Can improved specialty access moderate emergency department overuse?: Effect of neurology appointment delays on ED visits

Operational Impact of Neurology Rural Access Model: Reflections on the Importance of Demand-Shaping

Background and Objectives

Demand for specialty neurologic care has been steadily increasing over the past several decades, and health systems are needing to meet the demands of their patients while managing a dwindling workforce. This retrospective study investigates the operational impact of a regional neurology clinic staffed by advanced practice providers with remote physician oversight in a "hub and spoke" delivery model to serve lower complexity patients.

Methods

A retrospective, cross-sectional study was conducted to evaluate outcomes. Descriptive analysis of referral volumes, cancellation/no-show rates, and patient complexity as determined by the reason for referral were used to evaluate patients who received referrals from rural counties north of the primary neurology practice before and after the opening of the regional clinic. These metrics were evaluated longitudinally from counties of interest and for differences in patients seen at the regional clinic vs primary neurology practice.

Results

Referral volumes from the northern counties increased at significantly higher rates after the opening of the regional clinic than other counties in the serviced area. This resulted in an increase in patients seen in the hub clinics and spoke clinic. The regional clinic did see patients who were less complex than the primary practice; however, the total volume of low-complexity patients scheduled at the primary practice did not decrease. Cancellation and no-show rates did not seem to be affected in either clinic.

Discussion

The opening of a regional "spoke" clinic resulted in the generation of greater referral volumes that exceeded the capacity created by the clinic. Owing to this, there was an increase in the number of patients seen from the regional counties in the hub clinics, negating the potential benefit of improving access for high-complexity patients. Importance of demand-shaping and appropriate utilization as part of the value equation are discussed, followed by discussion of mitigation strategies.

Factors associated with frequent emergency department visits among health centre patients receiving primary care

RATIONALE, AIMS AND OBJECTIVES

We sought to examine specific care-seeking behaviours and experiences, access indicators, and patient care management approaches associated with frequency of emergency department (ED) visits among patients of Health Resources and Services Administration-funded health centres that provide comprehensive primary care to low-income and uninsured patients.

METHOD

We used cross-sectional data of a most recent nationally representative sample of health centre adult patients aged 18-64 (n = 4577) conducted between October 2014 and April 2015. These data were merged with the 2014 Uniform Data System to incorporate health centre characteristics. We measured care-seeking behaviours by whether the patient called the health centre afterhours, for an urgent appointment, or talked to a provider about a concern. Access to care indicators included health centre continuity of care and receipt of transportation or translation services. We included receipt of care coordination and specialist referral as care management indicators. We used a multilevel multinomial logistic regression model to identify the association of independent variables with number of ED visits (4 or more visits, 2-3 visits, 1 visit, vs. 0 visits), controlling for predisposing, enabling, and need characteristics.

RESULTS

Calling the health centre after-hours (OR = 2.41) or for urgent care (OR = 2.53), and being referred to specialists (OR = 2.36) were associated with higher odds of four or more ED visits versus none. Three or more years of continuity with the health centre (OR = 0.32) was also associated with lower odds of four or more ED visits versus none.

CONCLUSIONS

Findings underscore opportunities to reduce higher frequency of ED visits in health centres, which are primary care providers to many low-income populations. Our findings highlight the potential importance of improving patient retention, better access to providers afterhours or for urgent visits, and access to specialist as areas of care in need of improvement.

Predictors of No-Show in Neurology Clinics

In this study, we aim to identify predictors of a no-show in neurology clinics at our institution. We conducted a retrospective review of neurology clinics from July 2013 through September 2018. We compared odds ratio of patients who missed appointments (no-show) to those who were present at appointments (show) in terms of age, lead-time, subspecialty, race, gender, quarter of the year, insurance type, and distance from hospital. There were 60,012 (84%) show and 11,166 (16%) no-show patients. With each day increase in lead time, odds of no-show increased by a factor of 1.0019 (p < 0.0001). Odds of no-show were higher in younger (p ≤ 0.0001, OR = 0.49) compared to older (age ≥ 60) patients and in women (p < 0.001, OR = 1.1352) compared to men. They were higher in Black/African American (p < 0.0001, OR = 1.4712) and lower in Asian (p = 0.03, OR = 0.6871) and American Indian/Alaskan Native (p = 0.055, OR = 0.6318) as compared to White/Caucasian. Patients with Medicare (p < 0.0001, OR = 1.5127) and Medicaid (p < 0.0001, OR = 1.3354) had higher odds of no-show compared to other insurance. Young age, female, Black/African American, long lead time to clinic appointments, Medicaid/Medicare insurance, and certain subspecialties (resident and stroke clinics) are associated with high odds of no show. Possible suggested interventions include better communication and flexible appointments for the high-risk groups as well as utilizing telemedicine.

