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Samuels EA, Kelley L, Pham T, Cross J, Carmona J, Ellis P, Cobbs-Lomax D, D'Onofrio G, Capp R. "I wanted to participate in my own care": Evaluation of a Patient Navigation Program. West J Emerg Med 2021; 22:417-426. [PMID: 33856334 PMCID: PMC7972383 DOI: 10.5811/westjem.2020.9.48105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Accepted: 09/21/2020] [Indexed: 11/11/2022] Open
Abstract
Introduction Patient navigation programs can help people overcome barriers to outpatient care. Patient experiences with these programs are not well understood. The goal of this study was to understand patient experiences and satisfaction with an emergency department (ED)-initiated patient navigation (ED-PN) intervention for US Medicaid-enrolled frequent ED users. Methods We conducted a mixed-methods evaluation of patient experiences and satisfaction with an ED-PN program for patients who visited the ED more than four times in the prior year. Participants were Medicaid-enrolled, English- or Spanish-speaking, New Haven-CT residents over the age of 18. Pre-post ED-PN intervention surveys and post-ED-PN individual interviews were conducted. We analyzed baseline and follow-up survey responses as proportions of total responses. Interviews were coded by multiple readers, and interview themes were identified by consensus. Results A total of 49 participants received ED-PN. Of those, 80% (39/49) completed the post-intervention survey. After receiving ED-PN, participants reported high satisfaction, fewer barriers to medical care, and increased confidence in their ability to coordinate and manage their medical care. Interviews were conducted until thematic saturation was reached. Four main themes emerged from 11 interviews: 1) PNs were perceived as effective navigators and advocates; 2) health-related social needs were frequent drivers of and barriers to healthcare; 3) primary care utilization depended on clinic accessibility and quality of relationships with providers and staff; and 4) the ED was viewed as providing convenient, comprehensive care for urgent needs. Conclusions Medicaid-enrolled frequent ED users receiving ED-PN had high satisfaction and reported improved ability to manage their health conditions.
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Affiliation(s)
- Elizabeth A Samuels
- Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
| | | | - Timothy Pham
- Project Access-New Haven, New Haven, Connecticut
| | - Jeremiah Cross
- Highland General Hospital, Department of Emergency Medicine, Oakland, California
| | - Juan Carmona
- Project Access-New Haven, New Haven, Connecticut.,Yale University School of Medicine, Department of Medicine, New Haven, Connecticut
| | - Peter Ellis
- Project Access-New Haven, New Haven, Connecticut.,Yale University School of Medicine, Department of Medicine, New Haven, Connecticut
| | | | - Gail D'Onofrio
- Yale University School of Medicine, Department of Emergency Medicine, New Haven, Connecticut
| | - Roberta Capp
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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2
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Newman SA, Laughter MR, Williams NK, Peart J, Boyers LN, Capp R, Dunnick CA. The reliability and feasibility of teledermatology to diagnose patients referred from the emergency department to outpatient dermatology. J Am Acad Dermatol 2020; 85:992-994. [PMID: 33010312 DOI: 10.1016/j.jaad.2020.09.053] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 09/11/2020] [Accepted: 09/19/2020] [Indexed: 10/23/2022]
Affiliation(s)
- Sabrina A Newman
- Department of Dermatology, University of Colorado Denver School of Medicine, Aurora, Colorado.
| | | | - Nazanin Kalani Williams
- Department of Dermatology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Jenna Peart
- Department of Dermatology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Lindsay N Boyers
- Department of Dermatology, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Roberta Capp
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, Colorado
| | - Cory A Dunnick
- Department of Dermatology, University of Colorado Denver School of Medicine, Aurora, Colorado; Dermatology Service, US Department of Veteran Affairs, Eastern Colorado Health Care System, Aurora, Colorado
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Capp R. Commentary: Addressing the Challenges of the Homeless Patient. Ann Emerg Med 2019; 74:S38-S40. [PMID: 31655673 DOI: 10.1016/j.annemergmed.2019.08.441] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Filbin MR, Thorsen JE, Lynch J, Gillingham TD, Pasakarnis CL, Capp R, Shapiro NI, Mooncai T, Hou PC, Heldt T, Reisner AT. Challenges and Opportunities for Emergency Department Sepsis Screening at Triage. Sci Rep 2018; 8:11059. [PMID: 30038408 PMCID: PMC6056466 DOI: 10.1038/s41598-018-29427-1] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Accepted: 07/10/2018] [Indexed: 12/20/2022] Open
Abstract
Feasibility of ED triage sepsis screening, before diagnostic testing has been performed, has not been established. In a retrospective, outcome-blinded chart review of a one-year cohort of ED adult septic shock patients ("derivation cohort") and three additional, non-consecutive months of all adult ED visits ("validation cohort"), we evaluated the qSOFA score, the Shock Precautions on Triage (SPoT) vital-signs criterion, and a triage concern-for-infection (tCFI) criterion based on risk factors and symptoms, to screen for sepsis. There were 19,670 ED patients in the validation cohort; 50 developed ED septic shock, of whom 60% presented without triage hypotension, and 56% presented with non-specific symptoms. The tCFI criterion improved specificity without substantial reduction of sensitivity. At triage, sepsis screens (positive qSOFA vital-signs and tCFI, or positive SPoT vital-signs and tCFI) were 28% (95% CI: 16-43%) and 56% (95% CI: 41-70%) sensitive, respectively, p < 0.01. By the conclusion of the ED stay, sensitivities were 80% (95% CI: 66-90%) and 90% (95% CI: 78-97%), p > 0.05, and specificities were 97% (95% CI: 96-97%) and 95% (95% CI: 95-96%), p < 0.001. ED patients who developed septic shock requiring vasopressors often presented normotensive with non-specific complaints, necessitating a low threshold for clinical concern-for-infection at triage.
