The Association of Demographic, Socioeconomic, and Geographic Factors with Potentially Preventable Emergency Department Utilization

Investigation of geographic disparities of diabetes-related hospitalizations in Florida using flexible spatial scan statistics: An ecological study

BACKGROUND

Hospitalizations due to diabetes complications are potentially preventable with effective management of the condition in the outpatient setting. Diabetes-related hospitalization (DRH) rates can provide valuable information about access, utilization, and efficacy of healthcare services. However, little is known about the local geographic distribution of DRH rates in Florida. Therefore, the objectives of this study were to investigate the geographic distribution of DRH rates at the ZIP code tabulation area (ZCTA) level in Florida, identify significant local clusters of high hospitalization rates, and describe characteristics of ZCTAs within the observed spatial clusters.

METHODS

Hospital discharge data from 2016 to 2019 were obtained from the Florida Agency for Health Care Administration through a Data Use Agreement with the Florida Department of Health. Raw and spatial empirical Bayes smoothed DRH rates were computed at the ZCTA level. High-rate DRH clusters were identified using Tango's flexible spatial scan statistic. Choropleth maps were used to display smoothed DRH rates and significant high-rate spatial clusters. Demographic, socioeconomic, and healthcare-related characteristics of cluster and non-cluster ZCTAs were compared using the Wilcoxon rank sum test for continuous variables and Chi-square test for categorical variables.

RESULTS

There was a total of 554,133 diabetes-related hospitalizations during the study period. The statewide DRH rate was 8.5 per 1,000 person-years, but smoothed rates at the ZCTA level ranged from 0 to 101.9. A total of 24 significant high-rate spatial clusters were identified. High-rate clusters had a higher percentage of rural ZCTAs (60.9%) than non-cluster ZCTAs (41.8%). The median percent of non-Hispanic Black residents was significantly (p < 0.0001) higher in cluster ZCTAs than in non-cluster ZCTAs. Populations of cluster ZCTAs also had significantly (p < 0.0001) lower median income and educational attainment, and higher levels of unemployment and poverty compared to the rest of the state. In addition, median percent of the population with health insurance coverage and number of primary care physicians per capita were significantly (p < 0.0001) lower in cluster ZCTAs than in non-cluster ZCTAs.

CONCLUSIONS

This study identified geographic disparities of DRH rates at the ZCTA level in Florida. The identification of high-rate DRH clusters provides useful information to guide resource allocation such that communities with the highest burdens are prioritized to reduce the observed disparities. Future research will investigate determinants of hospitalization rates to inform public health planning, resource allocation and interventions.

Public Beliefs About Accessibility and Quality of Emergency Departments in Germany

Background

It is well established that emergency department (ED) crowding leads to worse health outcomes. Although various patient surveys provide information about reasons to visit EDs, less is known in terms of beliefs about EDs among the general population. This study examines public beliefs regarding accessibility and quality of EDs and their associations with social characteristics (gender, age, education, immigration background) as well as knowledge about emergency care services and health literacy.

Methods

We conducted a cross-sectional study based on a random sample of 2,404 adults living in Hamburg, Germany, in winter 2021/2022. We developed eight statements regarding accessibility and quality of EDs leading to two scales (Cronbach's α accessibility = 0.76 and quality of care = 0.75). Descriptive statistics of the eight items are shown and linear regression were conducted to determine associations of the two scales with social characteristics as well as knowledge about emergency care services and health literacy (HLS-EU-Q6).

Results

Nearly 44% of the respondents agreed that "you can always go to an ED, if you do not get a short-term appointment with a general practitioner or specialist." And 38% agreed with the statement, "If you do not have the time during normal practice hours due to your work, you can always go to an ED." In terms of quality, 38% believed that doctors in EDs are more competent than doctors in general practice, and 25% believed that doctors in EDs are more competent than doctors in specialized practices. In the fully adjusted model, public beliefs about emergency care accessibility and quality of EDs were significantly associated with all social characteristics and knowledge of emergency care options with the strongest associations between knowledge and accessibility (β = -0.17; P < 0.001) and between education and quality (β = -0.23; P < 0.001).

