnostic accuracy of the Ottawa 3DY and Short Blessed Test to detect cognitive dysfunction in geriatric patients presenting to the emergency department. BMJ Open 2018; 8:e019652. [PMID: 29549205 PMCID: PMC5857706 DOI: 10.1136/bmjopen-2017-019652] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023] Open
Abstract
OBJECTIVES Cognitive dysfunction (CD) is a common finding in geriatric patients presenting to the emergency department (ED). Our primary objective was to determine the diagnostic accuracy of the Ottawa 3DY (O3DY) and Short Blessed Test (SBT) as screening tools for the detection of CD in the ED. Our secondary objective was to estimate the inter-rater reliability of these instruments. METHODS We conducted a prospective cross-sectional comparative study at an inner-city academic medical centre (annual ED visit census 86 000). Patients aged 75 years or greater were evaluated for inclusion, 163 were screened, 150 were deemed eligible and 117 were enrolled. The research team completed the O3DY, SBT and Mini-Mental State Exam (MMSE) for each participant. Descriptive statistics were calculated. Sensitivity and specificity of the O3DY and SBT were calculated in STATA V.11.2 using the MMSE as our criterion standard. RESULTS We enrolled 117 patients from June to November 2016. The median ED length of stay at the time of completion of all tests was 1:40 (IQR 1:34-1:46). The sensitivity of the O3DY was 71.4% (95% CI 47.8 to 95.1), and specificity was 56.3% (46.7-65.9). Sensitivity of the SBT was 85.7% (67.4-99.9) and specificity was 58.3% (48.7-67.8). The receiver operating characteristic area under the curve was calculated for the O3DY (0.51; 95% CI 0.42 to 0.61) and SBT (0.52; 95% CI 0.43 to 0.61) relative to the MMSE. Inter-rater reliability for the O3DY (k=0.64) and SBT (k=0.63) were good. CONCLUSION In a cohort of geriatric patients presenting to an inner-city academic ED, the O3DY and SBT tools demonstrate moderate sensitivity and specificity for the detection of CD. Inter-rater reliability for the O3DY and SBT were good. Future research on this topic should attempt to derive and validate ED-specific screening tools, which will hopefully result in more robust likelihood ratios for the screening of CD in ED geriatric patients.
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Affiliation(s)
- David Barbic
- Department of Emergency Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Brian Kim
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Qadeem Salehmohamed
- Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Kate Kemplin
- School of Nursing, University of Tennessee Chattanooga, Chattanooga, Tennessee, USA
| | | | - Skye Pamela Barbic
- Department of Occupational Therapy and Occupational Science, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
- Centre for Health Evaluation Outcome Sciences, University of British Columbia, Vancouver, British Columbia, Canada
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Variations in elderly peoples’ visits to the emergency departments in Iceland: A five-year population study. Int Emerg Nurs 2018; 37:6-12. [DOI: 10.1016/j.ienj.2017.09.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Revised: 09/25/2017] [Accepted: 09/30/2017] [Indexed: 11/23/2022]
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Valtorta NK, Moore DC, Barron L, Stow D, Hanratty B. Older Adults' Social Relationships and Health Care Utilization: A Systematic Review. Am J Public Health 2018; 108:e1-e10. [PMID: 29470115 DOI: 10.2105/ajph.2017.304256] [Citation(s) in RCA: 94] [Impact Index Per Article: 15.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
BACKGROUND Deficiencies in older people's social relationships (including loneliness, social isolation, and low social support) have been implicated as a cause of premature mortality and increased morbidity. Whether they affect service use is unclear. OBJECTIVES To determine whether social relationships are associated with older adults' use of health services, independently of health-related needs. SEARCH METHODS We searched 8 electronic databases (MEDLINE, Embase, CINAHL, Web of Science, PsycINFO, Scopus, the Cochrane Library, and the Centre for Reviews and Dissemination) for data published between 1983 and 2016. We also identified relevant sources from scanning the reference lists of included studies and review articles, contacting authors to identify additional studies, and searching the tables of contents of key journals. SELECTION CRITERIA Studies met inclusion criteria if more than 50% of participants were older than 60 years or mean age was older than 60 years; they included a measure of social networks, received social support, or perceived support; and they reported quantitative data on the association between social relationships and older adults' health service utilization. DATA COLLECTION AND ANALYSIS Two researchers independently screened studies for inclusion. They extracted data and appraised study quality by using standardized forms. In a narrative synthesis, we grouped the studies according to the outcome of interest (physician visits, hospital admissions, hospital readmissions, emergency department use, hospital length of stay, utilization of home- and community-based services, contact with general health services, and mental health service use) and the domain of social relationships covered (social networks, received social support, or perceived support). For each service type and social relationship domain, we assessed the strength of the evidence across studies according to the quantity and quality of studies and consistency of findings. MAIN RESULTS The literature search retrieved 26 077 citations, 126 of which met inclusion criteria. Data were reported across 226 678 participants from 19 countries. We identified strong evidence of an association between weaker social relationships and increased rates of readmission to hospital (75% of high-quality studies reported evidence of an association in the same direction). In evidence of moderate strength, according to 2 high-quality and 3 medium-quality studies, smaller social networks were associated with longer hospital stays. When we considered received and perceived social support separately, they were not linked to health care use. Overall, the evidence did not indicate that older patients with weaker social relationships place greater demands on ambulatory care (including physician visits and community- or home-based services) than warranted by their needs. AUTHORS' CONCLUSIONS Current evidence does not support the view that, independently of health status, older patients with lower levels of social support place greater demands on ambulatory care. Future research on social relationships would benefit from a consensus on clinically relevant concepts to measure. Public Health Implications. Our findings are important for public health because they challenge the notion that lonely older adults are a burden on all health and social care services. In high-income countries, interventions aimed at reducing social isolation and loneliness are promoted as a means of preventing inappropriate service use. Our review cautions against assuming that reductions in care utilization can be achieved by intervening to strengthen social relationships.