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Affiliation(s)
- Michael R Filbin
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States.
| | - Jill E Thorsen
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
| | - James Lynch
- Department of Electrical and Biomedical Engineering, Massachusetts Institute of Technology, 45 Carleton Street, E25-330, Cambridge, MA, 02139, United States
| | - Trent D Gillingham
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
| | - Corey L Pasakarnis
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
| | - Roberta Capp
- Department of Emergency Medicine, University of Colorado Anschutz Medical Campus, Leprino Building, 12401 East 17th Avenue, Aurora, CO, 80045, United States
| | - Nathan I Shapiro
- Department of Emergency Medicine, Beth Israel Deaconess Center, 330 Brookline Avenue, Boston, MA, 02215, United States
| | - Theodore Mooncai
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
| | - Peter C Hou
- Department of Emergency Medicine, Brigham and Women's Hospital, 75 Francis Street, Boston, MA, 02115, United States
| | - Thomas Heldt
- Department of Electrical and Biomedical Engineering, Massachusetts Institute of Technology, 45 Carleton Street, E25-330, Cambridge, MA, 02139, United States
| | - Andrew T Reisner
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit Street, Boston, MA, 02114, United States
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Capp R, Misky GJ, Lindrooth RC, Honigman B, Logan H, Hardy R, Nguyen DQ, Wiler JL. Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users. Health Aff (Millwood) 2018; 36:1705-1711. [PMID: 28971914 DOI: 10.1377/hlthaff.2017.0612] [Citation(s) in RCA: 41] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities.
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Affiliation(s)
- Roberta Capp
- Roberta Capp is an assistant professor and director for care transitions in the Department of Emergency Medicine, University of Colorado School of Medicine, and medical director of Colorado Access Medicaid, both in Aurora
| | - Gregory J Misky
- Gregory J. Misky is an associate professor in the Hospitalist Division, Department of Internal Medicine, at the University of Colorado School of Medicine
| | - Richard C Lindrooth
- Richard C. Lindrooth is a professor in the Department of Health Systems, Management, and Policy at the Colorado School of Public Health, in Aurora
| | - Benjamin Honigman
- Benjamin Honigman is a professor in the Department of Emergency Medicine, University of Colorado School of Medicine
| | - Heather Logan
- Heather Logan is director of the Accountable Care Collaborative for the Metro Community Provider Network, in Arvada, Colorado
| | - Rose Hardy
- Rose Hardy is a graduate student in the Department of Health Systems, Management, and Policy at the Colorado School of Public Health
| | - Dong Q Nguyen
- Dong Q. Nguyen is an analyst in the Department of Emergency Medicine at the University of Colorado School of Medicine
| | - Jennifer L Wiler
- Jennifer L. Wiler is an associate professor in and vice chair of the Department of Emergency Medicine, University of Colorado School of Medicine
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Hoppe JA, McStay C, Sun BC, Capp R. Emergency Department Attending Physician Variation in Opioid Prescribing in Low Acuity Back Pain. West J Emerg Med 2017; 18:1135-1142. [PMID: 29085548 PMCID: PMC5654885 DOI: 10.5811/westjem.2017.7.33306] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Revised: 06/30/2017] [Accepted: 07/06/2017] [Indexed: 11/22/2022] Open
Abstract
Introduction Despite treatment guidelines suggesting alternatives, as well as evidence of a lack of benefit and evidence of poor long-term outcomes, opioid analgesics are commonly prescribed for back pain from the emergency department (ED). Variability in opioid prescribing suggests a lack of consensus and an opportunity to standardize and improve care. We evaluated the variation in attending emergency physician (EP) opioid prescribing for patients with uncomplicated, low acuity back pain (LABP). Methods This retrospective study evaluated the provider-specific proportion of LABP patients discharged from an urban academic ED over a seven-month period with a prescription for opioids. LABP was strictly defined as (1) back pain chief complaint, (2) discharged from ED with no interventions, and (3) predefined discharge diagnosis of back pain. We excluded providers if they had less than 25 LABP patients in the study period. The primary outcome was the physician-specific proportion of LABP patients discharged with an opioid analgesic prescription. We performed a descriptive analysis and then risk standardized prescribing proportion by adjusting for patient and clinical characteristics using hierarchical logistic regression. Results During the seven-month study period, 23 EPs treated and discharged at least 25 LABP patients and were included. Eight (34.8%) were female, and six (26.1%) were junior attendings (≤ 5 years after residency graduation). There were 943 LABP patients included in the analysis. Provider-specific proportions ranged from 3.7% to 88.1% (mean 58.4% [SD +/− 22.2]), and we found a 22-fold variation in prescribing proportions. There was a six-fold variation in the adjusted, risk-standardized prescribing proportion with a range from 12.0% to 78.2% [mean 50.4% (SD +/−16.4)]. Conclusion We found large variability in opioid prescribing practices for LABP that persisted after adjustment for patient and clinical characteristics. Our findings support the need to further standardize and improve adherence to treatment guidelines and evidence suggesting alternatives to opioids.
