Cost-benefit analysis of social work services in the emergency department: a conceptual model

Older Adult Frequent 9-1-1 Callers for Emergency Medical Services in a Large Metropolitan City: Individual- and System-Level Considerations

BACKGROUND

High utilizers of 9-1-1 place a substantial burden on emergency medical services (EMS). Results of a retrospective review of records data of the City of Los Angeles Fire Department (LAFD) showed a significant increase in older adult high utilizers of 9-1-1.

OBJECTIVE

The objective of this study was to explore individual- and system-level factors implicated in EMS use among older adults, and to provide system recommendations to mitigate overuse.

METHODS

A phenomenological study was conducted, drawing from LAFD EMS records between 2012 and 2016 to identify and contact high-utilizing patients older than 50 years, their family, agency representatives, and LAFD personnel. Interviews were recorded, transcribed, and coded and a thematic analysis was completed.

RESULTS

We conducted in-depth interviews with 27 participants, including patients (n = 8), their families (n = 6), social service agency representatives (n = 3), and LAFD personnel (n = 10). The following cross-cutting themes emerged: nature of 9-1-1 calls, barriers to access, and changing the system. In addition, LAFD and social service agency representatives identified the role of EMS responders and social agency representatives. Patients and their families agreed that previous encounters and interactions with emergency care responders were relevant factors.

CONCLUSIONS

This study described reasons for 9-1-1 calls related to medical and social service needs, including mental health care. Our analysis offers insight from different stakeholders' perspectives on access to medical care and types of barriers that interfere with medical care. All groups shared recommendations to advance access to medical and mental health care.

Quality of health economic evaluations in emergency medicine journals: a systematic review

OBJECTIVE

Health economic evaluations are used in decision-making regarding resource allocation and it is imperative that they are completed with rigor. The primary objectives were to describe the characteristics and assess the quality of economic evaluations published in emergency medicine journals.

METHODS

Two reviewers independently searched 19 emergency medicine-specific journals via Medline and Embase from inception until March 3, 2022. Quality assessment was completed using the Quality of Health Economic Studies (QHES) tool, and the primary outcome was the QHES score out of 100. Additionally, we identified factors that may contribute to higher-quality publications.

RESULTS

7260 unique articles yielded 48 economic evaluations that met inclusion criteria. Most studies were cost-utility analyses and of high quality, with a median QHES score of 84 (interquartile range, IQR: 72, 90). Studies based on mathematical models and those primarily designed as an economic evaluation were associated with higher quality scores. The most commonly missed QHES items were: (i) providing and justifying the perspective of the analysis, (ii) providing justification for the primary outcome, and (iii) selecting an outcome that was long enough to allow for relevant events to occur.

CONCLUSIONS

The majority of health economic evaluations in the emergency medicine literature are cost-utility analyses and are of high quality. Decision analytic models and studies primarily designed as economic analyses were positively correlated with higher quality. To improve study quality, future EM economic evaluations should justify the choice of the perspective of the analysis and the selection of the primary outcome.

Adverse Childhood Experiences and Healthcare Utilization of Children in Pediatric Emergency Departments

OBJECTIVE

To determine the prevalence of adverse childhood experiences (ACEs) and healthcare utilization patterns of children seen in pediatric emergency departments (PEDs).

STUDY DESIGN

In this cross-sectional study, caregivers of patients who presented to 2 urban PEDs completed a survey regarding their children's ACEs, health care utilization patterns, and acceptance of PED-based ACEs screening and resources. Inclusion criteria were English-speaking caregivers of patients 0-17 years of age not requiring acute stabilization. Prevalence estimates were compared with national and state data from the National Survey of Children's Health by calculating risk differences and 95% CIs. The association of cumulative ACEs with caregiver-reported health care utilization patterns was evaluated using ORs.

RESULTS

Among 1000 participants, 28.1% (95% CI 25.3-30.9) had 1 ACE; 17.8% (95% CI15.4-20.2) had ≥2 ACEs. Notably, children with higher cumulative ACEs were seen in the PED more frequently (0, 1, ≥2 visits) (OR 1.18, 95% CI 1.06-1.30, P = .002) and more likely to seek care in PEDs for sick visits (OR 1.16, 95% CI 1.04-1.30, P = .01). About 9% of children exposed to ACEs did not have a primary care provider. Over 85% of caregivers reported never discussing ACEs with their primary care provider. Most caregivers felt comfortable addressing ACEs in PEDs (84.4%) and would use referral resources (90.4%).