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Affiliation(s)
- Nicole K Valtorta
- Nicole K. Valtorta, Lynn Barron, Daniel Stow, and Barbara Hanratty are with the Institute of Health and Society/Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom. Danielle Collingridge Moore is with the International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
| | - Danielle Collingridge Moore
- Nicole K. Valtorta, Lynn Barron, Daniel Stow, and Barbara Hanratty are with the Institute of Health and Society/Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom. Danielle Collingridge Moore is with the International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
| | - Lynn Barron
- Nicole K. Valtorta, Lynn Barron, Daniel Stow, and Barbara Hanratty are with the Institute of Health and Society/Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom. Danielle Collingridge Moore is with the International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
| | - Daniel Stow
- Nicole K. Valtorta, Lynn Barron, Daniel Stow, and Barbara Hanratty are with the Institute of Health and Society/Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom. Danielle Collingridge Moore is with the International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
| | - Barbara Hanratty
- Nicole K. Valtorta, Lynn Barron, Daniel Stow, and Barbara Hanratty are with the Institute of Health and Society/Newcastle University Institute for Ageing, Newcastle University, Newcastle upon Tyne, United Kingdom. Danielle Collingridge Moore is with the International Observatory on End of Life Care, Lancaster University, Lancaster, United Kingdom
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Shen Y, Tay YC, Teo EWK, Liu N, Lam SW, Ong MEH. Association between the elderly frequent attender to the emergency department and 30-day mortality: A retrospective study over 10 years. World J Emerg Med 2018; 9:20-25. [PMID: 29290891 PMCID: PMC5717371 DOI: 10.5847/wjem.j.1920-8642.2018.01.003] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2017] [Accepted: 09/20/2017] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND To determine if elderly frequent attenders are associated with increased 30-day mortality, assess resource utilization by the elderly frequent attenders and identify associated characteristics that contribute to mortality. METHODS Retrospective observational study of electronic clinical records of all emergency department (ED) visits over a 10-year period to an urban tertiary general hospital in Singapore. Patients aged 65 years and older, with 3 or more visits within a calendar year were identified. Outcomes measured include 30-day mortality, admission rate, admission diagnosis and duration spent at ED. Chi-square-tests were used to assess categorical factors and Student t-test was used to assess continuous variables on their association with being a frequent attender. Univariate and multivariate logistic regressions were conducted on all significant independent factors on to the outcome variable (30-day mortality), to determine factor independent odds ratios of being a frequent attender. RESULTS 1.381 million attendance records were analyzed. Elderly patients accounted for 25.5% of all attendances, of which 31.3% are frequent attenders. Their 30-day mortality rate increased from 4.0% in the first visit, to 8.8% in the third visit, peaking at 10.2% in the sixth visit. Factors associated with mortality include patients with neoplasms, ambulance utilization, male gender and having attended the ED the previous year. CONCLUSION Elderly attenders have a higher 30-day mortality risk compared to the overall ED population, with mortality risk more marked for frequent attenders. This study illustrates the importance and need for interventions to address frequent ED visits by the elderly, especially in an aging society.
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Affiliation(s)
- Yuzeng Shen
- Department of Emergency Medicine, Singapore General Hospital, Singapore
| | - Yee Chien Tay
- Department of Emergency Medicine, Sengkang Health, Singapore
| | | | - Nan Liu
- Singhealth Health Services Research Centre, Singapore
| | - Shao Wei Lam
- Singhealth Health Services Research Centre, Singapore
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Lowthian JA, Brand C, Barker AL, Andrianopoulos N, Smith C, Batey C, Smit PD, Newnham HH, Hunter P, Cameron PA. Managing Older Patients Safely in the Time Critical Environment of an Emergency Department. HONG KONG J EMERG ME 2017. [DOI: 10.1177/102490791201900405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Demand for emergency department (ED) services is increasing worldwide. The fastest growth in ED presentations is by patients aged ≥65 years, currently representing 18% of all attendances. Older patients present with more complex clinical conditions and multiple co-morbidities. This means they are likely to spend more time in ED, are more likely to be admitted to hospital, and are more likely to re-attend. The Safe Elderly Emergency Discharge (SEED) project aims to determine whether current models of emergency care ensure safe discharge and facilitate optimal health outcomes for older patients; and develop a tailored evidence-based care framework applicable to Australian and international settings. Risk screening for unsafe discharge will be conducted on patients aged ≥65 years discharged home from ED. Patients will be followed for 6 months post-ED presentation to monitor health outcomes and map their care journey. Demographic, clinical, and functional characteristics will be collected. The primary outcome is unsafe discharge, defined as unplanned re-presentation/admission within 30 days of the index presentation. Secondary outcomes include unplanned ED re-presentation/hospital admission within 6 months; patient experience; change in functional status; functional decline; health service utilisation; and death within 6 months. The effectiveness of the ED discharge risk screening tools for predicting unsafe discharge will be evaluated at 30 days and 6 months. SEED will determine the risk factors for unplanned ED re-presentation/hospital admission at 30 days for patients aged ≥65 years presenting to ED; which will inform the development of an evidence-based older patient care framework for EDs.
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Affiliation(s)
| | | | | | | | - C Smith
- Alfred Health, Alfred Emergency & Trauma Centre, Melbourne, Australia
| | - C Batey
- Alfred Health, Alfred Emergency & Trauma Centre, Melbourne, Australia
| | - PDeV Smit
- Alfred Health, Alfred Emergency & Trauma Centre, Melbourne, Australia
| | - HH Newnham
- Alfred Health, General Medicine, Melbourne, Australia
| | - P Hunter
- Alfred Health, Alfred Emergency & Trauma Centre, Melbourne, Australia
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Pimouguet C, Rizzuto D, Lagergren M, Fratiglioni L, Xu W. Living alone and unplanned hospitalizations among older adults: a population-based longitudinal study. Eur J Public Health 2017; 27:251-256. [PMID: 28339511 DOI: 10.1093/eurpub/ckw150] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
Background The association of living alone with hospitalization among the general elderly population has been rarely investigated, and the influence of common disorders on this association remains unknown. Methods We used data on participants in the Swedish National study on Aging and Care in Kungsholmen ( n = 3130). Risk and number of unplanned hospitalizations and length of hospital stays were studied over a period of 2 years. We used Cox proportional hazard models to estimate hazard ratios (HRs) of incident hospitalization and zero-inflated negative binomial regression models adjusted for potential confounders to estimate incident rate ratios (IRR) of the number of hospitalizations and total length of stay associated with living alone. Results A total of 1768 participants (56.5%) lived alone. Five hundred and sixty-one (31.7%) of those who lived alone had at least one unplanned hospitalization. In the multivariate analyses, living alone was significantly associated with the risk of unplanned hospitalization (HR = 1.21, 95% confidence interval [CI] 1.01-1.45) and the number of hospitalizations (IRR = 1.35, 95% CI 1.04-1.76) but not with the length of hospital stays. In stratified analyses, the association between living alone and unplanned hospitalizations remained statistically significant only among men (HR = 1.52, 95% CI 1.17-1.99). Conclusions Living alone is associated with higher risks of unplanned hospitalization in elderly, especially for men.