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Affiliation(s)
- Jason A Hoppe
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Christopher McStay
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Benjamin C Sun
- Oregon Health and Science University, Department of Emergency Medicine, Portland, Oregon
| | - Roberta Capp
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Davis S, Campbell A, Capp R. A NATIONAL APPROACH TO IMPROVING DEMENTIA CARE: THE DEMENTIA DYNAMICS TOOLKIT. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.1924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S. Davis
- Applied Gerontology, Flinders University, Bamawm, Victoria, Australia
| | - A. Campbell
- Applied Gerontology, Flinders University, Bamawm, Victoria, Australia
| | - R. Capp
- Applied Gerontology, Flinders University, Bamawm, Victoria, Australia
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8
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Davis S, Campbell A, Capp R. PROFESSIONAL DEVELOPMENT OPPORTUNITIES FOR PERSONAL CARE WORKERS: SEE THEM SHINE. Innov Aging 2017. [DOI: 10.1093/geroni/igx004.2001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- S. Davis
- Applied Gerontology, Flinders University, Bamawm, Victoria, Australia
| | - A. Campbell
- Applied Gerontology, Flinders University, Bamawm, Victoria, Australia
| | - R. Capp
- Applied Gerontology, Flinders University, Bamawm, Victoria, Australia
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Horney C, Capp R, Boxer R, Burke RE. Factors Associated With Early Readmission Among Patients Discharged to Post-Acute Care Facilities. J Am Geriatr Soc 2017; 65:1199-1205. [DOI: 10.1111/jgs.14758] [Citation(s) in RCA: 29] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2016] [Revised: 09/09/2016] [Accepted: 10/26/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Carolyn Horney
- Department of Medicine; Division of Geriatric Medicine; University of Colorado; Aurora Colorado
- Geriatric Section; Medicine Service; Denver VA Medical Center; Denver Colorado
| | - Roberta Capp
- Department of Emergency Medicine; University of Colorado School of Medicine; Aurora Colorado
| | - Rebecca Boxer
- Department of Medicine; Division of Geriatric Medicine; University of Colorado; Aurora Colorado
- Geriatrics Research; Education and Clinical Center; VA Eastern Colorado Health Care System; Denver Colorado
| | - Robert E. Burke
- Research and Hospital Medicine Sections; Medicine Service; Denver VA Medical Center; Denver Colorado
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10
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Bergamo C, Blumhagen R, Weitzenkamp D, Capp R. 226 Frequent Emergency Department Utilization: Evaluating the Role of the Patient, Hospital, and Community Characteristics. Ann Emerg Med 2016. [DOI: 10.1016/j.annemergmed.2016.08.240] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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11
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Jones CD, Wald HL, Boxer RS, Masoudi FA, Burke RE, Capp R, Coleman EA, Ginde AA. Characteristics Associated with Home Health Care Referrals at Hospital Discharge: Results from the 2012 National Inpatient Sample. Health Serv Res 2016; 52:879-894. [PMID: 27196526 DOI: 10.1111/1475-6773.12504] [Citation(s) in RCA: 37] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
OBJECTIVE To assess patient- and hospital-level factors associated with home health care (HHC) referrals following nonelective U.S. patient hospitalizations in 2012. DATA SOURCE The 2012 National Inpatient Sample (NIS). STUDY DESIGN Retrospective, cross-sectional multivariable logistic regression modeling to assess patient- and hospital-level variables in patient discharges with versus without HHC referrals. DATA COLLECTION Analysis included 1,109,905 discharges in patients ≥65 years with Medicare. PRINCIPAL FINDINGS About 29.2 percent of discharges were referred to HHC, which were more likely with older age, female sex, urban location, low income, longer length of stay, higher severity of illness scores, diagnoses of heart failure or sepsis, and hospital location in New England (referent: Pacific). CONCLUSIONS As health policy changes influence postacute HHC, defining specific diagnoses and regional patterns associated with HHC is a first step to optimize postacute HHC services.
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Affiliation(s)
- Christine D Jones
- Hospital Medicine Section, Division of General Internal Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Heidi L Wald
- Hospital Medicine Section, Division of General Internal Medicine, Division of Health Care Policy and Research, University of Colorado Denver School of Medicine, Aurora, CO
| | - Rebecca S Boxer
- Division of Geriatric Medicine, University of Colorado Denver School of Medicine, VA Eastern Colorado Health Care System, Aurora, CO
| | - Frederick A Masoudi
- Division of Cardiology, University of Colorado Denver School of Medicine, Aurora, CO
| | - Robert E Burke
- Department of Medicine, VA Eastern Colorado Health Care System, Denver, CO.,Division of General Internal Medicine, University of Colorado Denver School of Medicine, Denver, CO
| | - Roberta Capp
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO
| | - Eric A Coleman
- Division of Health Care Policy and Research, University of Colorado Denver School of Medicine, Aurora, CO
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado Denver School of Medicine, Aurora, CO
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12
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Holst JA, Perman SM, Capp R, Haukoos JS, Ginde AA. Undertriage of Trauma-Related Deaths in U.S. Emergency Departments. West J Emerg Med 2016; 17:315-23. [PMID: 27330664 PMCID: PMC4899063 DOI: 10.5811/westjem.2016.2.29327] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2015] [Revised: 02/14/2016] [Accepted: 02/17/2016] [Indexed: 02/03/2023] Open
Abstract
Introduction Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers. Methods This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression. Results We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0–46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1–37.1]) and most rural ED visits (86.4%, 95% CI [81.5–90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70–0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1–40,999) (OR 0.54, 95% CI [0.43–0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71–1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38–0.66]). Conclusion We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.
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Affiliation(s)
- Jenelle A Holst
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado
| | - Sarah M Perman
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Roberta Capp
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
| | - Jason S Haukoos
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado; Denver Health Medical Center, Department of Emergency Medicine, Denver, Colorado
| | - Adit A Ginde
- University of Colorado School of Medicine, Department of Emergency Medicine, Aurora, Colorado
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Capp R, Kelley L, Ellis P, Carmona J, Lofton A, Cobbs-Lomax D, D'Onofrio G. Reasons for Frequent Emergency Department Use by Medicaid Enrollees: A Qualitative Study. Acad Emerg Med 2016; 23:476-81. [PMID: 26932230 DOI: 10.1111/acem.12952] [Citation(s) in RCA: 48] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 12/27/2015] [Accepted: 01/05/2016] [Indexed: 11/30/2022]
Abstract
BACKGROUND The Affordable Care Act initiated several care coordination programs tailored to reduce emergency department (ED) use for Medicaid-enrolled frequent ED users. It is important to clarify from the patient's perspective why Medicaid enrollees who want to receive care coordination services to improve primary care utilization frequently use the ED. METHODS We conducted a qualitative data analysis of patient summary reports obtained from Medicaid enrolled frequent ED users who agreed to participate in a randomized control trial (RCT) evaluating the impact of patient navigation intervention compared with standard of care on ED use and hospital admissions. We defined frequent ED users as those who used the ED four to 18 times in the past year. The study was conducted at an urban, teaching hospital ED with approximately 90,000 visits per year. The research staff conducted interviews (~30-40 minutes), regarding the patient's medical history, reasons for ED visits, health care access issues, and social distresses. The aforementioned findings were summarized in a 1- to 2-page report and presented to the RCT's project team (social worker, emergency medicine physician, primary care physician, and patient navigators) on a weekly basis to further understand the needs of this patient population. A diverse team of researchers (program staff and physicians) coded all reports and reached consensus using reflexive team analysis. We reconciled differences in code interpretations and generated themes. RESULTS One-hundred patients enrolled in the RCT from March 2013 to February 2014, and all 100 patient summary reports were evaluated. We identified three key themes associated with Medicaid enrollee frequent ED use: 1) negative personal experiences with the healthcare system, 2) challenges associated with having low socioeconomic status, and 3) significant chronic mental and physical disease burden. CONCLUSIONS Medicaid frequent ED users engaged in receiving patient navigation services with the goal to reduce ED use and hospital admissions describe barriers that go beyond timely primary care access issues. These include sociodeterminants of health, lack of trust in primary care providers, and healthcare system.