CONCLUSIONS

Given higher PED utilization in children with more ACEs and caregiver acceptance of PED-based screening and intervention, PEDs may represent a strategic and opportune setting to both assess and respond to ACEs among vulnerable populations.

Characteristics of Emergency Department Patient Visits Referred for Follow-Up Medical Care After Discharge, National Hospital Ambulatory Medicare Care Survey—United States, 2018

Objective

To describe characteristics of a nationally representative sample of patient visits that ended with a referral for follow-up medical care after discharge from hospital emergency department (ED) visits.

Methods

We used 2018 National Hospital Ambulatory Medical Care Survey data to identify patient characteristics associated with higher rates of visits with referrals for follow-up medical care after ED discharge from nonfederal short-stay and general hospitals throughout the United States. Referral included categories of all disposition variables that indicated referral to a source of care consistent with the patient’s clinical condition at ED discharge.

Results

Approximately 97 million of 130 million visits (29 700/100 000 US resident population) were referred for follow-up medical care during 2018. Visit referral rates were higher among females (33 100) than among males (26 300/100 000 population); higher among Black patients (61 700) than among White patients (25 600/100 000 population); highest in the South (33 200/100 000 population); and similar rates in Nonmetropolitan (29 900/100 000 population) and Metropolitan Statistical Areas (30 200/100 000 population). Visit referral rates were higher for patients with Medicaid/Children's Health Insurance Program (CHIP) (66 900) than those with Medicare (31 500) or private insurance (14 000/100 000 population). Abnormal clinical findings and injuries were the discharge diagnoses most often referred for follow-up medical care.

Conclusion

Higher visit referral rates were observed among female sex, non-Hispanic Black race, Medicaid/CHIP, abnormal clinical findings, and injuries. Future studies might reveal reasons that prompted higher referral rates among various patients’ characteristics.

Predicting 72-hour and 9-day return to the emergency department using machine learning

OBJECTIVES

To predict 72-h and 9-day emergency department (ED) return by using gradient boosting on an expansive set of clinical variables from the electronic health record.

METHODS

This retrospective study included all adult discharges from a level 1 trauma center ED and a community hospital ED covering the period of March 2013 to July 2017. A total of 1500 variables were extracted for each visit, and samples split randomly into training, validation, and test sets (80%, 10%, and 10%). Gradient boosting models were fit on 3 selections of the data: administrative data (demographics, prior hospital usage, and comorbidity categories), data available at triage, and the full set of data available at discharge. A logistic regression (LR) model built on administrative data was used for baseline comparison. Finally, the top 20 most informative variables identified from the full gradient boosting models were used to build a reduced model for each outcome.

RESULTS

A total of 330 631 discharges were available for analysis, with 29 058 discharges (8.8%) resulting in 72-h return and 52 748 discharges (16.0%) resulting in 9-day return to either ED. LR models using administrative data yielded test AUCs of 0.69 (95% confidence interval [CI] 0.68-0.70) and 0.71(95% CI 0.70-0.72), while gradient boosting models using administrative data yielded test AUCs of 0.73 (95% CI 0.72-0.74) and 0.74 (95% CI 0.73-0.74) for 72-h and 9-day return, respectively. Gradient boosting models using variables available at triage yielded test AUCs of 0.75 (95% CI 0.74-0.76) and 0.75 (95% CI 0.74-0.75), while those using the full set of variables yielded test AUCs of 0.76 (95% CI 0.75-0.77) and 0.75 (95% CI 0.75-0.76). Reduced models using the top 20 variables yielded test AUCs of 0.73 (95% CI 0.71-0.74) and 0.73 (95% CI 0.72-0.74).

DISCUSSION AND CONCLUSION

Gradient boosting models leveraging clinical data are superior to LR models built on administrative data at predicting 72-h and 9-day returns.

Characterizing behavioral health-related emergency department utilization among children with Medicaid: Comparing high and low frequency utilizers

While the frequency of children's behavioral health (BH)-related visits to the emergency department (ED) is rising nationwide, few studies have examined predictors of high rates of ED use. This study examines Florida Medicaid claims (2011-2012) for children age 0-18 who were seen in an emergency department (ED) for behavioral health (BH) conditions. A logistic regression model was used to explore factors associated with frequent ED use and patterns of psychotropic medication utilization. The majority (95%) of patients with at least one BH-related ED visit had three or fewer of these visits, but 5% had four or more. Seventy-four percent of ED visits were not associated with psychotropic medication, including over half (54%) of visits for attention deficit hyperactivity disorder (ADHD). Frequent ED use was higher among older children and those with substance use disorders. The implementation of interventions that reduce non-emergent ED visits through the provision of care coordination, social work services, and/or the use of community health workers as care navigators may address these findings.