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Affiliation(s)
- Clément Pimouguet
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Debora Rizzuto
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
| | - Marten Lagergren
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Laura Fratiglioni
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden.,Stockholm Gerontology Research Center, Stockholm, Sweden
| | - Weili Xu
- Aging Research Center, Department of Neurobiology, Care Sciences and Society, Karolinska Institutet and Stockholm University, Stockholm, Sweden
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Lee S, Herrin J, Bobo WV, Johnson R, Sangaralingham LR, Campbell RL. Predictors of Return Visits Among Insured Emergency Department Mental Health and Substance Abuse Patients, 2005-2013. West J Emerg Med 2017; 18:884-893. [PMID: 28874941 PMCID: PMC5576625 DOI: 10.5811/westjem.2017.6.33850] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 05/08/2017] [Accepted: 06/26/2017] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Our goal was to describe the pattern and identify risk factors of early-return ED visits or inpatient admissions following an index mental health and substance abuse (MHSA)-related ED visit in the United States. METHODS We performed a retrospective cohort study using Optum Labs Data Warehouse, a nationally representative database containing administrative claims data on privately insured and Medicare Advantage enrollees. Authors identified patients presenting to an ED with a primary diagnosis of MHSA between 2005 and 2013 who were discharged home. Study inclusion required continuous insurance enrollment for the 12 months preceding and the 31 days following the index ED visit. During the study period we included only the first ED visit for each patient. RESULTS A total of 49,672 (14.2%) had a return visit to the ED or had a hospitalization within 30 days following discharge. Mean time to the next ED visit or inpatient admission was 11.7 days. An increased age (age 65+ vs. age <18 years; OR 1.65, 95% CI [1.57 to 1.74]), chronic medical comorbidities (Hwang comorbidity 5+ vs 0; OR 1.31, 95% CI [1.27 to 1.35]), prior ED and inpatient utilization (4+ visits vs 0 visits; OR 5.59, 95% CI [5.41 to 5.78]) were associated with return visits within 30 days following discharge. CONCLUSION In an analysis of nearly 350,000 ED visits for MHSA, 14.2 % of patients returned to the ED or hospital within 30 days. This study identified a number of factors associated with return visits for acute care.
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Affiliation(s)
- Sangil Lee
- The University of Iowa Carver College of Medicine, Department of Emergency Medicine, Iowa City, Iowa
| | - Jeph Herrin
- Yale University School of Medicine, Department of Cardiology, New Havens, Connecticut.,Health Research & Educational Trust, Chicago, Illinois
| | - William V Bobo
- Mayo Clinic, Department of Psychiatry, Rochester, Minnesota
| | - Ryan Johnson
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Lindsey R Sangaralingham
- Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery, Mayo Clinic, Rochester, Minnesota
| | - Ronna L Campbell
- Mayo Clinic, Department of Emergency Medicine, Rochester, Minnesota
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Earl-Royal EC, Kaufman EJ, Hanlon AL, Holena DN, Rising KL, Kit Delgado M. Factors associated with hospital admission after an emergency department treat and release visit for older adults with injuries. Am J Emerg Med 2017; 35:1252-1257. [PMID: 28410919 PMCID: PMC5854494 DOI: 10.1016/j.ajem.2017.03.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 03/19/2017] [Accepted: 03/21/2017] [Indexed: 11/24/2022] Open
Abstract
INTRODUCTION Emergency Department (ED) visits for injury often precede hospital admissions in older adults, but risk factors for these admissions are poorly characterized. We sought to determine the incidence and risk factors for hospitalization shortly following discharge home from an ED visit for traumatic injury in older adults. We hypothesized higher risk for admission in those with increased age, discharged home after falls, with increased comorbidity burden, and who live in poor neighborhoods. METHODS We identified all community-dwelling patients ≥65years old treated and released for traumatic injury at non-federal EDs in Florida using the 2011 State Inpatient Database and State ED Database of the Agency for Healthcare Research and Quality. Outcome measures were hospitalization within 9 and 30days of discharge from the ED. Multivariable logistic regression was used to establish independent risk factors for hospital admission. RESULTS Of 163,851 index ED injury visits, 6298 (3.8%) resulted in inpatient admissions within 9days and 12,938 (7.9%) within 30days. Factors associated with increased odds of admission within 9days included: each additional comorbidity, ≥moderate injury to abdomen or pelvis/extremities, and median neighborhood income<$39,000. Additional factors associated with increased odds of admission within 30days included: lack of private insurance supplement and median neighborhood income<$48,000. CONCLUSION Among older adults treated and discharged from the ED for an injury, those who have high comorbidity burdens, have abdominal or orthopedic injuries, and live in poor neighborhoods are at increased risk of hospitalization within 9 or 30days of ED discharge.
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Affiliation(s)
- Emily C Earl-Royal
- Department of Emergency Medicine, Stanford University, Stanford, CA, United States.
| | - Elinore J Kaufman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, United States; New York-Presbyterian Weill Cornell Medical Center, New York, NY, United States
| | - Alexandra L Hanlon
- Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, PA, United States; Penn Nursing Science, University of Pennsylvania, Philadelphia, PA, United States
| | - Daniel N Holena
- Division of Traumatology, Surgical Critical Care and Emergency Surgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; The Penn Injury Science Center at the University of Pennsylvania, Philadelphia, PA, United States
| | - Kristin L Rising
- Department of Emergency Medicine, Sidney Kimmel Medical College at Thomas Jefferson University, Philadelphia, PA, United States
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, United States; Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; The Penn Injury Science Center at the University of Pennsylvania, Philadelphia, PA, United States; Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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Burkett E, Martin-Khan MG, Gray LC. Quality indicators in the care of older persons in the emergency department: A systematic review of the literature. Australas J Ageing 2017; 36:286-298. [PMID: 28762246 DOI: 10.1111/ajag.12451] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE A systematic review of the literature was undertaken to assess the methodological quality of existing quality indicators (QIs) for the emergency department (ED) care of older persons. METHODS MEDLINE, CINAHL, EMBASE and grey literature were searched. Articles were included if they addressed ED care of persons aged ≥65 years and defined a QI amenable to influence by ED providers. The methodological quality of QIs was assessed using relevant items from the Appraisal of Indicators through Research and Evaluation and the QUALIFY tools. RESULTS Sixty-one articles were included in the review, with identification of 50 QIs meeting predefined inclusion criteria. Thirty-six of fifty ED QIs for older persons were process indicators. The appraisal instruments' total ratings ranged from 39 to 67%, with only 18 QIs scoring 50% or more for all five domains. CONCLUSION There is a need for a balanced, methodologically robust set of QIs for care of older persons in the ED.
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Affiliation(s)
- Ellen Burkett
- Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia.,School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Melinda G Martin-Khan
- Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland, Australia.,Centre for Online Health, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Leonard C Gray
- Princess Alexandra Hospital, University of Queensland, Brisbane, Queensland, Australia.,Centre for Research in Geriatric Medicine, University of Queensland, Brisbane, Queensland, Australia.,Centre for Online Health, School of Medicine, University of Queensland, Brisbane, Queensland, Australia
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Lowthian JA, Straney LD, Brand CA, Barker A, Smit PDV, Newnham H, Hunter P, Smith C, Cameron PA. Predicting functional decline in older emergency patients-the Safe Elderly Emergency Discharge (SEED) project. Age Ageing 2017; 46:219-225. [PMID: 27932362 DOI: 10.1093/ageing/afw210] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2016] [Indexed: 11/13/2022] Open
Abstract
Objective to profile the trajectory of, and risk factors for, functional decline in older patients in the 30 days following Emergency Department (ED) discharge. Methods prospective cohort study of community-dwelling patients aged ≥65 years, discharged home from a metropolitan Melbourne ED, 31 July 2012 to 30 November 2013. The primary outcome was functional decline, comprising either increased dependency in personal activities of daily living (ADL) or in skills required for living independently instrumental ADL (IADL), deterioration in cognitive function, nursing home admission or death. Univariate analyses were used to select risk factors and logistic regression models constructed to predict functional decline. Results at 30 days, 34.4% experienced functional decline; with 16.7% becoming more dependent in personal ADL, 17.5% more dependant in IADL and 18.4% suffering deterioration in cognitive function. Factors independently associated with decline were functional impairment prior to the visit in personal ADL (Odds Ratio [OR] 3.21, 95% confidence interval [CI] 2.26-4.53) or in IADL (OR 6.69, 95% CI 4.31-10.38). The relative odds were less for patients with moderately impaired cognition relative to those with normal cognition (OR 0.38, 95% CI 0.19-0.75). There was a 68% decline in the relative odds of functional decline for those with any impairment in IADL who used an aid for mobility (OR 0.32, 95% CI 0.14-0.7). Conclusion older people with pre-existing ADL impairment were at high risk of functional decline in the 30 days following ED presentation. This effect was largely mitigated for those who used a mobility aid. Early intervention with functional assessments and appropriate implementation of support services and mobility aids could reduce functional decline after discharge.
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Affiliation(s)
- Judy A. Lowthian
- Department of Epidemiology & Preventive Medicine, Monash University, Level 6, Alfred Centre 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Lahn D. Straney
- Department of Epidemiology & Preventive Medicine, Monash University, Level 6, Alfred Centre 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Caroline A. Brand
- Department of Epidemiology & Preventive Medicine, Monash University, Level 6, Alfred Centre 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | - Anna Barker
- Department of Epidemiology & Preventive Medicine, Monash University, Level 6, Alfred Centre 99 Commercial Road, Melbourne, Victoria 3004, Australia
| | | | | | - Peter Hunter
- Caulfield Hospital, Alfred Health, Department of Aged Care, Melbourne, Victoria, Australia
| | - Cathie Smith
- Alfred Health, Emergency & Trauma Centre, Melbourne, Victoria, Australia
| | - Peter A. Cameron
- Department of Epidemiology & Preventive Medicine, Monash University, Level 6, Alfred Centre 99 Commercial Road, Melbourne, Victoria 3004, Australia
- Alfred Health, Emergency & Trauma Centre, Melbourne, Victoria, Australia
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Lowthian JA, Lennox A, Curtis A, Dale J, Browning C, Smit DV, Wilson G, O'Brien D, Rosewarne C, Boyd L, Garner C, Cameron P. HOspitals and patients WoRking in Unity (HOW R U?): protocol for a prospective feasibility study of telephone peer support to improve older patients' quality of life after emergency department discharge. BMJ Open 2016; 6:e013179. [PMID: 27913561 PMCID: PMC5168602 DOI: 10.1136/bmjopen-2016-013179] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2016] [Revised: 11/10/2016] [Accepted: 11/14/2016] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Older people presenting to an emergency department (ED) have a higher likelihood of social isolation, loneliness and depression; which are all associated with negative health outcomes and increased health service use, including higher rates of ED attendance. The HOW R U? study aims to ascertain the feasibility and acceptability of a postdischarge telephone support programme for older ED patients following discharge. The intervention, which aims to improve quality of life, will be delivered by hospital-based volunteers. METHODS AND ANALYSIS A multicentre prospective uncontrolled feasibility study will enrol 50 community-dwelling patients aged ≥70 years with symptoms of loneliness or depression who are discharged home within 72 hours from the ED or acute medical ward. Participants will receive weekly supportive telephone calls over a 3-month period from a volunteer-peer. Feasibility will be assessed in terms of recruitment, acceptability of the intervention to participants and level of retention in the programme. Changes in level of loneliness (UCLA-3 item Loneliness Scale), mood (Geriatric Depression Scale-5 item) and health-related quality of life (EQ-5D-5L and EQ-VAS) will also be measured postintervention (3 months). ETHICS AND DISSEMINATION Research ethics and governance committee approval has been granted for this study by each participating centre (reference: 432/15 and 12-09-11-15). Study findings will inform the design and conduct of a future multicentre randomised controlled trial of a postdischarge volunteer-peer telephone support programme to improve social isolation, loneliness or depressive symptoms in older patients. Results will be disseminated through peer-reviewed journal publication, and conference and seminar presentation. TRIAL REGISTRATION NUMBER ACTRN12615000715572, Pre-results.