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Affiliation(s)
- Roberta Capp
- Department of Emergency Medicine; University of Colorado; School of Medicine; Aurora CO
| | | | - Peter Ellis
- Department of Medicine; Yale University School of Medicine; New Haven CT
| | | | | | | | - Gail D'Onofrio
- Department of Emergency Medicine; Yale University School of Medicine; New Haven CT
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14
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Bergamo C, Juarez-Colunga E, Capp R. Association of mental health disorders and Medicaid with ED admissions for ambulatory care-sensitive condition conditions. Am J Emerg Med 2016; 34:820-4. [PMID: 26887865 DOI: 10.1016/j.ajem.2016.01.023] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2015] [Revised: 01/14/2016] [Accepted: 01/18/2016] [Indexed: 10/22/2022] Open
Abstract
INTRODUCTION Adult Medicaid enrollees are more likely to have mental health disorders (MHDs) than privately insured patients and also have high rates of emergency department (ED) visits for ambulatory care-sensitive conditions (ACSCs). We aimed to evaluate the association of MHD and insurance type with ED admissions for ACSC in the United States. METHODS We conducted a cross-sectional study of ED visits made by adults aged 18 to 64 years using the corrected 2011 National Emergency Department Survey. Using multivariable logistic regression analysis, we controlled for sociodemographics and clinical variables to determine the association between insurance type, MHD, Medicaid, and MHD (as an interaction variable) and ED admissions for ACSC. RESULTS There were 131 million ED visits in 2011; after exclusions, 1.4 million admissions were included in our study. Of all ED visits, 44.7% had an MHD, of which 49.9% were covered by Medicaid and 38.1% were covered by private insurance. A total of 32.6% (95% confidence interval, 32.5%-32.7%) of ED admissions were for an ACSC. Medicaid-covered ED visits were more likely to result in ACSC hospital admission (odds ratio, 1.32; 95% confidence interval, 1.30-1.35) compared with visits covered by private insurance. Among patients with MHD, those with Medicaid insurance had 1.6 times the odds of ACSC admission compared with those privately insured. CONCLUSION Among all ED admissions, patients covered by Medicaid are more likely to be admitted for an ACSC when compared with those covered by private insurance, with a larger association being present among patients with MHD comorbidities.
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Affiliation(s)
- Cara Bergamo
- Denver Health Emergency Medicine Program, Denver Health Medical Center, Denver, CO.
| | | | - Roberta Capp
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO
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15
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Capp R, Sun B, Boatright D, Gross C. The impact of emergency department observation units on United States emergency department admission rates. J Hosp Med 2015; 10:738-42. [PMID: 26503082 DOI: 10.1002/jhm.2447] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Revised: 07/09/2015] [Accepted: 07/22/2015] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Prior studies suggesting that the presence of emergency department (ED) observation units decrease overall ED hospital admissions have been either single-center studies or based on model simulations. The objective of this preliminary national study is to determine if the presence of ED observation units is associated with hospitals having lower ED admission rates. METHODS We conducted a retrospective cross-sectional analysis using the 2010 National Hospital Ambulatory Care Survey and estimated ED risk-standardized hospital admission rates (RSHAR) for each center. The following were excluded from the study: ages <18 years, leaving prior to completion of ED visit, died in the ED, transferred to another facility, and missing disposition. Hospitals with less than 30 ED visits or unknown observation unit status were also excluded. We used linear regression analysis to determine the association between ED RSHAR and presence of observation units. RESULTS There were 24,232 ED visits in 315 hospitals in the United States. Of these, 82 (20.6%) hospitals had an ED observation unit. The average ED risk-standardized hospital admission rates for hospitals with observation units and without hospital observation units were 13.7% (95% confidence interval [CI]: 11.3-16.0) and 16.0% (95% CI: 14.1-17.7), respectively. The difference of 2.3% was not statistically significant. CONCLUSIONS In this preliminary study, we did not find an association between the presence of observation units and ED hospital admission rates. Further studies with larger sample sizes should be performed to further evaluate the impact of ED observation units on ED hospital admission rates.
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Affiliation(s)
- Roberta Capp
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Benjamin Sun
- Department of Emergency Medicine, Oregon Health and Science University, Portland, Oregon
| | - Dowin Boatright
- Department of Emergency Medicine, Denver Health Medical Center, Denver, Colorado
| | - Cary Gross
- Robert Wood Johnson Foundation Clinical Scholars Program, Section of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Capp R, West DR, Doran K, Sauaia A, Wiler J, Coolman T, Ginde AA. Characteristics of Medicaid-Covered Emergency Department Visits Made by Nonelderly Adults: A National Study. J Emerg Med 2015; 49:984-9. [PMID: 26482830 DOI: 10.1016/j.jemermed.2015.07.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2015] [Revised: 07/06/2015] [Accepted: 07/25/2015] [Indexed: 11/18/2022]
Abstract
BACKGROUND The Affordable Care Act has added millions of new Medicaid enrollees to the health care system. These patients account for a large proportion of emergency department (ED) utilization. OBJECTIVE Our aim was to characterize this population and their ED use at a national level. METHODS We used the 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS) to describe demographics and clinical characteristics of nonelderly adults (≥18 years old and ≤64 years old) with Medicaid-covered ED visits. We defined frequent ED users as individuals who make ≥4 ED visits/year and business hours as 8 am to 5 pm. We used descriptive statistics to describe the epidemiology of Medicaid-covered ED visits. RESULTS NHAMCS included 21,800 ED visits by nonelderly adults in 2010, of which 5,659 (24.09%) were covered by Medicaid insurance. Most ED visits covered by Medicaid were made by patients who are young (25 and 44 years old) and female (67.95%; 95% confidence interval [CI] 66.00-69.89). A large proportion of the ED visits covered by Medicaid were revisits within 72 h (14.66%; 95% CI 9.13-20.19) and from frequent ED users (32.32%; 95% CI 24.29-40.35). Almost half of all ED visits covered by Medicaid occurred during business hours (45.44%; 95% CI 43.45-47.43). CONCLUSIONS The vast majority of Medicaid enrollees who used the ED were young females, with a large proportion of visits occurring during business hours. Almost one-third of all visits were from frequent ED users.