The Neurology Access Clinic: A Model to Improve Access to Neurologic Care in an Academic Medical Center

Background:

Delays in access to neurologic care is a major problem. In this pilot program, we aimed to evaluate the effectiveness of a novel staffing model for neurology outpatient clinic within an academic neurology center to increase access to neurological care, while incorporating such a model into a growing academic neurology department.

Methods:

We created a new model for provision of access to neurological care that could be introduced in an academic neurological department, the “access clinic”. One attending was assigned to staff the access clinic for one week at a time. This was introduced as rotation equal to conventional on-service inpatient rotations. Descriptive analyses were performed to characterize the access clinic’s performance characteristics. Comparisons were made to the previously established traditional faculty clinic model.

Results:

5,917 access clinic visits were compared to 6,000 traditional clinic visits. Lead time dropped from 142 to 18 days for new patients, and from 64 to 0 days for return visits. While total readmission rates were similar during both clinic periods, readmission through the emergency room was less for access clinic patients. Access clinic resulted in significant improvement in patient satisfaction ratings. The access clinic model was financially profitable.

Conclusions:

Our findings suggest that introducing an access clinic as service rotation for neurology faculty is both effective in offering enhanced access for patients to neurological care and for patient satisfaction. Future studies may test this model in other centers, and should address effect on provider satisfaction.

Characteristics of pediatric emergency department frequent visitors and their risk of a return visit: A large observational study using electronic health record data

Background

Among pediatric emergency department (ED) visits, a subgroup of children repeatedly visits the ED, making them frequent visitors (FVs). The aim of this study is to get insight into the group of pediatric ED FVs and to determine risk factors associated with a revisit.

Methods and findings

Data of all children aged 0–18 years visiting the ED of a university hospital in the Netherlands between 2017 and 2020 were included in this observational study based on routine data extraction. Children with 4 or more ED visits within 365 days were classified as FVs. Descriptive analysis of the study cohort at patient- and visit-level were performed. Risk factors for a recurrent ED visit were determined using a Prentice Williams and Peterson gap time cox-based model. Our study population of 10,209 children with 16,397 ED visits contained 500 FVs (4.9%) accounting for 3,481 visits (21.2%). At patient-level, FVs were younger and more often suffered from chronic diseases (CDs). At visit-level, frequent visits were more often initiated by self-referral and were more often related to medical problems (compared to trauma’s). Overall, FVs presented at the ED more often because of an infection (41.3%) compared to non-FVs (27.4%), either associated or not with the body system affected by the CD. We identified the presence of a comorbidity (non-complex CD HR 1.66; 1.52–1.81 and complex CD HR 2.00; 1.84–2.16) as determinants with the highest hazard for a return visit.

Conclusion

Pediatric ED FVs are a small group of children but account for a large amount of the total ED visits. FVs are younger patients, suffering from (complex) comorbidities and present more often with infectious conditions compared to non-FVs. Healthcare pathways, including safety-netting strategies for acute manifestations from their comorbidity, or for infectious conditions in general may contribute to support parents and redirect some patients from the ED.

Wernicke's encephalopathy mimicking multiple sclerosis in a young female patient post-bariatric gastric sleeve surgery

We describe a case of Wernicke's encephalopathy secondary to thiamine (B1) deficiency in a patient status post-bariatric sleeve gastrectomy. The presenting symptoms of new-onset weakness, diplopia, and confusion in a young female patient raised suspicion for multiple sclerosis (MS), but given a history of bariatric surgery, thiamine levels were checked, revealing significant Vitamin B1 (thiamine) deficiency. This case highlights the importance of thorough history taking, as a misdiagnosis of MS in this case could have resulted in irreversible neurological deterioration and hematological and infectious consequences associated with the inappropriate administration of disease-modifying therapies. It is also important to note that severe vitamin deficiency occurred despite medication compliance.

Hospital Utilization Among Rural Children Served by Pediatric Neurology Telemedicine Clinics

Importance

Telemedicine is increasingly used to provide outpatient pediatric neurology consultations in underserved communities. Although telemedicine clinics have been shown to improve access, little is known about how they alter patients' utilization of hospital services.

Objective

To evaluate the association between access to telemedicine clinics and hospital utilization among underserved children with neurologic conditions.

Design, Setting, and Participants

This retrospective cross-sectional study included 4169 patients who received outpatient care from pediatric neurologists affiliated with an academic children's hospital in California between January 1, 2009, and July 31, 2017, either in person or using telemedicine.

Exposures

Consultation modality (telemedicine or in person) in the outpatient neurology clinics.

Main Outcomes and Measures

Demographic and clinical variables were abstracted from the hospital's electronic medical records. The association between the modality of outpatient neurology care and patients' utilization of the emergency department and hospitalizations was evaluated. Both all-cause and neurologic condition-related hospital utilization were analyzed using multivariable negative binomial regression in overall and matched samples.

Results

The telemedicine cohort comprised 378 patients (211 [55.8%] male), and the in-person cohort comprised 3791 patients (2090 [55.1%] male). The mean (SD) age at the first encounter was 7.4 (5.4) years for the telemedicine cohort and 7.8 (5.1) years for the in-person cohort. The telemedicine cohort was more likely than the in-person cohort to have nonprivate insurance (public insurance, self-pay, or uninsured), lower education, and lower household income. The rates of all-cause and neurologic hospital encounters were lower among children who received pediatric neurology consultations over telemedicine compared with children who received care in the in-person clinics (5.7 [95% CI, 3.5-8.0] vs 20.1 [95% CI, 18.1-22.1] per 100 patient-years and 3.7 [95% CI, 2.0-5.3] vs 8.9 [95% CI, 7.8-10.0] per 100 patient-years, respectively; P < .001). Even after adjusting for demographic and clinical factors, the telemedicine cohort had a lower risk of hospital encounters (emergency department visits and admissions) with an adjusted incidence rate ratio of 0.57 (95% CI, 0.38-0.88) for all-cause encounters and an adjusted incidence rate ratio of 0.60 (95% CI, 0.36-0.99) for neurologic encounters. After matching on travel time to the neurology clinic, the adjusted incidence rate ratio was 0.19 (95% CI, 0.04-0.83) for all-cause admissions and 0.14 (95% CI, 0.02-0.82) for neurologic admissions.

Conclusions and Relevance

Pediatric neurology care through real-time, audiovisual telemedicine consultations was associated with lower hospital utilization compared with in-person consultations, suggesting that high-cost hospital encounters can be prevented by improving subspecialty access.

Appointment completion in pediatric neurology telemedicine clinics serving underserved patients

Background

To determine whether telemedicine improves access to outpatient neurology care for underserved patients, we compared appointment completion between urban, in-person clinics and telemedicine clinics held in rural and underserved communities where neurology consultations are provided remotely.

Methods

In this retrospective study, we identified patients scheduled for outpatient care from UCDH pediatric neurologists between January 1, 2009, and July 31, 2017, in person and by telemedicine. Demographic and clinical variables were abstracted from electronic medical records. We evaluated the association between consultation modality and visit completion in overall and matched samples using hierarchical multivariable logistic regression.

Results

We analyzed 13,311 in-person appointments by 3,831 patients and 1,158 telemedicine appointments by 381 patients. The average travel time to the site of care was 45.8 ± 52.1 minutes for the in-person cohort and 22.3 ± 22.7 minutes for the telemedicine cohort. Telemedicine sites were located at an average travel time of 217.1 ± 114.8 minutes from UCDH. Telemedicine patients were more likely to have nonprivate insurance, lower education, and lower household income. They had different diagnoses and fewer complex chronic conditions. Telemedicine visits were more likely to be completed than either "cancelled" or missed ("no show") compared with in-person visits (OR 1.57, 95% CI: 1.34-1.83; OR 1.66, 95% CI: 1.31-2.10 matched on travel time to the site of care; OR 2.22, 95% CI: 1.66-2.98 matched on travel time to UCDH).

Conclusions

The use of telemedicine for outpatient pediatric neurology visits has high odds of completion and can serve as an equal adjunct to in-person clinic visits.