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Affiliation(s)
- Judy A Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Alyse Lennox
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Andrea Curtis
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Colette Browning
- RDNS Institute, RDNS, Melbourne, Victoria, Australia
- International Institute for Primary Health Care Research, Shenzhen, China
- School of Primary Health Care, Monash University, Melbourne, Victoria, Australia
| | - De Villiers Smit
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Gillian Wilson
- Volunteer Services, Alfred Health, Melbourne, Victoria, Australia
| | - Debra O'Brien
- Emergency Department, Cabrini Health, Malvern, Victoria, Australia
| | - Cate Rosewarne
- Volunteer Services, Cabrini Health, Malvern, Victoria, Australia
| | - Lee Boyd
- Nursing Services, Cabrini Institute, Cabrini Health, Malvern, Victoria, Australia
| | - Cath Garner
- Department of Mission and Strategy, Cabrini Health, Malvern, Victoria,
| | - Peter Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
- Emergency and Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
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Characteristics and outcomes of patients with emergency department revisits within 72 hours and subsequent admission to the intensive care unit. Tzu Chi Med J 2016; 28:151-156. [PMID: 28757746 PMCID: PMC5442903 DOI: 10.1016/j.tcmj.2016.07.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2016] [Revised: 06/13/2016] [Accepted: 07/19/2016] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This study aimed to investigate the characteristics and outcomes of patients with emergency department (ED) revisits within 72 hours and subsequent admission to the intensive care unit (ICU). MATERIALS AND METHODS The medical records of all adult patients revisiting the ED of a single tertiary referral medical center with ICU admissions between January 2012 and September 2014 were reviewed in terms of patient characteristics, clinical manifestations, diagnoses, triage according to the Taiwan Triage and Acuity Scale, causes of revisits, and mortality. RESULTS The majority of the 51 patients reviewed were male (64.7%). Their mean age was 62.9 ± 14.9 years. Most patients visited the ED during the evening shift (51%) and were categorized into triage Level III (76.5%) during their first ED visit. The causes of revisits were doctor-related (21/51, 41.1%), illness-related (18/51, 35.3%), and patient-related (12/51, 23.5%). Disease categories included the neurological (23.5%), digestive (23.5%), and cardiovascular systems (21.6%). Abdominal pain and vertigo/dizziness were the two most common initial manifestations. The mortality rate was 27.5%. Malignancy and hepatic diseases were the two most common underlying medical conditions for nonsurvivors. In addition, patients initially presenting to the ED with lower triage scores (III & IV) had a higher mortality rate than those with higher scores (I & II). CONCLUSION Most of the patients who revisited the ED within 72 hours and were subsequently admitted to the ICU visited the ED during the evening shift and were categorized into triage Level III on their first visit. The most common chief complaint at the first visit was abdominal pain. The most common cause of revisits with ICU admission was doctor-related, while the most common underlying disease was hypertension. Significantly higher mortality was observed after ED revisits in patients with lower triage scores with underlying malignancy and liver cirrhosis.
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Revisits within 48 Hours to a Thai Emergency Department. Emerg Med Int 2016; 2016:8983573. [PMID: 27478642 PMCID: PMC4961813 DOI: 10.1155/2016/8983573] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2016] [Revised: 06/02/2016] [Accepted: 06/19/2016] [Indexed: 11/23/2022] Open
Abstract
Objective. Emergency department (ED) revisits are a common ED quality measure. This study was undertaken to ascertain the contributing factors of revisits within 48 hours to a Thai ED and to explore physician-related, illness-related, and patient-related factors behind those revisits. Methods. This study was a chart review from one tertiary care, urban Thai hospital from October 1, 2009, to September 31, 2010. We identified patients who returned to the ED within 48 hours for the same or related complaints after their initial discharge. Three physicians classified revisit as physician-related, illness-related, and patient-related factors. Results. Our study included 172 ED patients' charts. 86/172 (50%) were male and the mean age was 38 ± 5.6 (SD) years. The ED revisits contributing factors were physician-related factors [86/172 (50.0%)], illness-related factors [61/172 (35.5%)], and patient-related factor [25/172 (14.5%)], respectively. Among revisits classified as physician-related factors, 40/86 (46.5%) revisits were due to misdiagnosis and 36/86 (41.9%) were due to suboptimal management. Abdominal pain [27/86 (31.4%)] was the majority of physician-related chief complaints, followed by fever [16/86 (18.6%)] and dyspnea [15/86 (17.4%)]. Conclusion. Misdiagnosis and suboptimal management contributed to half of the 48-hour repeat ED visits in this Thai hospital.
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Lowthian J, Straney LD, Brand CA, Barker AL, Smit PDV, Newnham H, Hunter P, Smith C, Cameron PA. Unplanned early return to the emergency department by older patients: the Safe Elderly Emergency Department Discharge (SEED) project. Age Ageing 2016; 45:255-61. [PMID: 26764254 DOI: 10.1093/ageing/afv198] [Citation(s) in RCA: 62] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2015] [Accepted: 12/02/2015] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND an emergency department (ED) visit is a sentinel event for an older person, with increased likelihood of adverse outcomes post-discharge including early re-presentation. OBJECTIVES to determine factors associated with early re-presentation. METHODS prospective cohort study conducted in the ED of a large acute Melbourne tertiary hospital. Community-dwelling patients ≥65 years were interviewed including comprehensive assessment of cognitive and functional status, and mood. Logistic regression was used to identify risk factors for return within 30 days. RESULTS nine hundred and fifty-nine patients, median age 77 years, were recruited. One hundred and forty patients (14.6%) re-presented within 30 days, including 22 patients (2.3%) on ≥2 occasions and 75 patients (7.8%) within 7 days. Risk factors for re-presentation included depressive symptoms, cognitive impairment, co-morbidity, triaged as less urgent (ATS 4) and attendance in the previous 12 months, with a decline in risk after 85 years of age. Logistic regression identified chronic obstructive pulmonary disease (OR 1.78, 95% CI 1.02-3.11), moderate cognitive impairment (OR 2.07, 95% CI 1.09-3.90), previous ED visit (OR 2.11, 95% CI 1.43-3.12) and ATS 4 (OR 2.34, 95% CI 1.10-4.99) as independent risk factors for re-presentation. Age ≥85 years was associated with reduced risk (OR 0.81, 95% CI 0.70-0.93). CONCLUSION older discharged patients had a high rate of early re-presentation. Previously identified risk factors-increased age, living alone, functional dependence and polypharmacy-were not associated with early return in this study. It is not clear whether these inconsistencies represent a change in patient case-mix or strategies implemented to reduce re-attendance. This remains an important area for future research.