Conclusion

We found endorsement of public beliefs about accessibility and quality of EDs that can lead to inappropriate utilization. Our results also suggest that knowledge of different emergency services plays an important role. Therefore, after system-related reorganizations of emergency care, information campaigns about such services tailored to socially deprived populations may help alleviate the issue of crowding.

Emergency Department Utilization for Pediatric Gastrostomy Tubes Across the United States

INTRODUCTION

Emergency Department (ED) visits for gastrostomy tube complications in children represent a substantial health-care burden, and many ED visits are potentially preventable. The number and nature of ED visits to community hospitals for pediatric gastrostomy tube complications is unknown.

METHODS

Using the 2019 Nationwide Emergency Department Sample, we performed a retrospective cross-sectional analysis of pediatric patients (<18 y) with a primary diagnosis of gastrostomy tube complication. Our primary outcome was a potentially preventable ED visit, defined as an encounter that did not result in any imaging, procedures, or an inpatient admission. Univariate and multivariable logistic regression analyses were used to determine the associations between patient factors and our primary outcome.

RESULTS

We observed 32,036 ED visits at 535 hospitals and 15,165 (47.3%) were potentially preventable. The median (interquartile range) age was 2 (1, 6) years and 17,707 (55%) were male. Compared to White patients, patients with higher odds of potentially preventable visits were Black (adjusted odds ratio (aOR) [95% confidence interval {CI}]: 1.07 [1.05-1.11], P < 0.001) and Hispanic (aOR [95% CI]: 1.05 [1.02-1.08], P = 0.004). Patients with residential zip codes in the first (aOR [95% CI]: 1.08 [1.04, 1.12], P < 0.001), second (aOR [95% CI]: 1.07 [1.03, 1.11], P < 0.001), and third (aOR [95% CI]: 1.09 [1.05, 1.13], P < 0.001) median household income quartiles had higher odds of potentially preventable visits compared to the highest.

CONCLUSIONS

In a nationally representative sample of EDs, 47.3% of visits for pediatric gastrostomy tubes were potentially preventable. Efforts to improve outpatient management are warranted to reduce health-care utilization for these patients.

Nonspecific Complaints in Older Emergency Department Patients

Nonspecific complaints such as generalized weakness and fatigue are common in older adults presenting to an emergency department. These complaints may be caused by acute or chronic medical problems, or they may be exacerbated or caused by socioeconomic risks factors. Acute causes may be related to serious medical conditions requiring prompt treatment. A thorough history and physical examination in conjunction with an interdisciplinary approach allows emergency departments to identify acute conditions as well as geriatric syndromes and unmet home needs, such as food insecurity and caregiver burden. A whole-health system approach should be used for safe transitions of care.

Transition-of-care program from emergency department to gastroenterology clinics improves follow-up

OBJECTIVES

Patients discharged from the emergency department (ED) with gastrointestinal (GI) symptoms need to appropriately transition their care to a GI outpatient clinic in a timely manner to have their health needs met and avoid significant morbidity. When this transition isn't optimal, patients are lost to follow-up, potentially placing them at risk for adverse events. We sought to study the effectiveness of implementing an electronic medical record (EMR) based transition-of-care (TOC) program from the ED to outpatient GI clinics.

METHODS

We performed a retrospective single center cohort study of patients discharged from the ED of a tertiary care academic medical center referred to outpatient GI clinic before (Pre-TOC patients) and after implementation of an EMR based TOC program (TOC patients). We further stratified patients based on the Distressed Communities Index (DCI), which is a composite measure of economic well-being. We compared rates of appointment scheduling and appointment attendance between the two groups, as well as 30-day readmission rates to the ED. We also performed a subgroup analysis to determine if socioeconomic status would affect patient follow-up rates.