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Affiliation(s)
- Roberta Capp
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - David R West
- Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Kelly Doran
- Department of Emergency Medicine and the Department of Population Health, New York University School of Medicine and Bellevue Hospital Center, New York, New York
| | - Angela Sauaia
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado; Department of Family Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jennifer Wiler
- Department of Surgery, Denver Health Medical Center, Denver, Colorado; University of Colorado Schools of Public Health and Medicine, Aurora, Colorado
| | - Tyler Coolman
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Park A, Anderson A, Nguyen J, Saltzman D, Kastetter B, Winsauer L, Philips C, Capp R. 182 Assessing Economic and Health Care Access Social Determinants of Health in the Emergency Department. Ann Emerg Med 2015. [DOI: 10.1016/j.annemergmed.2015.07.214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Zhan J, Wiler J, Jones C, Schroeder A, Favaro C, McLean R, Harpin S, Capp R. 137 Frequent Emergency Department Users: Describing Care Coordination Services. Ann Emerg Med 2015. [DOI: 10.1016/j.annemergmed.2015.07.169] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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Anderson ME, Glasheen JJ, Anoff D, Pierce R, Capp R, Jones CD. Understanding predictors of prolonged hospitalizations among general medicine patients: A guide and preliminary analysis. J Hosp Med 2015; 10:623-6. [PMID: 26126812 DOI: 10.1002/jhm.2414] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2015] [Revised: 05/26/2015] [Accepted: 06/09/2015] [Indexed: 11/08/2022]
Abstract
Targeting patients with prolonged hospitalizations may represent an effective strategy for reducing average hospital length of stay (LOS). We sought to characterize predictors of prolonged hospitalizations among general medicine patients to guide future improvement efforts. We conducted a retrospective cohort study using administrative data of general medicine patients discharged from inpatient status from our academic medical center between 2012 and 2014. Multivariable logistic regression was performed to assess the association between sociodemographic and clinical variables with prolonged LOS, defined as >21 days. Of 18,363 discharges, 416 (2.3%) demonstrated prolonged LOS. Prolonged hospitalizations accounted for 18.6% of total inpatient days and contributed 0.8 days to an average LOS of 4.8 days during the study period. Prolonged hospitalizations were associated with younger age (odds ratio [OR]: 0.80 per 10-year increase in age, 95% confidence interval [CI]: 0.73-0.87) and Medicaid insurance (OR: 1.99, 95% CI: 1.29-3.05, REF = Medicare). Compared to patients without prolonged LOS, prolonged LOS patients were more likely to have methicillin-resistant Staphylococcus aureus septicemia (OR: 8.83, 95% CI: 1.72-45.36); require a palliative care consult (OR: 4.63, 95% CI: 2.86-7.49), ICU stay (OR: 6.66, 95% CI: 5.22-8.50), or surgery (OR: 5.04, 95% CI: 3.90-6.52); and be discharged to a post-acute-care facility (OR: 10.37, 95% CI: 6.92-15.56). Prolonged hospitalizations in a small proportion of patients were an important contributor to overall LOS and particularly affected Medicaid enrollees with complex hospital stays who were not discharged home. Further studies are needed to determine the reasons for discharge delays in this population.
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Affiliation(s)
- Mary E Anderson
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Jeffrey J Glasheen
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Debra Anoff
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Read Pierce
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Roberta Capp
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado
| | - Christine D Jones
- Hospital Medicine Section, Division of General Internal Medicine, Department of Medicine, University of Colorado School of Medicine, Aurora, Colorado
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Venkatesh AK, Dai Y, Ross JS, Schuur JD, Capp R, Krumholz HM. Variation in US hospital emergency department admission rates by clinical condition. Med Care 2015; 53:237-44. [PMID: 25397965 DOI: 10.1097/mlr.0000000000000261] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Variation in hospitalization rates have been described for decades, yet little is known about variation in emergency department (ED) admission rates across clinical conditions. We sought to describe variation in ED risk-standardized admission rates (RSAR) and the consistency between condition-specific ED admission rates within hospitals. METHODS Cross-sectional analysis of the 2009 National Emergency Department Sample, an all-payer administrative, claims dataset. We identify the 15 most frequently admitted conditions using Clinical Classification Software. To identify conditions with the highest ED RSAR variation, we compared both the ratio of the 75th percentile to the 25th percentile hospital and coefficient of variation between conditions. We calculate Spearman correlation coefficients to assess within-hospital correlation of condition-specific ED RSARs. RESULTS Of 21,885,845 adult ED visits, 4,470,105 (20%) resulted in admission. Among the 15 most frequently admitted conditions, the 5 with the highest magnitude of variation were: mood disorders (ratio of 75th:25th percentile, 6.97; coefficient of variation, 0.81), nonspecific chest pain (2.68; 0.66), skin and soft tissue infections (1.82; 0.51), urinary tract infections (1.58; 0.43), and chronic obstructive pulmonary disease (1.57; 0.33). For these 5 conditions, the within-hospital RSAR correlations between each pair of conditions were >0.4, except for mood disorders, which was poorly correlated with all other conditions (r<0.3). CONCLUSIONS There is significant condition-specific variation in ED admission rates across US hospitals. This variation appears to be consistent between conditions with high variation within hospitals.