Cohort study of a specialist social worker intervention on hospital use for patients at risk of long stay

BACKGROUND

Long-stay patients in acute hospitals commonly present with complex psychosocial needs and use high levels of hospital resources.

OBJECTIVE

To determine whether a specialist social worker-led model of care was associated with a reduction in length of stay for medically stable patients with complex psychosocial needs who were at risk of long stay, and to determine the economic value of this model relative to the decision makers' willingness to pay for bed days released.

DESIGN

A prospective, matched cohort study with historical controls.

SETTING

A large, tertiary teaching and referral hospital in metropolitan Southeast Queensland, Australia.

METHODS

Length of hospital stay for a cohort of patients seen under the specialist social worker-led model of care was compared with a matched control group of patients admitted to the hospital prior to the introduction of the new model of care using a multistate model with the social worker model of care as an intermediate event. Costs associated with the model of care were calculated and an estimate of the 'cost per bed day' was produced.

RESULTS

The model of care reduced mean length of stay by 33 days. This translated to 9999 bed days released over 12 months. The cost to achieve this was estimated to be $A229 000 over 12 months. The cost per bed day released was $23, which is below estimates of hospital decision makers' willingness to pay for a bed day to be released for an alternate use.

CONCLUSIONS

The specialist social worker-led model of care was associated with a reduced length of stay at a relatively low cost. This is likely to represent a cost-effective use of hospital resources. The limitations of our historic control cohort selection mean that results should be interpreted with caution. Further research is needed to confirm these findings.

Emergency Departments as the Health Safety Nets of Society: A Descriptive and Multicenter Analysis of Social Worker Support in the Emergency Room

Introduction

Social Work (SW) referrals made in the emergency department (ED) highlight the weaknesses in the existing support system for vulnerable and disadvantaged patients. SW personnel play a pivotal role in some EDs but are not integrated into the team in several jurisdictions. Our objective was to provide a detailed description of the need for SW support in the ED setting by describing SW consultation patterns in an urban ED location.

Methods

A three-year analysis of ED SW referrals made through a network of four acute care hospitals serving a city population of 1.2 million inhabitants where social workers operate from 8 a.m. to 10 p.m. The study design was descriptive reporting proportions. The descriptors of interest were the types of ED patients receiving SW consultations and the reasons for patient referral to the SW Department.

Results

During the study period, there were 46,970 SW consultations, representing 8.02% of the 572,804 patients who visited the ED across Calgary, yielding 42.9 referrals per day to social workers through the ED. Consultations for domestic violence were three times more prevalent for women (6% of referrals). However, domestic violence consultations were still an active issue for men (1.9%). Comparisons by age group yielded illness adjustments (15.3%), discharge planning (31.2%), and legal decision making (23.9%) as the most common reasons for referral of patients over 75 years old; 92.8% of patients over 75 years were admitted following the SW consultation. Reasons for deferral of patients under 30 years of age were illness adjustments (12.2%), discharge planning (16.4 %), and legal decision making (1.4%); 57.3% of patients under 30 years were admitted following the consultation. Addiction/drug use and homelessness were more common in those under the age of 30, comprising 24.1% and 15.4% of the SW referrals, respectively, compared to 1.6% and 0.4% of referrals for those over age 75, respectively.

Conclusions

The demand for SW support is significant and complex in these large urban EDs. However, the impact on patient care and resource use is substantial, and the data indicates that SW integration may be of universal benefit to EDs. Further studies are warranted to accurately characterize the amount and type of SW necessary for optimal patient outcomes and hospital resource use.

Effectiveness of early assessment and intervention by interdisciplinary teams including health and social care professionals in the emergency department: protocol for a systematic review

INTRODUCTION

Finding cost-effective strategies to improve patient care in the emergency department (ED) is an increasing imperative given growing numbers of ED attendees. Encouraging evidence indicates that interdisciplinary teams including health and social care professionals (HSCPs) enhance patient care across a variety of healthcare settings. However, to date no systematic reviews of the effectiveness of early assessment and/or interventions carried by such teams in the ED exist. This systematic review aims to explore the impact of early assessment and/or intervention carried out by interdisciplinary teams including HSCPs in the ED on the quality, safety and cost-effectiveness of care, and to define the content of the assessment and/or intervention offered by HSCPs.