RESULTS

We included 380 Pre-TOC and 399 TOC patients in our analysis. TOC patients were found to both schedule appointments (50% vs 27% p-value <0.01) as well as show up to appointments (34% vs 24% p-value <0.01) at significantly higher rates compared to Pre-TOC patients. There was no significant difference between 30-day readmission rates between the two groups. In addition, TOC patients from At-Risk and Distressed Communities were over 22 times more likely to schedule an appointment compared to Pre-TOC patients from similar neighborhoods (OR 22.18, 95% CI 4.23-116.32).

CONCLUSION

Our study shows that patients who are discharged from the ED with outpatient GI follow-up are more likely to both schedule and show up to appointments with implementation of an EMR-based direct referral program compared to no patient navigation, particularly among patients of lower socioeconomic status.

Emergency department utilization among patients who receive outpatient specialty care for headache: A retrospective cohort study analysis

OBJECTIVES

To compare clinical characteristics among outpatient headache clinic patients who do and do not self-report visiting the emergency department for headache.

BACKGROUND

Headache is the fourth most common reason for emergency department visits, compromising 1%-3% of visits. Limited data exist about patients who are seen in an outpatient headache clinic but still opt to frequent the emergency department. Clinical characteristics may differ between patients who self-report emergency department use and those who do not. Understanding these differences may help identify which patients are at greatest risk for emergency department overutilization.

METHODS

This observational cohort study included adults treated at the Cleveland Clinic Headache Center between October 12, 2015 and September 11, 2019, who completed self-reported questionnaires. Associations between self-reported emergency department utilization and demographics, clinical characteristics, and patient-reported outcome measures (PROMs: Headache Impact Test [HIT-6], headache days per month, current headache/face pain, Patient Health Questionnaire-9 [PHQ-9], Patient-Reported Outcomes Measurement Information System [PROMIS] Global Health [GH]) were evaluated.

RESULTS

Of the 10,073 patients (mean age 44.7 ± 14.9, 78.1% [7872/10,073] female, 80.3% [8087/10,073] White patients) included in the study, 34.5% (3478/10,073) reported visiting the emergency department at least once during the study period. Characteristics significantly associated with self-reported emergency department utilization included younger age (odds ratio = 0.81 [95% CI = 0.78-0.85] per decade), Black patients (vs. White patients) (1.47 [1.26-1.71]), Medicaid (vs. private insurance) (1.50 [1.29-1.74]), and worse area deprivation index (1.04 [1.02-1.07]). Additionally, worse PROMs were associated with greater odds of emergency department utilization: higher (worse) HIT-6 (1.35 [1.30-1.41] per 5-point increase), higher (worse) PHQ-9 (1.14 [1.09-1.20] per 5-point increase), and lower (worse) PROMIS-GH Physical Health T-scores (0.93 [0.88-0.97]) per 5-point increase.

CONCLUSION

Our study identified several characteristics associated with self-reported emergency department utilization for headache. Worse PROM scores may be helpful in identifying which patients are at greater risk for utilizing the emergency department.

Social determinants of health and preventable emergency department patient encounters among adults with hypertension

Limited access to resources promoting optimal health outcomes can lead to increased emergency department utilization for conditions often manageable by primary care resulting in rising healthcare costs, overcrowding in emergency departments, and poor patient outcomes. Social determinants of health often affect an individual's ability to achieve optimal health. To examine the association between social determinants of health and hypertension-related patient encounters among adults, we analyzed data from a 340-bed community hospital in the southeast region of the United States. Gender, race, and geographic location were strongly associated with hypertension-related encounters. Hypertension-related encounters in the emergency department were highest in women, African Americans, and young adults. Insurance status and geographic location were also strongly associated. Public health nursing is positioned to prevent disease and increase access to care, considering hypertension-related encounters in the emergency department account for a significant number of overall visits.