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Affiliation(s)
- Arjun K Venkatesh
- *Robert Wood Johnson Clinical Scholars Program †Department of Emergency Medicine, Yale University School of Medicine ‡Center for Outcomes Research and Evaluation, Yale-New Haven Hospital §Department of Internal Medicine, Section of General Internal Medicine, Yale University School of Medicine ∥Department of Health Policy and Management, Yale School of Public Health, New Haven, CT ¶Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA #Department of Emergency Medicine, University of Colorado School of Medicine, Denver, CO **Department of Internal Medicine, Section of Cardiovascular Medicine, Yale University School of Medicine, New Haven, CT
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Holst J, Perman S, Capp R, Ginde A. 54 Increased Charges Without Increased Resuscitative Efforts Among Emergency Department Deaths at Teaching Hospitals and Trauma Centers. Ann Emerg Med 2014. [DOI: 10.1016/j.annemergmed.2014.07.079] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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Capp R, Rooks SP, Wiler JL, Zane RD, Ginde AA. National study of health insurance type and reasons for emergency department use. J Gen Intern Med 2014; 29:621-7. [PMID: 24366398 PMCID: PMC3965734 DOI: 10.1007/s11606-013-2734-4] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Revised: 10/18/2013] [Accepted: 12/02/2013] [Indexed: 11/28/2022]
Abstract
BACKGROUND The rates of emergency department (ED) utilization vary substantially by type of health insurance, but the association between health insurance type and patient-reported reasons for seeking ED care is unknown. OBJECTIVE We evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED. DESIGN, PATIENTS This was a cross-sectional analysis of the 2011 National Health Interview Survey. Adults whose last ED visit did not result in hospitalization (n = 4,606) were asked structured questions about reasons for seeking ED care. We classified responses as 1) perceived need for immediate evaluation (acuity issues), or 2) barriers to accessing outpatient services (access issues). MAIN MEASURES We analyzed survey-weighted data using multivariable logistic regression models to test the association between health insurance type and reasons for ED visits, while adjusting for sociodemographic characteristics. KEY RESULTS Overall, 65.0% (95% CI 63.0-66.9) of adults reported ≥ 1 acuity issue and 78.9% (95% CI 77.3-80.5) reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2% reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05; 95% CI 0.79-1.40) and those with Medicare (OR 0.98; 95% CI 0.66-1.47) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50; 95% CI 1.06-2.13) and Medicaid + Medicare (dual eligible) (OR 1.94; 95% CI 1.18-3.19) were more likely than those with private insurance to seek ED care for access issues. CONCLUSION Variability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.
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Affiliation(s)
- Roberta Capp
- Department of Emergency Medicine, University of Colorado School of Medicine, 12401 E. 17th Avenue, B-215, Aurora, CO, 80045, USA
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23
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Capp R, Ross JS, Fox JP, Wang Y, Desai MM, Venkatesh AK, Krumholz HM. Hospital variation in risk-standardized hospital admission rates from US EDs among adults. Am J Emerg Med 2014; 32:837-43. [PMID: 24881514 DOI: 10.1016/j.ajem.2014.03.033] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2013] [Revised: 03/21/2014] [Accepted: 03/21/2014] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Variation in hospital admission rates of patients presenting to the emergency department (ED) may represent an opportunity to improve practice. We seek to describe national variation in hospital admission rates from the ED and to determine the degree to which variation is not explained by patient characteristics or hospital factors. METHODS We conducted a cross-sectional analysis of a nationally representative sample of ED visits among adults within the 2010 National Hospital Ambulatory Care Survey ED data of hospitals with admission rates from the ED between 5% and 50%. We calculated risk-standardized hospital admission rates (RSARs) from the ED using contemporary hospital profiling methodology, accounting for patients' sociodemographic and clinical characteristics. RESULTS Among 19831 adult ED visits in 252 hospitals, there were 4148 hospital admissions from the ED. After accounting for patients' sociodemographic and clinical factors, the median RSAR from the ED was 16.9% (interquartile range, 15.0%-20.4%), and 8.1% of the variation in RSARs was attributable to an institution-specific effect. Even after accounting for hospital teaching status, ownership, urban/rural location, and geographical location, 7.0% of the variation in RSARs from the ED was still attributable to an institution-specific effect. CONCLUSIONS AND RELEVANCE There was variation in hospital admission rates from the ED in the United States, even after adjusting for patients' sociodemographic and clinical characteristics and accounting for hospital factors. Our findings suggest that suggesting that the likelihood of being admitted from the ED is not only dependent on clinical factors but also at which hospital the patient seeks care.
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Affiliation(s)
- Roberta Capp
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT; University of Colorado, Medical School, Department of Emergency Medicine, Aurora, CO.
| | - Joseph S Ross
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Section of General Internal Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT
| | - Justin P Fox
- Department of Surgery, Boonshoft School of Medicine, Wright State University, Dayton, OH
| | - Yongfei Wang
- Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT
| | - Mayur M Desai
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Surgery, Boonshoft School of Medicine, Wright State University, Dayton, OH; Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
| | - Arjun K Venkatesh
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Harlan M Krumholz
- Robert Wood Johnson Foundation Clinical Scholars Program, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Center for Outcomes Research and Evaluation, Yale-New Haven Hospital, New Haven, CT; Section of Cardiovascular Medicine, Department of Internal Medicine, Yale University School of Medicine, New Haven, CT; Department of Health Policy and Management, Yale School of Public Health, New Haven, CT
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Vinton DT, Capp R, Rooks SP, Abbott JT, Ginde AA. Frequent users of US emergency departments: characteristics and opportunities for intervention. Emerg Med J 2014; 31:526-532. [PMID: 24473411 DOI: 10.1136/emermed-2013-202407] [Citation(s) in RCA: 109] [Impact Index Per Article: 10.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2013] [Revised: 12/23/2013] [Accepted: 12/28/2013] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To compare the characteristics of US adults by frequency of emergency department (ED) utilisation, specifically the prevalence of chronic diseases and outpatient primary care and mental health utilisation. METHODS We analysed 157 818 adult participants of the 2004-2009 US National Health Interview Survey, an annual nationally representative sample. We defined ED utilisation during the past 12 months as non-users (0 ED visits), infrequent users (1-3 visits), frequent users (4-9 visits) and super-frequent users (≥10 visits). We compared demographic data, socioeconomic status, chronic diseases and access to care between these ED utilisation groups using multivariable logistic regression. RESULTS Overall, super-frequent use was reported by 0.4% of US adults, frequent use by 2% and infrequent ED use by 19%. Patients reporting ≥4 ED visits were more likely to have Medicaid insurance (OR 1.57; 95% CI 1.34 to 1.85 vs private); fair or poor self-reported health (OR 2.98; 95% CI 2.57 to 3.46 vs excellent-very good); and chronic diseases such as coronary artery disease (OR 1.61; 95% CI 1.40 to 1.86), stroke (OR 1.58; 95% CI 1.36 to 1.83) or asthma (OR 1.64; 95% CI 1.46 to 1.85). While patients reporting the ED as their usual source of sick care were more likely to have ≥4 ED visits (OR 7.09; 95% CI 5.61 to 8.95 vs outpatient clinic as source), ≥10 outpatient visits in the past 12 months was also associated with frequent ED use (OR 11.4; 95% CI 9.09 to 14.2 vs no outpatient visits). CONCLUSIONS Frequent ED users had a large burden of chronic diseases that also required high outpatient resources. Interventions designed to divert frequent ED users should focus on chronic disease management and access to outpatient services, particularly for Medicaid beneficiaries and other high risk subpopulations.