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Affiliation(s)
- Judy Lowthian
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Lahn D Straney
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Caroline A Brand
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Anna L Barker
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - P de Villiers Smit
- Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Harvey Newnham
- General Medicine, Alfred Health Melbourne, Victoria, Australia
| | - Peter Hunter
- Subacute and Medical Services Alfred Health, Melbourne, Victoria, Australia
| | - Cathie Smith
- Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
| | - Peter A Cameron
- School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia Emergency & Trauma Centre, Alfred Health, Melbourne, Victoria, Australia
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Behr JG, Diaz R. Emergency Department Frequent Utilization for Non-Emergent Presentments: Results from a Regional Urban Trauma Center Study. PLoS One 2016; 11:e0147116. [PMID: 26784515 PMCID: PMC4718591 DOI: 10.1371/journal.pone.0147116] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 12/29/2015] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES First, to test a model of the drivers of frequent emergency department utilization conceptualized as falling within predisposing, enabling, and need dimensions. Second, to extend the model to include social networks and service quality as predictors of frequent utilization. Third, to illustrate the variation in thresholds that define frequent utilization in terms of the number of emergency department encounters by the predictors within the model. DATA SOURCE Primary data collection over an eight week period within a level-1 trauma urban hospital's emergency department. STUDY DESIGN Representative randomized sample of 1,443 adult patients triaged ESI levels 4-5. Physicians and research staff interviewed patients as they received services. Relationships with the outcome variable, utilization, were tested using logistic regression to establish odds-ratios. PRINCIPAL FINDINGS 70.6 percent of patients have two or more, 48.3 percent have three or more, 25.3 percent have four or more, and 14.9 percent have five or more emergency department visits within 12 months. Factors associated with frequent utilization include gender, race, poor mental health, mental health drugs, prescription drug abuse, social networks, employment, perceptions of service quality, seriousness of condition, persistence of condition, and previous hospital admittance. CONCLUSIONS Interventions targeting associated factors will change global emergency department encounters, although the mutability varies. Policy interventions to address predisposing factors such as substance abuse or access to mental health treatment as well as interventions that speak to enabling factors such as promoting the resiliency of social networks may result in decreased frequency of emergency department utilization.
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Affiliation(s)
- Joshua G. Behr
- Virginia Modeling, Analysis and Simulation Center, Old Dominion University, Suffolk, Virginia, United States of America
- * E-mail:
| | - Rafael Diaz
- Zaragoza Logistics Center, Massachusetts Institute of Technology, Zaragoza, España
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Choi NG, Marti CNN, DiNitto DM, Choi BY. Alcohol Use as Risk Factors for Older Adults' Emergency Department Visits: A Latent Class Analysis. West J Emerg Med 2015; 16:1146-58. [PMID: 26759670 PMCID: PMC4703192 DOI: 10.5811/westjem.2015.9.27704] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2015] [Revised: 09/21/2015] [Accepted: 09/23/2015] [Indexed: 11/12/2022] Open
Abstract
INTRODUCTION Late middle-aged and older adults' share of emergency department (ED) visits is increasing more than other age groups. ED visits by individuals with substance-related problems are also increasing. This paper was intended to identify subgroups of individuals aged 50+ by their risk for ED visits by examining their health/mental health status and alcohol use patterns. METHODS Data came from the 2013 National Health Interview Survey's Sample Adult file (n=15,713). Following descriptive analysis of sample characteristics by alcohol use patterns, latent class analysis (LCA) modeling was fit using alcohol use pattern (lifetime abstainers, ex-drinkers, current infrequent/light/moderate drinkers, and current heavy drinkers), chronic health and mental health status, and past-year ED visits as indicators. RESULTS LCA identified a four-class model. All members of Class 1 (35% of the sample; lowest-risk group) were infrequent/light/moderate drinkers and exhibited the lowest probabilities of chronic health/mental health problems; Class 2 (21%; low-risk group) consisted entirely of lifetime abstainers and, despite being the oldest group, exhibited low probabilities of health/mental health problems; Class 3 (37%; moderate-risk group) was evenly divided between ex-drinkers and heavy drinkers; and Class 4 (7%; high-risk group) included all four groups of drinkers but more ex-drinkers. In addition, Class 4 had the highest probabilities of chronic health/mental problems, unhealthy behaviors, and repeat ED visits, with the highest proportion of Blacks and the lowest proportions of college graduates and employed persons, indicating significant roles of these risk factors. CONCLUSION Alcohol nonuse/use (and quantity of use) and chronic health conditions are significant contributors to varying levels of ED visit risk. Clinicians need to help heavy-drinking older adults reduce unhealthy alcohol consumption and help both heavy drinkers and ex-drinkers improve chronic illnesses self-management.
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Affiliation(s)
- Namkee G. Choi
- The University of Texas at Austin, School of Social Work, Austin, Texas
| | | | - Diana M. DiNitto
- The University of Texas at Austin, School of Social Work, Austin, Texas
| | - Bryan Y. Choi
- Brown University, Department of Emergency Medicine, Providence, Rhode Island
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Predicting Factors and Risk Stratification for Return Visits to the Emergency Department Within 72 Hours in Pediatric Patients. Pediatr Emerg Care 2015; 31:819-24. [PMID: 25875996 DOI: 10.1097/pec.0000000000000417] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES A return visit (RV) to the emergency department (ED) is usually used as a quality indicator for EDs. A thorough comprehension of factors affecting RVs is beneficial to enhancing the quality of emergency care. We performed this study to identify pediatric patients at high risk of RVs using readily available characteristics during an ED visit. METHODS We retrospectively collected data of pediatric patients visiting 6 branches of an urban hospital during 2007. Potential variables were analyzed using a multivariable logistic regression analysis to determine factors associated with RVs and a classification and regression tree technique to identify high-risk groups. RESULTS Of the 35,435 visits from which patients were discharged home, 2291 (6.47%) visits incurred an RV within 72 hours. On multivariable analysis, younger age, weekday visits, diagnoses belonging to the category of symptoms, signs, and ill-defined conditions, and being seen by a female physician were associated with a higher probability of RVs. Children younger than 6.5 years who visited on weekdays or between midnight and 8:00 AM on weekends or holidays had the highest probability of returning to the ED within 72 hours. CONCLUSIONS Our study reexamined several important factors that could affect RVs of pediatric patients to the ED and identified high-risk groups of RVs. Further intervention studies or qualitative research could be targeted on these at-risk groups.