METHODS AND ANALYSIS

Using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses standardised guidelines, we will conduct a systematic review of randomised controlled trials (RCTs), non-RCTs, controlled before-after studies, interrupted time series and repeated measures studies that report the impact of early assessment and/or intervention provided to adults aged 18+ by interdisciplinary teams including HSCPs in the ED. Searches will be carried in Cumulative Index of Nursing and Allied Health Literature, Embase, Cochrane Library and MEDLINE from inception to March 2018. We will also hand-search the reference lists of relevant studies. Following a two-step screening process, two independent reviewers will extract data on the type of population, intervention, comparison, outcomes and study design. The quality of the studies will be appraised using the Cochrane Risk of Bias Tool. The findings will be synthesised in a narrative summary, and a meta-analysis will be conducted where appropriate.

ETHICS AND DISSEMINATION

Ethical approval will not be sought since it is not required for systematic reviews. The results of this review will be disseminated through publication in a peer-review journal and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

CRD42018091794.

Factors associated with the use of social workers for assistance with lifetime and 12-month behavioral health disorders

This study examined the use of social workers for assistance with a behavioral health disorder. Data were from the Collaborative Psychiatric Epidemiology Surveys. The analytic sample included respondents who reported using professional services for assistance with a behavioral health disorder during their lifetime (n = 5,585). Logistic regression was used to examine the use of a social worker during the respondent's lifetime or 12 months prior to the interview. Ten percent of respondents visited a social worker for help with a behavioral health disorder during their lifetime and 3% did so in the 12 months prior to the interview. Women were less likely than men to report using a social worker. Those who visited a social worker tended to also use other professionals for a behavioral health disorder although overall respondents reported visiting social workers less frequently for this reason than other types of professionals.

When high pressure, system constraints, and a social justice mission collide: A socio-structural analysis of emergency department social work services

The emergency department (ED) can be a critical intervention point for many patients with multifaceted needs. Social workers have long been part of interdisciplinary ED teams. This study aimed to contribute to the limited understanding of social worker-patient interactions and factors influencing social work services in this setting. This paper reports a qualitative content analysis of social work medical record notes (N = 1509) of services provided to trauma patients in an urban, public, level 1 trauma center and an in-depth analysis of semi-structured interviews with ED social workers (N = 10). Eight major social work roles were identified: investigator, gatekeeper, resource broker, care coordinator, problem solver, crisis manager, advocate, discharge planner. Analyses revealed a complex interplay between ED social work services and multi-layered contexts. Using a social-ecological framework, we identified the interactions between micro or individual level factors, mezzo or local system level factors and macro environmental and systemic factors that play a role in ED interactions and patient services. Macro-level contextual influences were socio-structural forces including socioeconomic barriers to health, social hierarchies that reflected power differentials between providers and patients, and distrust or bias. Mezzo-level forces were limited resources, lack of healthcare system coordination, a challenging hierarchy within the medical model and the pressure to discharge patients quickly. Micro-level factors included characteristics of patients and social workers, complexity of patient stressors, empathic strain, lack of closure and compassion. All of these forces were at play in patient-social worker interactions and impacted service provision. Social workers were at times able to successfully navigate these forces, yet at other times these challenges were insurmountable. A conceptual model of ED social work and the influences on the patient-social worker interactions was developed to assist in guiding innovative research and practice models to improve services and outcomes in the complex, fast-paced ED.

Emergency Department Visits Following Joint Replacement Surgery in an Era of Mandatory Bundled Payments

OBJECTIVES

The Center for Medicare & Medicaid Services (CMS) is actively testing bundled payments models. This study sought to identify relevant details for 90-day postdischarge emergency department (ED) visits of Medicare beneficiaries following total joint replacement (TJR) surgery meeting eligibility for a CMS bundled payment program.

METHODS

The CMS research identifiable file for the State of Texas for 2011-2012 was used to identify patients who underwent TJR. Qualifying inpatient claims were linked to 90-day postdischarge ED claims. The claims associated with live discharge were divided into three cohorts: elective total hip replacement (THR), emergent (THR), and total knee replacement. The frequency, distribution, diagnoses, and disposition for these ED visits were identified and stratified by timing within the postdischarge period as well as discharge diagnosis. Visits were correlated with age, sex, joint replaced, and fracture.

RESULTS

There were 50,838 TJR surgeries in Texas in 2011-2012 that would have been eligible for inclusion in the CMS defined CJR program. A total of 12,747 ED visits by 9,299 patients occurred in the 90-day postdischarge period. Visits to the ED by patients 85 and older predominated in the case of THR performed secondary to a hip fracture. Patients 65-74 years predominated in both elective surgery categories. There were 2,370 ED visits within 90 days of 10,786 elective THRs, of which 55.5% were discharged home, 34.6% were hospitalized or transferred, and 6.9% were admitted to observation. Of the 3,438 ED visits among 8,475 emergent hip replacement cases, 22.4% were discharged home, 50.2% were hospitalized or transferred, and 5.3% were admitted to observation. Of the 6,939 visits among 31,387 knee replacement cases, 61.9% were discharged home, 30.6% were readmitted or transferred, and 7.1% were admitted to observation. The discharge diagnoses varied by volume and timing in the postdischarge period. The most prevalent diagnoses across groups included injury/trauma, physiologic decompensation, cardiopulmonary events, and infection.

CONCLUSIONS

ED services are frequent for Medicare TJR bundle-eligible patients within the postdischarge period. ED utilization, discharge diagnosis and disposition varied by age, and elective and emergent surgeries. The ED is an important site for identifying and managing postoperative adverse outcomes.

An ED paradox: patients who arrive by ambulance and then leave without consulting an ED provider

BACKGROUND

Scientists have called for strategies to identify ED patients with unmet needs. We identify the unique profile of ED patients who arrive by ambulance and subsequently leave without consulting a provider (ie, a paradoxical visit, PV).

METHODS

Using a retrospective cohort design, administrative data from Winnipeg, Manitoba were interrogated to identify all ED patients 17+ years old as having zero, single or multiple PVs in 2012/2013. Analyses compare the sociodemographic, physical (eg, arthritis), mental (eg, substance abuse) and concurrent healthcare use profile of non-PV, single and multiple PV patients.

RESULTS

The study cohort consisted of 122 639 patients with 250 754 ED visits. Across all ED sites, 2.3% of patients (N=2815) made 3387 PVs, comprising 1.4% of all ED visits. Descriptively, more single versus non-PV patients lived in urban core and lowest-income areas, were frequent ED users generally, were substance abusers and had seven plus primary care physician visits. Multiple PV patients had a similar but more extreme profile versus their single PV counterparts (eg, 54.7% of multiple vs 27.4% of single PV patients had substance abuse challenges). From multivariate statistics, single versus non-PV patients are defined uniquely by their frequent ED use, by their substance abuse, as living in a core and low income area, and as having multiple visits with primary care physicians.

CONCLUSIONS

PV patients have needs that do not align with the acute model of ED care. These patients may benefit from a more integrated care approach likely involving allied health professionals.

A conceptual model of emergency physician decision making for head computed tomography in mild head injury

The use of computed tomographic scanning in blunt head trauma has increased dramatically in recent years without an accompanying rise in the prevalence of injury or hospital admission for serious conditions. Because computed tomography is neither harmless nor inexpensive, researchers have attempted to optimize utilization, largely through research that describes which clinical variables predict intracranial injury, and use this information to develop clinical decision instruments. Although such techniques may be useful when the benefits and harms of each strategy (neuroimaging vs observation) are quantifiable and amenable to comparison, the exact magnitude of these benefits and harms remains unknown in this clinical scenario. We believe that most clinical decision instrument development efforts are misguided insofar as they ignore critical, nonclinical factors influencing the decision to image. In this article, we propose a conceptual model to illustrate how clinical and nonclinical factors influence emergency physicians making this decision. We posit that elements unrelated to standard clinical factors, such as personality of the physician, fear of litigation and of missed diagnoses, patient expectations, and compensation method, may have equal or greater impact on actual decision making than traditional clinical factors. We believe that 3 particular factors deserve special consideration for further research: fear of error/malpractice, financial incentives, and patient engagement. Acknowledgement and study of these factors will be essential if we are to understand how emergency physicians truly make these decisions and how test-ordering behavior can be modified.

Geriatric assessment in frail older patients in the emergency department

Emergency care of elderly patients is frequent and complex in the emergency department. Frail older patients have a high risk of poor short-term results following emergency care. There is no practical universal or standardized tool defining frailty. It must be systematically identified in older patients at risk using a screening test, and in those who are positive, a diagnostic scale of frailty or preferably a geriatric scale adapted to emergency care is carried out. An adapted geriatric assessment including brief scales related to clinical, mental, functional and social aspects has been proposed. There are currently no geriatric intervention models with sufficient evidence in frail older patients.

Good intentions, increased inequities: developing social care services in Emergency Departments in the UK

Addressing the quality of services provided in Emergency Departments (EDs) has been a central area of development for UK government policy since 1997. Amongst other aspects of this concern has been the recognition that EDs constitute a critical boundary between the community and the hospital and a key point for the identification of social care needs. Consequently, EDs have become the focus for a variety of service developments which combine the provision of acute medical and nursing assessment and care with a range of activities in which social care is a prominent feature. One approach to this has been the establishment of multidisciplinary teams aiming to prevent re-attendance or admission, re-direct patients to other services, or speed patients through EDs with the aim of providing improved quality of care. This study, carried out between September 2007 and April 2008, was the first UK national survey of social care initiatives based in EDs and aimed to determine the objectives, organisation, extent, functions, funding and evidence on outcomes of such interventions. Eighty-three per cent of UK Type I and II EDs responded to the survey. Approximately, one-third of EDs had embedded social care teams, with two-thirds relying on referrals to external social care services. These teams varied in their focus, size and composition, leadership, availability, funding and permanence. As a result, the unintended effect has been to increase inequities in access to social care services through EDs. Three further conclusions are drawn about policy led, locally-based service development. This survey adds to international evidence pointing to the potential benefits of a variety of social care interventions being based in EDs and justifies the establishment of a research programme which can provide answers to key outstanding questions.

The efficacy and value of emergency medicine: a supportive literature review

Study objectives

The goal of this study was to identify publications in the medical literature that support the efficacy or value of Emergency Medicine (EM) as a medical specialty and of clinical care delivered by trained emergency physicians. In this study we use the term "value" to refer both to the "efficacy of clinical care" in terms of achieving desired patient outcomes, as well as "efficiency" in terms of effective and/or cost-effective utilization of healthcare resources in delivering emergency care. A comprehensive listing of publications describing the efficacy or value of EM has not been previously published. It is anticipated that the accumulated reference list generated by this study will serve to help promote awareness of the value of EM as a medical specialty, and acceptance and development of the specialty of EM in countries where EM is new or not yet fully established.

Methods

The January 1995 to October 2010 issues of selected journals, including the EM journals with the highest article impact factors, were reviewed to identify articles of studies or commentaries that evaluated efficacy, effectiveness, and/or value related to EM as a specialty or to clinical care delivered by EM practitioners. Articles were included if they found a positive or beneficial effect of EM or of EM physician-provided medical care. Additional articles that had been published prior to 1995 or in other non-EM journals already known to the authors were also included.

Results

A total of 282 articles were identified, and each was categorized into one of the following topics: efficacy of EM for critical care and procedures (31 articles), efficacy of EM for efficiency or cost of care (30 articles), efficacy of EM for public health or preventive medicine (34 articles), efficacy of EM for radiology (11 articles), efficacy of EM for trauma or airway management (27 articles), efficacy of EM for using ultrasound (56 articles), efficacy of EM faculty (34 articles), efficacy of EM residencies (24 articles), and overviews and editorials of EM efficacy and value (35 articles).

Conclusion

There is extensive medical literature that supports the efficacy and value for both EM as a medical specialty and for emergency patient care delivered by trained EM physicians.

Recruitment and retention of patients into emergency medicine clinical trials

The emergency medicine (EM) and prehospital environments are unlike any other clinical environments and require special consideration to allow the successful implementation of clinical trials. This article reviews the specific issues involved in EM clinical trials and provides strategies from EM and non-EM trials to maximize recruitment and retention. While the evidence supporting some of these strategies is deficient, addressing recruitment and retention issues with specific strategies will help researchers deal with these issues in their funding applications and in turn develop the necessary infrastructure to participate in EM clinical trials.

The value of the presence of social work in emergency departments

The value of the presence of social work in emergency rooms is supported by directly examining the hospitalization rates of patients seen by social workers. It utilizes a 3-year-long data set of social work self-reports on medical emergency room outcomes at a large, teaching hospital in the New York Metropolitan area with a sample size of 3370. The study findings suggest that social workers in this acute care hospital's emergency room often are referred the most complex cases. The data on this site indicate that the majority of social work dispositions were to home (54%) or a nursing facility (8.4%). Only 16% of the patients seen by social work were admitted to the hospital. These findings support the cost-effective nature of social work in the emergency room setting and the importance of finding alternatives to hospital admissions. The results of a logistic regression suggest that the criteria used by social workers to assess patients are based on sound psychosocial factors. Patients who were assessed as having "Environmental" (p = .00) or "Relationship" problems (p = .00) were much less likely to be admitted. Conversely, patients with "Care/ADL" problems (p = .00) and behavior problems (p = .00) had a heightened chance of being admitted. Being African American has less effect but was still relevant.

The role of the emergency department in the care of homeless and disadvantaged populations

This article provides an overview of the role of the emergency department (ED) in the care of homeless and disadvantaged populations. It suggests that organized emergency medicine can have a significant impact on total community health by maintaining a universal "safety net" for the delivery of integrated health and human services. The epidemiology of social deprivation among ED patients is examined, with a particular focus on homelessness. Current research on the value of socio-medical integration in the ED setting is discussed, with emphasis on selected initiatives that have demonstrated feasibility, cost-effectiveness, and impact.

The State Children's Health Insurance Program: a multicenter trial of outreach through the emergency department

OBJECTIVES

We evaluated emergency department (ED)-based outreach for the State Children's Health Insurance Program (SCHIP).

METHODS

We conducted a multicenter trial among uninsured children (< or = 18 years) who presented to 5 EDs in 2001 and 2002. On-site staff enrolled consecutive subjects for a control period followed by an intervention period during which staff handed out SCHIP applications to the uninsured. The primary outcome was state-level confirmation of insured status at 90 days.

RESULTS

We followed 223 subjects (108 control, 115 intervention) by both phone interview and state records. Compared to control subjects, those receiving a SCHIP application were more likely to have state health insurance at 90 days (42% vs 28%; P<.05; odds ratio [OR]=3.8; 95% confidence interval [CI]=1.7, 8.6). Although the intervention effect was prominent among 118 African Americans (50% insured after intervention vs 31% of controls, P<.05), lack of family enrollment in other public assistance programs was the primary predictor of intervention success (OR=3.7; 95% CI=1.6, 8.4).

CONCLUSIONS

Handing out insurance applications in the ED can be an effective SCHIP enrollment strategy, particularly among minority children without connections to the social welfare system. Adopted nationwide, this simple strategy could initiate insurance coverage for more than a quarter million additional children each year.

Social care's impact on emergency medicine: a model to test

Mainly in response to the policy drive to avoid unnecessary acute hospital admissions and delayed discharge on social grounds, there has been a gradual development of social work services attached to emergency departments (EDs) in the UK. In the absence of a clearly articulated evidence base or debate about the roles of ED attached social workers, a model of ED based social work practice and indicative supporting evidence is presented. It is argued that social workers may be able to contribute to the efficiency and effectiveness of hospital services while providing a key point of access to social care services. A number of obstacles remain to the implementation of this model of service, including the narrow focus of current social care practice, the hours that a social work service is normally provided, chronic under-funding, and continuing perverse incentives in the health and social care system. More systematic evidence in the UK context is needed to support the case for change.

Child health insurance outreach through the emergency department: a pilot study

In 1997 the U.S. government funded the Children's Health Insurance Program (CHIP), but the 48 billion dollars initiative has had limited success in finding and enrolling uninsured children. While such children are more likely to receive care in emergency departments (EDs), no national initiative has targeted EDs for child health insurance outreach.

OBJECTIVE

As a pilot study for a national multicenter study, this study evaluated the effectiveness of child health insurance outreach in an ED setting.

METHODS

This was a prospective observational study of the outreach efforts of a single case manager from August 1998 to July 1999, performed at Foote Hospital ED in Jackson, Michigan (45,000 visits/year). All patients <or=18 years old presenting during the duty-hours of the intervention worker were eligible. The case manager approached the parent of all uninsured children and provided information and an application for government-sponsored health insurance. She followed up with a brief phone interview of each parent to determine whether the targeted child had received the insurance, and whether the new coverage was due to the ED referral. Missing information was confirmed from state insurance records. Data were analyzed with frequency tabulations and 95% confidence intervals.

RESULTS

Seventy-eight children participated (median age 7 years; 55% male; 87% white). Forty-four percent (95% CI = 32% to 55%) of families referred for government-sponsored child health insurance successfully obtained it; 31% (95% CI = 21% to 42%) could be traced directly to intervention efforts by interview (n = 17) or by state records (n = 7). Nineteen percent (95% CI = 11% to 30%) got other private insurance. Of those who got government-sponsored insurance due to the intervention, all but one were covered by Medicaid.

CONCLUSIONS

The ED may be an important outreach site for child health insurance programs. National efforts to address the lack of insurance among children should include partnerships with the ED.

Safety net research in emergency medicine: proceedings of the Academic Emergency Medicine Consensus Conference on "The Unraveling Safety Net"

A primary goal of the Academic Emergency Medicine Consensus Conference, "The Unraveling Safety Net: Research Opportunities and Priorities," was to explore a formal research agenda for safety net research in emergency medicine. This paper represents the thoughts of active health services researchers regarding the structure and direction of such work, including some examples from their own research. The current system for safety net care is described, and the emergency department is conceptualized as a window on safety net patients and systems, uniquely positioned to help study and coordinate integrated processes of care.

[Impact in the quality of health care and cost-effectiveness analysis of the reform of an emergency medicine service]

BACKGROUND

To determine the effects that the reform of an emergency department (ED) have on efficacy, health care quality and efficiency.

MATERIAL AND METHOD

Reforms consisted of 50% and 34% increases in structural and human resources, respectively. Roles of each ED member were redetermined, new assistance pathways were implemented, and the relationship between ED and the remaining hospital departments was reassessed. As efficacy markers, we determined the number of patients waiting to be attended (Pesp), the waiting time of patients to receive medical assistance (T(esp)),and the total waiting time of patients staying in the ED (T(total)). As health-care quality markers, we determined the percentage of patients leaving ED without having been visited by a physician(IPNV), the percentage of patients who were visited again (IPR),and the percentage of mortality (IPF). We also quantified the number of visits to the ED. All these data were obtained daily over 3 weeks, before (February 1999) and after (February 2000)the reforms. Effectiveness was estimated from the ratio P(total)/T(esp)(E1) and P(total)/P(esp) (E2). Costs were recorded for both periods and a cost-effectiveness analysis was performed to study the efficiency.

RESULTS

In 2000, the number of visits increased by +12% (CI 95%: 2% to 22%). Despite this increase, we observed an improvement of most efficacy and health-care quality markers after the ED reforms. E1 increased by 996% (CI 95%: 335% to 1,658%) and E2 increased by 186% (CI 95%: -23%to 395%). Cost-effectiveness analysis showed 70% (CI 95%: 33%to 107%) and 56% (CI 95%: 18% to 94%) increases regarding E1 and E2, respectively, after the reforms.

CONCLUSIONS

Providing ED with the necessary resources leads to an objective improvement of its efficacy and health-care quality and, consequently, the service and quality perceived by users improve. Despite the total cost increase after the ED reforms, efficiency also improves.

Where health and welfare meet: social deprivation among patients in the emergency department

CONTEXT

As a safety net provider for many disadvantaged Americans, the emergency department (ED) may be an efficient site not only for providing acute medical care, but also for addressing serious social needs.

OBJECTIVE

To characterize the social needs of ED patients, and to evaluate whether the most disadvantaged patients have connections with the health and welfare system outside the ED.

DESIGN

Cross-sectional survey conducted over 24 hours in the fall of 1997.

SETTING

Three EDs: an urban public teaching hospital, a suburban university hospital, and a semirural community hospital.

PARTICIPANTS

Consecutive patients presenting for care, including those transported by ambulance. The survey response rate was 91% (N = 300; urban = 115, suburban = 102, rural = 83).

MAIN OUTCOME MEASURE

Index of socioeconomic deprivation described by the US Census Bureau (based on food, housing, and utilities).

RESULTS

Of all ED patients, 31% reported one or more serious social deprivations. For example, 13% of urban patients reported not having enough food to eat, and 9% of rural patients reported disconnection of their gas or electricity (US population averages both less than 3%). While 40% of all patients had no consistent health care outside the ED (< or = 1 visit/year), those with higher levels of social deprivation had the least contact with the health care system outside the ED (P < .01). Although those with higher levels of deprivation were more likely to receive public assistance, still almost one-quarter of patients with high-level social deprivation were not receiving public aid.

CONCLUSION

Many ED patients suffer from fundamental social deprivations that threaten basic health. The most disadvantaged of these patients frequently lack contact with other medical care sites or public assistance networks. Community efforts to address serious social deprivation should include partnerships with the local ED.