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Affiliation(s)
- Deborah T Vinton
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Roberta Capp
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Sean P Rooks
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Jean T Abbott
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
| | - Adit A Ginde
- Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, Colorado, USA
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Capp R, Rosenthal MS, Desai MM, Kelley L, Borgstrom C, Cobbs-Lomax DL, Simonette P, Spatz ES. Characteristics of Medicaid enrollees with frequent ED use. Am J Emerg Med 2013; 31:1333-7. [PMID: 23850143 DOI: 10.1016/j.ajem.2013.05.050] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2013] [Revised: 05/22/2013] [Accepted: 05/29/2013] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Medicaid enrollees are disproportionately represented among patients with frequent Emergency Department (ED) visits, yet prior studies investigating frequent ED users have focused on patients with all insurance types. METHODS This was a single center, retrospective study of Medicaid-insured frequent ED users (defined as ≥4 ED visits/year not resulting in hospital admission) to assess patients' sociodemographic and clinical characteristics and evaluate differences in these characteristics by frequency of use (4-6, 7-17, and ≥18 ED visits). RESULTS Twelve percent (n = 1619) of Medicaid enrollees who visited the ED during the 1-year study period were frequent ED users, accounting for 38% of all ED visits (n = 10,337). Most frequent ED users (n = 1165, 72%) had 4-6 visits; 416 (26%) had 7-17 visits, and 38 (2%) had ≥18 visits. Overall, 67% had a primary care provider and 56% had at least one chronic medical condition. The most common ED diagnosis among patients with 4-6 visits was abdominal pain (7%); among patients with 7-17 and ≥18 ED visits, the most common diagnosis was alcohol-related disorders (11% and 36%, respectively). Compared with those who had 4-6 visits, patients with ≥18 visits were more likely to be homeless (7% vs 42%, P < .05) and suffer from alcohol abuse (15% vs 42%, P < .05). CONCLUSION One out of 8 Medicaid enrollees who visited the ED had ≥4 visits in a year. Efforts to reduce frequent ED use should focus on reducing barriers to accessing primary care. More tailored interventions are needed to meet the complex needs of adults with ≥18 visits per year.
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Affiliation(s)
- Roberta Capp
- Robert Wood Johnson Foundation Clinical Scholars Program, Yale School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
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Soremekun OA, Capp R, Biddinger PD, White BA, Chang Y, Carignan SB, Brown DFM. Impact of physician screening in the emergency department on patient flow. J Emerg Med 2012; 43:509-15. [PMID: 22445677 DOI: 10.1016/j.jemermed.2012.01.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2011] [Revised: 10/25/2011] [Accepted: 01/16/2012] [Indexed: 11/15/2022]
Abstract
BACKGROUND Physician triage is one of many front-end interventions being implemented to improve emergency department (ED) efficiency. STUDY OBJECTIVE We aim to determine the impact of this intervention on some key components of ED patient flow, including time to physician evaluation, treatment order entry, diagnostic order entry, and disposition time for admitted patients. METHODS We conducted a 2-year before-after analysis of a physician triage system at an urban tertiary academic center with 90,000 annual visits. The goal of the physician in triage was to arrange safe disposition of straightforward patients as well as to initiate work-ups. All medium-acuity patients arriving during the hours of the intervention were impacted and thus included in the analysis. Our primary outcome was the time to disposition decision. In addition to before-after analysis, comparison was made with high-acuity patients, a group not impacted by this intervention. Patient flow data were extracted from the ED information system. Outcomes were summarized with medians and interquartiles. Multivariable regression analysis was performed to investigate the intervention effect controlling for potential confounding variables. RESULTS The median time to disposition decision decreased by 6min, and the time to physician evaluation, analgesia, antiemetic, antibiotic, and radiology order decreased by 16, 70, 66, 36, and 16min, respectively. These findings were all statistically significant. Similar results were observed from the multivariable regression models after controlling for potential confounding factors. CONCLUSIONS Physician triage led to earlier evaluation, physician orders, and a decrease in the time to disposition decision.
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Affiliation(s)
- Olanrewaju A Soremekun
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA
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Capp R, Soremekun OA, Biddinger PD, White BA, Sweeney LM, Chang Y, Brown DFM. Impact of physician-assisted triage on timing of antibiotic delivery in patients admitted to the hospital with community-acquired pneumonia (CAP). J Emerg Med 2012; 43:502-8. [PMID: 22244295 DOI: 10.1016/j.jemermed.2011.08.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2011] [Revised: 07/26/2011] [Accepted: 08/27/2011] [Indexed: 11/28/2022]
Abstract
BACKGROUND Time to antibiotic delivery in patients with diagnosis of pneumonia is a publicly reported quality measure. OBJECTIVE We aim to describe the impact of emergency department (ED) physician-assisted triage (PAT) on The Joint Commission (TJC) and Centers for Medicare and Medicaid Services (CMS) pneumonia core quality measures of timing to antibiotic delivery. METHODS Retrospective case series studies of patients admitted to the hospital through the ED with diagnosis of community-acquired pneumonia were identified over a period of 48 months. Patients were included in the study if they met TJC/CMS PN-5 (antibiotic timing) criteria. We compared antibiotic delivery timing before and after implementation of PAT in moderate-acuity patients using Wilcoxon rank sum tests. A linear regression analysis was done to account for age, sex, ED volume, and acuity level. RESULTS A total of 659 patients were identified: 497 patients and 162 patients enrolled pre- and post-implementation of a PAT, respectively. The median antibiotic delivery times for moderate-acuity patients during open hours of operation of PAT were 180min (pre) and 195min (post), p=0.027; this was unchanged when ED volume, age, sex, and acuity level were accounted for. A total of 43 patients (9%) and 13 patients (8%) failed to receive antibiotics within 6h of ED presentation before and after implementation of PAT, respectively. CONCLUSION In this study, implementation of PAT did not result in overall decrease in antibiotic delivery time in patients admitted to the hospital with CAP. We postulate several explanations for this delay in antibiotic delivery time.
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Affiliation(s)
- Roberta Capp
- Harvard Affiliated Emergency Medicine Residency, Brigham & Women's Hospital and Massachusetts General Hospital, Boston, MA 02115, USA
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Capp R, Chang Y, Brown DF. Accuracy of Microscopic Urine Analysis and Chest Radiography in Patients with Severe Sepsis and Septic Shock. J Emerg Med 2012; 42:52-7. [DOI: 10.1016/j.jemermed.2010.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2010] [Revised: 09/08/2010] [Accepted: 10/31/2010] [Indexed: 10/18/2022]
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Horton C, Capp R, Odewole M, Marill K. 337 Are Patients Admitted to the Hospital From the Emergency Department With Sepsis Due to Health Care-Associated Infections More Likely to Have Severe Sepsis or Septic Shock in the Initial 4 Hours of Emergency Department Arrival? Ann Emerg Med 2011. [DOI: 10.1016/j.annemergmed.2011.06.368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
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Capp R, Brown D. 330: Antibiotic Prescription by Emergency and ICU Physicians in Patients Admitted to the Intensive Care Unit With the Diagnosis of Septic Shock. Ann Emerg Med 2009. [DOI: 10.1016/j.annemergmed.2009.06.361] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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Liteplo AS, Marill KA, Villen T, Miller RM, Murray AF, Croft PE, Capp R, Noble VE. Emergency thoracic ultrasound in the differentiation of the etiology of shortness of breath (ETUDES): sonographic B-lines and N-terminal pro-brain-type natriuretic peptide in diagnosing congestive heart failure. Acad Emerg Med 2009; 16:201-10. [PMID: 19183402 DOI: 10.1111/j.1553-2712.2008.00347.x] [Citation(s) in RCA: 202] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVES Sonographic thoracic B-lines and N-terminal pro-brain-type natriuretic peptide (NT-ProBNP) have been shown to help differentiate between congestive heart failure (CHF) and chronic obstructive pulmonary disease (COPD). The authors hypothesized that ultrasound (US) could be used to predict CHF and that it would provide additional predictive information when combined with NT-ProBNP. They also sought to determine optimal two- and eight-zone scanning protocols when different thresholds for a positive scan were used. METHODS This was a prospective, observational study of a convenience sample of adult patients presenting to the emergency department (ED) with shortness of breath. Each patient had an eight-zone thoracic US performed by one of five sonographers, and serum NT-ProBNP levels were measured. Chart review by two physicians blinded to the US results served as the criterion standard. The operating characteristics of two- and eight-zone thoracic US alone, compared to, and combined with NT-ProBNP test results for predicting CHF were calculated using both dichotomous and interval likelihood ratios (LRs). RESULTS One-hundred patients were enrolled. Six were excluded because of incomplete data. Results of 94 patients were analyzed. A positive eight-zone US, defined as at least two positive zones on each side, had a positive likelihood ratio (LR+) of 3.88 (99% confidence interval [CI] = 1.55 to 9.73) and a negative likelihood ratio (LR-) of 0.5 (95% CI = 0.30 to 0.82), while the NT-ProBNP demonstrated a LR+ of 2.3 (95% CI = 1.41 to 3.76) and LR- of 0.24 (95% CI = 0.09 to 0.66). Using interval LRs for the eight-zone US test alone, the LR for a totally positive test (all eight zones positive) was infinite and for a totally negative test (no zones positive) was 0.22 (95% CI = 0.06 to 0.80). For two-zone US, interval LRs were 4.73 (95% CI = 2.10 to 10.63) when inferior lateral zones were positive bilaterally and 0.3 (95% CI = 0.13 to 0.71) when these were negative. These changed to 8.04 (95% CI = 1.76 to 37.33) and 0.11 (95% CI = 0.02 to 0.69), respectively, when congruent with NT-ProBNP. CONCLUSIONS Bedside thoracic US for B-lines can be a useful test for diagnosing CHF. Predictive accuracy is greatly improved when studies are totally positive or totally negative. A two-zone protocol performs similarly to an eight-zone protocol. Thoracic US can be used alone or can provide additional predictive power to NT-ProBNP in the immediate evaluation of dyspneic patients presenting to the ED.
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Affiliation(s)
- Andrew S Liteplo
- Department of Emergency Medicine, Division of Emergency Ultrasound, Massachusetts General Hospital, Boston, MA, USA.
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Noble VE, Murray AF, Capp R, Sylvia-Reardon MH, Steele DJR, Liteplo A. Ultrasound assessment for extravascular lung water in patients undergoing hemodialysis. Time course for resolution. Chest 2009; 135:1433-1439. [PMID: 19188552 DOI: 10.1378/chest.08-1811] [Citation(s) in RCA: 216] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Sonographic B-lines, also known as lung comets, have been shown to correlate with the presence of extravascular lung water (EVLW). Absent in normal lungs, these sonographic findings become prominent as interstitia and alveoli fill with fluid. Characterization of the dynamics of B-lines, specifically their rate of disappearance as volume is removed, has not been previously described. In this study, we describe the dynamics of B-line resolution in patients undergoing hemodialysis. METHODS Patients undergoing hemodialysis underwent three chest ultrasound examinations: before, at the midpoint, and after dialysis. We followed a previously described chest ultrasound protocol that counts the number of B-lines visualized in 28 lung zones. