Public health preventive services, surveillance, and screening: the emergency Department's potential

Intervention to increase colorectal cancer screening among emergency department patients: results from a randomised pilot study

BACKGROUND

Colorectal cancer (CRC) is the second leading cause of cancer-related deaths worldwide. Emergency departments (ED) represent a promising setting to address preventive health measures like CRC screening.

OBJECTIVES

The current study adapted an existing cervical cancer screening intervention for use in catalysing CRC screening. We evaluated feasibility of identification, provided preliminary effect size estimates and documented participant acceptability.

METHODS

This study was funded by the University of Rochester (ClinicalTrials.gov # NCT05004376). We enrolled ED patients, 45-75 years old, in the Greater Rochester, NY region into a randomised controlled pilot from January to May 2022. Patients were excluded if non-English speaking, lacking a cell phone or had a history of CRC, colorectal resection, inflammatory bowel disease or abdominal radiation. Participants were surveyed to determine adherence with recommended CRC screening guidelines. Patients found non-adherent were randomised to receive (1) recommendation for CRC screening only or (2) recommendation and a text-based intervention aimed at generating intention and motivation to get screened. Patients were blind to allocation at enrolment. The primary outcome was patient CRC screening or scheduling.

RESULTS

1438 patients were approached, with 609 found ineligible, 576 declining participation and 253 enrolled. A randomised sample of 114 non-adherent patients were split evenly between the control and intervention arms. Among participants with follow-up data (n control=38, n intervention=36), intervention participants had a 2%-3% higher rate of scheduling or receiving screening (7%-27% relative improvement). When using the complete sample (n=114) and conservatively assuming no screening for those lost to follow-up, differences in screening across arms were mildly decreased (0%-2% absolute difference). Acceptability of CRC intervention was high, and participants offered formative feedback.

CONCLUSION

The piloted text message intervention through the ED shows potential promise for catalysing CRC screening. Subsequent replication in a fully powered trial is needed.

An Intervention to Increase Uptake of Cervical Cancer Screening Among Emergency Department Patients: Results of a Randomized Pilot Study

BACKGROUND

Emergency departments (EDs) have the potential to promote critical public and preventive health interventions. Cervical cancer (CC) screening has been a cornerstone of preventive health efforts for decades. Approximately 20% of U.S. women are not adherent with CC screening guidelines-considerably below the U.S. Federal Government's target. ED patients are disproportionately nonadherent with CC screening guidelines. The ED, therefore, is an optimal setting to target women with an intervention that promotes CC screening.

OBJECTIVES

To assess the feasibility and potential efficacy of an intervention, grounded in behavioral change theory, to promote uptake of CC screening among ED patients.

METHODS

Design: Randomized clinical trial pilot study; Patients: Women aged 21-65 years that were identified in the ED to be nonadherent with CC screening recommendations; Setting: Single center urban academic ED.

RESULTS

Among enrolled participants, 355 (79%) were determined to be adherent with screening recommendations and 95 (21%) were determined to be either nonadherent or have uncertain adherence. Among the nonadherent/uncertain group, 47 were randomized to the control condition (referral only) and 48 were randomized to the intervention condition. Thirty-six percent of participants in the control condition received or scheduled screening during the follow-up period. In the intervention condition, 43% received or scheduled screening during the follow-up period-a 19% relative improvement over the control condition.

CONCLUSION

This pilot study demonstrates feasibility and preliminary efficacy of a behavioral intervention to increase uptake of CC screening among ED patients.

Primary care in the emergency department -- an untapped resource for public health research and innovation

With rising patient volumes and increasingly complex cases, the specialty of emergency medicine faces a growing array of challenges. Efforts have been made to improve patient throughput, yet little attention has been directed to the increasing amount of primary care delivered in emergency departments (EDs) for chronic disease states such as hypertension and diabetes. Management of chronic medical conditions is traditionally seen as beyond the purview of the ED and emergency physicians tend to defer critical aspects of related patient care to other components of the healthcare continuum. As a result, vulnerable patients are often forced to navigate exceedingly complex and fragmented systems of care with little guidance, which often leads to inadequate treatment and exposure to increased risk for development of potentially avoidable complications. As evidenced by our experience with hypertension in an under resourced community, there is a crucial need for emergency physicians to espouse their role as providers of healthcare across the acuity spectrum and lead the way in defining regionally relevant solutions to better manage patients with chronic medical problems.

Characteristics of patients who accept and decline ED rapid HIV testing

PURPOSE

Understanding differences between patients who accept and decline HIV testing is important for developing methods to reduce decliner rates among patients at risk for undiagnosed HIV. The objectives of this study were to determine the rates of acceptance and reasons for declining, and to determine if differences exist in patient or visit characteristics between those who accept and decline testing.

BASIC PROCEDURES

This was a retrospective medical record review of all patients offered an emergency department (ED) HIV test from 11/1/11 to 10/31/12. Patient demographic characteristics, health characteristics, and ED visit characteristics were compared to assess differences between those who accept and those who decline testing.

FINDINGS

Of 4510 ED patients offered an HIV test, 3470 accepted for an acceptance rate of 77%. The most common reasons for declining were "no perceived risk" and "tested in the last 3 months." Those who accepted testing were more likely to be unmarried, less than age 35, Hispanic or African American, Spanish speaking, foreign born, have no primary care provider, report no pain at triage, have a daytime ED visit, and be discharged from the ED compared to admitted. Sex, employment status, and ED length of stay did not affect whether patients accepted testing.

PRINCIPAL CONCLUSIONS

Acceptance of ED-based rapid HIV testing is not universal, and there are both patient and visit characteristics consistently associated with declining testing. This detracts from the goal of using the ED to screen a large number of at-risk patients who do not have access to testing elsewhere.

What do patients think about HIV mass screening in France? A qualitative study

Background

Since 2009, HIV mass screening of the 15–70-year-old general population in low-risk situations has been recommended in France. This, not yet implemented, untargeted screening would be cost-effective with a positive impact on public health. No previous studies had interrogated primary care patients about it. This study aimed at exploring perceptions of patients attending general practitioner’s on HIV mass screening and at identifying barriers to its implementation.

Methods

We conducted a qualitative study through semi-structured individual interviews. Participants were recruited according to age, gender and location of their physician’s practice. Data analysis was based on triangulation by two researchers.

Results

Twenty-four interviews were necessary to obtain data saturation. HIV transmission was mostly associated with sexual intercourse; main barriers stemming from the screening were related to sexuality, often seen as questioning spouse’s faithfulness. It could interfere with religiosity, implying an upsetting perception of sexuality among the elderly. Patients’ beliefs and perceptions regarding HIV/AIDS, the fear to be screened and difficulties to talk about sexuality were other barriers.

Conclusion

To our knowledge, no studies had previously interrogated primary care patients about barriers to HIV mass screening in France. Although relevance of this untargeted screening is debated in France, our results could be helpful to a better understanding of patients’ attitudes toward this and to an outstanding contribution to reduce the number of new cases of HIV contamination.

Do US medical students report more training on evidence-based prevention topics?

Little is known about the extent to which evidence-based prevention topics are taught in medical school. All class of 2003 medical students (n = 2316) at 16 US schools were eligible to complete three questionnaires: at the beginning of first and third years and in their senior year, with 80.3% responding. We queried these students about 21 preventive medicine topics, concerning the extent of their training and their patient counseling frequency at some of these time points. At the beginning of the third year, self-reported extensive training was low for all preventive medicine topics (range 7-26%). USPSTF-recommended topics received more curricular time (median for topics: 36% if recommended versus 24.5% if not, P = 0.025), as did topics addressed through testing rather than through discussion (median for topics: 37% for testing and 25% for discussion, P = 0.005). Extensive training was always associated with higher counseling frequency, and intention to go into primary care, female gender, a positive attitude toward prevention and positive personal health habits were associated with higher counseling frequency. Although some bemoan the overall low levels of US medical students' prevention-related training and practice, we demonstrate that at least they are preferentially evidence-based, a novel and encouraging finding for preventionists.

Cost-effectiveness analysis and HIV screening: the emergency medicine perspective

Cost-effectiveness analysis is a useful tool for decisionmakers charged with prioritizing of the myriad medical interventions in the emergency department (ED). This analytic approach may be especially helpful for ranking programs that are competing for scarce resources while attempting to maximize net health benefits. In this article, we review the health economics literature on HIV screening in EDs and introduce the methods of cost-effectiveness analysis for medical interventions. We specifically describe the incremental cost-effectiveness ratio--its calculation, the derivation of ratio components, and the interpretation of these ratios.

Public health and clinical impact of increasing emergency department-based HIV testing: perspectives from the 2007 conference of the National Emergency Department HIV Testing Consortium

OBJECTIVE

Understanding perceived benefits and disadvantages of HIV testing in emergency departments (EDs) is imperative to overcoming barriers to implementation. We codify those domains of public health and clinical care most affected by implementing HIV testing in EDs, as determined by expert opinion.

METHODS

Opinions were systematically collected from attendees of the 2007 National ED HIV Testing Consortium meeting. Structured evaluation of strengths, weaknesses, opportunities, and threats analysis was conducted to assess the impact of ED-based HIV testing on public health. A modified Delphi method was used to assess the impact of ED-based HIV testing on clinical care from both individual patient and individual provider perspectives.

RESULTS

Opinions were provided by 98 experts representing 42 academic and nonacademic institutions. Factors most frequently perceived to affect public health were (strengths) high volume of ED visits and high prevalence of HIV, (weaknesses) undue burden on EDs, (opportunities) reduction of HIV stigma, and (threats) lack of resources in EDs. Diagnostic testing and screening for HIV were considered to have a favorable impact on ED clinical care from both individual patient and individual provider perspectives; however, negative test results were not perceived to have any benefit from the provider's perspective. The need for HIV counseling in the ED was considered to have a negative impact on clinical care from the provider's perspective.

CONCLUSION

Experts in ED-based HIV testing perceived expanded ED HIV testing to have beneficial impacts for both the public health and individual clinical care; however, limited resources were frequently cited as a possible impediment. Many issues must be resolved through further study, education, and policy changes if the full potential of HIV testing in EDs is to be realized.

Mammography promotion in the emergency department: a pilot study

OBJECTIVES

The objective of this pilot study is to assess the need, desire, and applicability of a mammography promotion project in the emergency department (ED).

DESIGN AND SAMPLE

A convenience sample from the ED of a public University hospital was surveyed to determine their mammography status, interest in a program to promote mammography, and barriers to mammography.

MEASURES

The survey included demographics information, health care access, including health insurance and primary care provider, mammography status and date of mammogram, as well as a checklist of potential barriers. Participants were also asked whether they would be interested in mammography promotion in this setting.

RESULTS

More than 15% of the 197 women surveyed had never received a mammogram, and more than half had not received 1 in the past year. The most common barriers to mammography were competing demands and money. Three quarters of the women said they would be interested in mammography promotion while waiting for care in the ED.

CONCLUSIONS

This study provides promise that mammography promotion activities may be appropriately placed in the ED and provides a solid platform from which researchers and nurses may launch efforts to develop preventive health interventions in innovative public health care settings.

The controversy on screening for intimate partner violence: a question of semantics?

In this paper, we review the basis of the U.S. Preventive Services Task Force's recommendations related to routine screening for intimate partner violence (IPV), focus on two of the arguments of those who have rejected these recommendations, and based on these, suggest that this controversy has occurred, in part, as a result of different interpretations of the meaning of "screening." We differentiate screening from situations in which asking about IPV is essential for differential diagnosis, that is, exploring exposure to IPV when there are signs and symptoms that might result from this exposure. Finally, we describe the randomized, controlled trial CDC is conducting to contribute to the evidence the U.S. Preventive Services Task Force requries to make its recommendations.

Negative opinions about cancer screening and contraceptive measures by female emergency department patients

We sought to determine the extent to which adult female emergency department participants viewed two women's cancer screening and two contraceptive measures negatively. The study also explored the relationship between having a negative opinion about these measures and participant demography, lack of knowledge, and lack of usage of these measures. Few women expressed negative opinions about these measures. Lack of knowledge about and lack of use of these measures were associated with having negative opinions on these cancer screening and contraceptive measures. Having any negative opinion about one cancer screening or contraceptive measure was associated with a higher risk of having any negative opinion on another measure. The results suggest that influencing opinion and knowledge about these measures might impact the success of emergency department-based cancer screening and contraceptive health programs. Editors' Strategic Implications: Emergency departments (and primary care settings) provide key opportunities for prevention. Replication is needed, but the authors present important data on knowledge, attitudes, and characteristics that might influence women's receptivity to consent to and engage in behaviors consistent with prevention, screening, and health promotion.

A model for preventing serious traffic injury in teens: or "keep those teenagers out of our ICU!"

Traffic crashes are the leading cause of injury, disability, and death in the youth of the United States. Risky driving, behind-the-wheel behaviors when operating a motor vehicle in a manner that may lead to harm or injury to oneself or others, contributes to the human and economic cost of risky driving. An acute or critical care hospitalization provides an ideal opportunity for nurses to initiate prevention strategies with parents and teens to reduce risky driving.

Socioeconomic factors, hazardous alcohol consumption, and smoking in patients with minor trauma in an inner-city emergency department

Emergency Department (ED) patients show a high prevalence of hazardous alcohol consumption and smoking. The objective of this study was to determine if socioeconomic factors and smoking status help to optimize screening for hazardous alcohol consumption (HAC) in patients with minor trauma. A survey was conducted in an ED in an inner-city university hospital. A total of 2562 patients with minor trauma were screened for HAC (≥ 8 points in men and ≥ 5 points in women on the Alcohol Use Disorders Identification Test), smoking status, and socioeconomic factors. The median age of participants was 32 years, with 62.1% being male. A total of 84.2% of patients had an Injury Severity Score of 1, indicating minor trauma. Overall, 23.5% of patients showed a pattern of HAC, whereas 46.2% were current smokers. Compared to patients without HAC, those with HAC were characterized by lower incomes, no partnership, living in a single-household, and being unemployed. The strongest discriminative variable for HAC for patients aged ≤ 53 years was smoking status. Gender differences played a role only in patients older than 53 years. Although socioeconomic factors showed a non-equal distribution in patients with respectively without HAC, solely age, gender, and smoking status may provide a successful stratification for alcohol screening and intervention in these patients.

A novel emergency department based prevention intervention program for people living with HIV: evaluation of early experiences

BACKGROUND

HIV prevention is increasingly focused on people living with HIV (PLWH) and the role of healthcare settings in prevention. Emergency Departments (EDs) frequently care for PLWH, but do not typically endorse a prevention mission. We conducted a pilot exploratory evaluation of the first reported ED program to address the prevention needs of PLWH.

METHODS

This retrospective observational cohort evaluation reviewed program records to describe the first six months of participants and programmatic operation. Trained counselors provided a risk assessment and counseling intervention combined with three linkage interventions: i) linkage to health care, ii) linkage to case management, and iii) linkage to partner counseling and referral.

RESULTS

Of 81 self-identified PLWH who were approached, 55 initially agreed to participate. Of those completing risk assessment, 17/53 (32%, 95 CI 20% to 46%) reported unprotected anal/vaginal intercourse or needle sharing in the past six months with a partner presumed to be HIV negative. Counseling was provided to 52/53 (98%). For those requesting services, 11/15 (73%) were linked to healthcare, 4/23 (17%) were coordinated with case management, and 1/4 (25%) completed partner counseling and referral.

CONCLUSION

Given base resources of trained counselors, it was feasible to implement a program to address the prevention needs for persons living with HIV in an urban ED. ED patients with HIV often have unmet needs which might be addressed by improved linkage with existing community resources. Healthcare and prevention barriers for PLWH may be attenuated if EDs were to incorporate CDC recommended prevention measures for healthcare providers.

Determining appropriateness for rehabilitation or other subacute care: is there a role for utilisation review?

BACKGROUND

Rehabilitation and other forms of subacute care play an important role in the Australian health care system, yet there is ambiguity around clinical definitions of subacute care, how it differs from acute care, where it is best done and what resources are required. This leads to inconsistent and often poorly defined patient selection criteria as well as a lack of research into efficient models of care.

METHODS

A literature review on the potential role of utilisation review in defining levels of care and in facilitating appropriate care, with a focus on the interface between acute care and rehabilitation.

RESULTS

In studies using standardised utilisation review tools there is consistent reporting of high levels of 'inappropriate' bed days in acute care settings. These inappropriate bed days include both inappropriate admissions to acute care and inappropriate continuing days of stay. While predominantly an instrument of payers in the United States, concurrent utilisation review programs have also been used outside of the US, where they help in the facilitation of appropriate care. Some utilisation review tools also have specific criteria for determining patient appropriateness for rehabilitation and other subacute care.

CONCLUSION

The high levels of 'inappropriate' care demonstrated repeatedly in international studies using formal programs of utilisation review should not be ignored in Australia. Utilisation review tools, while predominantly developed in the US, may complement other Australian patient flow initiatives to improve efficiency while maintaining patient safety. They could also play a role in the identification of patients who may benefit from transfer from acute care to another type of care and thus be an adjunct to physician assessment. Testing of the available utilisation review tools in the Australian context is now required.

Injury as a Global Phenomenon of Concern in Nursing Science

PURPOSE

To discuss injury research as a phenomenon of concern in nursing science.

ORGANIZING CONSTRUCT

Injury is defined as the physical damage that results when the human body is briefly subjected to intolerable levels of energy. It is the leading cause of death in the first 4 decades of life in high-income nations and is second only to infectious diseases as a leading cause of death in low- and middle-income nations.

METHODS

Review and discussion of relevant scientific and theoretical literature in both injury and nursing science.

FINDINGS

Nurse scientists can apply unique perspectives to increase understanding of injury and its consequences. Fertile areas for nursing inquiry include identifying people at risk, developing models to explain the association between risk-taking and injury, testing interventions to prevent and limit injury, and creating and refining interventions that are culturally relevant to subpopulations most at risk for injury.

CONCLUSIONS

The mandate to improve global heath should lead to nursing inquiry about this phenomenon, including developing and testing interventions to prevent and reduce injury.

Health promotion and disease prevention in the emergency department

This article provides an overview of health promotion and disease and injury prevention concepts. It provides an emergency medicine perspective and reviews approaches that can be used in the emergency department. It discusses examples of innovative emergency medicine-based preventive activities including prevention in the prehospital setting. This article ends with a discussion of the importance of a system approach to prevention and suggests a role for a preventionist as a new member of the emergency medicine team.

Predicting smoking stage of change among emergency department patients and visitors

OBJECTIVES

Little is known about whether emergency department (ED) patients or those who accompany them (visitors) are interested in smoking cessation. The authors hypothesized that several variables would be associated with stage of change, including nicotine dependence, self-efficacy, presence of a smoking-related illness, and anticipated cessation-related health improvement.

METHODS

For two 24-hour periods, consecutive patients and visitors aged 18 years and older presenting to four Boston EDs were interviewed. The authors assessed a range of smoking-related constructs. Exclusion criteria included severe illness, cognitive insufficiency, and acute distress.

RESULTS

One thousand ten subjects were screened (56% patients, 44% visitors). Two hundred thirty-seven (23%) subjects were current smokers, with 57% being in precontemplation, 31% in contemplation, and 12% in preparation stages. When ordinal regression was used, the variables most strongly associated with stage of change were as follows: self-efficacy (odds ratio [OR] = 5.1; p < 0.001), anticipated cessation-related health improvement (OR = 2.7; p = 0.02), and having a smoking-related health problem (OR = 1.9; p = 0.08).

CONCLUSIONS

Because many disenfranchised Americans use the ED as a regular source of health care, increased attention to smoking in the ED setting holds tremendous public health potential. This study's results reinforce the validity of the stage-of-change model within the ED setting. Developers of ED-initiated interventions will have to consider the heterogeneity in stage of change when designing their treatments.

Health department collaboration with emergency departments as a model for public health programs among at-risk populations

OBJECTIVES

Accessing at-risk and underserved populations for intervention remains a major obstacle for public health programs. Emergency departments (EDs) care for patients not otherwise interacting with the health care system, and represent a venue for such programs. A variety of perceived and actual barriers inhibit widespread implementation of ED-based public health programs. Collaboration between local health departments and EDs may overcome such barriers. The goal of this study was to assess the effectiveness of a health department-funded, ED-based public health program in comparison with other similar community-based programs through analysis of data reported by health department-funded HIV counseling and testing centers in one Ohio county.

METHOD

Data for HIV counseling and testing at publicly funded sites in southwestern Ohio from January 1999 through December 2002 were obtained from the Ohio Department of Health. Demographic and risk-factor profiles were compared between the counseling and testing program located in the ED of a large, urban teaching hospital and the other publicly funded centers in the same county.

RESULTS

A total of 26,382 patients were counseled and tested; 5,232 were ED patients, and 21,150 were from community sites. HIV positivity was 0.86% (95% confidence interval [CI] 0.64%, 1.15%) in the ED and 0.65% (95% CI 0.55%, 0.77%) elsewhere. The ED program accounted for 19.8% of all tests and 24.7% of all positive results. The ED notified 77.3% of individuals testing positive and 84.4% of individuals testing negative. At community program centers, 88.3% of patients testing positive and 63.8% of patients testing negative were notified of results. All ED patients notified of positive status were successfully referred to infectious disease specialists.

CONCLUSIONS

Public health programs can operate effectively in the ED. EDs should have a rapidly expanding role in the national public health system.