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L Reed R, Isherwood L, Ben-Tovim D. Why do older people with multi-morbidity experience unplanned hospital admissions from the community: a root cause analysis. BMC Health Serv Res 2015; 15:525. [PMID: 26613614 PMCID: PMC4662024 DOI: 10.1186/s12913-015-1170-z] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2015] [Accepted: 11/09/2015] [Indexed: 11/22/2022] Open
Abstract
Background Increasing demand for hospital services by older people is a major concern for Australian health care providers. To date there has been little in-depth research that encompasses contextual and systems factors contributing to hospital admissions. The objective of this study was to determine the reasons why older patients experienced unplanned hospital admissions to a major public hospital. Methods A retrospective qualitative study using a Root Cause Analysis (RCA) methodology was conducted in a major public hospital in Adelaide, South Australia and surrounding community. Community dwelling older people admitted to the hospital who were well enough to give informed consent and be interviewed were invited to take part in the study. With patients consent, family members, general practitioners (GPs) and specialists were also interviewed and patient hospital records reviewed. Using a purposive sampling technique to obtain maximum variability, thirty-six older people (aged 70 years and older) participated in the study. GPs (n = 17), family members (n = 14), and other healthcare providers (n = 12) involved in their care were also interviewed. Cases were then analysed according to a standardized protocol to determine the root cause of admission. Root causes were then assigned to broader categories using thematic analysis. Results The root causes of unplanned admissions were identified and categorised into six causal groups: a consequence of minimal care, progression of disease, home care accessibility, high complexity, clinical error, and delayed care-seeking by the patient. Conclusions RCA can be effectively applied to determine the causes of unplanned hospital admissions although the process is time consuming. Four categories of admission (minimal care, clinical error, home care access, delayed care-seeking) were deemed potentially preventable. This methodology and classification approach may assist in designing interventions to prevent future hospitalisations in this high-risk population. Electronic supplementary material The online version of this article (doi:10.1186/s12913-015-1170-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Richard L Reed
- Discipline of General Practice, Flinders University, GPO Box 2100, Adelaide, 5001, South Australia.
| | - Linda Isherwood
- National Institute of Labour Studies, Flinders University, GPO Box 2100, Adelaide, 5001, South Australia.
| | - David Ben-Tovim
- Discipline of General Practice, Flinders University, GPO Box 2100, Adelaide, 5001, South Australia.
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Walsh PG, Currier GW, Shah MN, Friedman B. Older Adults with Mental Disorders: What Factors Distinguish Those Who Present to Emergency Departments for Mental Health Reasons from Those Who Do Not? Am J Geriatr Psychiatry 2015; 23:1162-71. [PMID: 26238232 DOI: 10.1016/j.jagp.2015.05.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/09/2014] [Revised: 05/17/2015] [Accepted: 05/21/2015] [Indexed: 10/23/2022]
Abstract
OBJECTIVE To identify among older adults with mental disorders factors associated with those who present to emergency departments (EDs) for mental health reasons versus those who do not. METHODS The authors conducted a secondary, cross-sectional analysis of the Medical Expenditure Panel Survey (MEPS), which comprises a representative sample of the U.S. civilian noninstitutionalized population. Of the MEPS participants ages 66 and older on December 31 of the survey years 2000-2005, the analysis sample (2,757) included the 177 persons with at least one mental health ED visit and the 2,580 persons with mental disorders without such a visit. The three categories of the Andersen behavioral model for healthcare services utilization-predisposing, enabling, and need factors-were used as the theoretical framework for the independent variables. RESULTS Logistic regression analysis indicated that four need factors (adjustment disorder [OR: 3.42], psychosis [OR: 2.68], fair perceived physical health status [OR: 2.24], and anxiety disorder [OR: 1.85]) and two predisposing characteristics (widowed and living alone [OR: 1.68] and female [OR: 1.56]) were significantly associated with older adults with mental disorders who present to an ED for mental health reasons. Good perceived mental health status (OR: 0.55) was protective against presenting to an ED. CONCLUSION EDs that serve populations with higher proportions of older persons that are women, widowed and living alone, with adjustment disorder, psychosis, anxiety disorders, or fair perceived physical health should expect to have a greater likelihood of older persons visiting the ED for mental health reasons.
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Affiliation(s)
- Patrick G Walsh
- Department of Psychiatry, University of Rochester, Rochester, NY; Department of Public Health Sciences, University of Rochester, Rochester, NY
| | - Glenn W Currier
- Department of Psychiatry, University of Rochester, Rochester, NY
| | - Manish N Shah
- Department of Public Health Sciences, University of Rochester, Rochester, NY; Department of Emergency Medicine, University of Rochester, Rochester, NY; Department of Medicine, University of Rochester, Rochester, NY
| | - Bruce Friedman
- Department of Psychiatry, University of Rochester, Rochester, NY; Department of Public Health Sciences, University of Rochester, Rochester, NY.
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Choi NG, DiNitto DM, Marti CN, Choi BY. Associations of Mental Health and Substance Use Disorders With Presenting Problems and Outcomes in Older Adults' Emergency Department Visits. Acad Emerg Med 2015; 22:1316-26. [PMID: 26473592 DOI: 10.1111/acem.12803] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2015] [Revised: 06/24/2015] [Accepted: 06/28/2015] [Indexed: 11/26/2022]
Abstract
OBJECTIVES The increasing prevalence of mental health and/or substance use disorders in older adults is a significant public health issue affecting their health, health care use, and health care outcomes. These disorders are especially prevalent in emergency department (ED) visits. This study examined the effect of mental health and substance use disorders on older adults' ED presenting problems and outcomes. METHODS Data were from the publicly available 2012 Nationwide Emergency Department Sample data set (unweighted n = 5,344,743 visits by the 65+ years age group). We used binary logistic regression analysis to test relationships between mental health and substance use disorders and suicide attempts, falls, and other injuries and multinomial logistic regression analysis to test relationships between the disorders and ED outcomes of death, hospital admission, transfer to institutional care, home health care, leaving against medical advice (AMA), or other or unknown destinations, as opposed to routine care. RESULTS Of ED visits by older adults, 5.1% involved anxiety disorders, 7.1% involved mood disorders, 10.45% involved delirium/dementia, 1.4% involved alcohol use disorders, and 0.6% involved drug use disorders; 0.2% were suicide-related, 12.0% involved falls, and 10.2% involved other injuries. Mental health and substance use disorders had large-to-medium effects on suicide attempts. Both dementia and delirium and alcohol use disorders had a small effect on falls. Drug use disorders had a small effect on other injuries. Anxiety disorder had a small effect on the risk of death in the ED or in the hospital, relative to routine care. Suicide attempts and drug use disorders had a medium effect on hospital admission. Suicide attempts had a large effect, delirium and dementia and other mental disorders had medium effects, and mood disorder had a small effect on the risk of transfer to another facility. Delirium and dementia, suicide attempts, and drug use disorders had small effects on the risk of discharge with home health care. Alcohol use disorders and drug use disorders had a small effect on the risk of leaving AMA. Finally, suicide attempts had a medium effect on the risk of other outcomes and unknown destinations. CONCLUSIONS Late-life mental health and substance use disorders are significant risk factors for both intentional self-harm and unintentional injuries that bring older adults to the ED and contribute to ED dispositions and outcomes that involve more intensive and longer-term health care services. The findings underscore the importance of detection and treatment of these disorders among older adults before they end up in the ED.
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Affiliation(s)
- Namkee G. Choi
- University of Texas at Austin School of Social Work; Austin TX
| | | | - C. Nathan Marti
- University of Texas at Austin School of Social Work; Austin TX
| | - Bryan Y. Choi
- Department of Emergency Medicine; Warren Alpert Medical School; Brown University; Providence RI
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McCabe JJ, Kennelly SP. Acute care of older patients in the emergency department: strategies to improve patient outcomes. Open Access Emerg Med 2015; 7:45-54. [PMID: 27147890 PMCID: PMC4806806 DOI: 10.2147/oaem.s69974] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Older patients in the emergency department (ED) are a vulnerable population who are at a higher risk of functional decline and hospital reattendance subsequent to an ED visit, and have a high mortality rate in the months following an ED attendance. The delivery of acute care in a busy environment to this population presents its own unique challenge. The purpose of this review is to detail the common geriatric syndromes encountered in the ED as well as the appropriate strategies and instruments, which can be utilized to support the clinical decision matrix and improve outcomes.
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Affiliation(s)
- John J McCabe
- Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
| | - Sean P Kennelly
- Department of Age-Related Health Care, Tallaght Hospital, Dublin, Ireland
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Deschodt M, Devriendt E, Sabbe M, Knockaert D, Deboutte P, Boonen S, Flamaing J, Milisen K. Characteristics of older adults admitted to the emergency department (ED) and their risk factors for ED readmission based on comprehensive geriatric assessment: a prospective cohort study. BMC Geriatr 2015; 15:54. [PMID: 25928799 PMCID: PMC4417280 DOI: 10.1186/s12877-015-0055-7] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2014] [Accepted: 04/22/2015] [Indexed: 01/04/2023] Open
Abstract
Background Patients aged 75 years and older represent 12% of the overall emergency department (ED) population, and this proportion will increase over the next decades. Many of the discharged patients suffer an unplanned readmission in the immediate and midterm post-discharge period, suggesting under recognition of psychosocial, cognitive and medical problems. The aim of this study was to compare the characteristics of older patients admitted and discharged from the ED and to determine independent predictors for ED readmission 1 month and 3 months after ED discharge based on comprehensive geriatric assessment (CGA). Methods Cohort study in a Belgian university hospital. A CGA, including demographic and medical data (e.g. reason for admission, comorbidity, number of medications), functional (e.g. activities of daily living, falls), mental (i.e. cognition, dementia, delirium), and nutritional status, and pain, was performed in 442 ED patients aged 75 years or older. Results Patients discharged from the ED (n = 117, 26.5%) were significantly less dependent for ADL, mobility, shopping and finances compared with hospitalised patients. Hospitalised patients (n = 325, 73.5%) were significantly more at risk for having nutritional problems, had a higher comorbidity index, and a lower cognitive status compared with those discharged. Ninety-seven patients (82.9%) were discharged home from the ED. Of the latter, 18 (18.6%) and 28 patients (28.9%) suffered an ED readmission within 1 and 3 months, respectively. At one month post-discharge, nursing care at home, meals on wheels, and risk for depression; and at 3 months post-discharge previous hospitalisation in the last 3 months, physiotherapy and meals on wheels were found to be independent predictors for ED readmission, respectively. Conclusions This study observed a geriatric risk profile in older adults at the ED and a high readmission rate of those discharged, and suggests the potential value of CGA in identifying older patients at high risk for ED readmission.
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Affiliation(s)
- Mieke Deschodt
- Department of Public Health and Primary Care, Health Services and Nursing Research, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium. .,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Els Devriendt
- Department of Public Health and Primary Care, Health Services and Nursing Research, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium. .,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Marc Sabbe
- Department of Public Health and Primary Care, Emergency Medicine, Kapucijnenvoer 35/4, 3000, Leuven, Belgium. .,Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Daniel Knockaert
- Department of Internal Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Peter Deboutte
- Department of Emergency Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Steven Boonen
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Johan Flamaing
- Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
| | - Koen Milisen
- Department of Public Health and Primary Care, Health Services and Nursing Research, KU Leuven, Kapucijnenvoer 35/4, 3000, Leuven, Belgium. .,Department of Geriatric Medicine, University Hospitals Leuven, Herestraat 49, 3000, Leuven, Belgium.
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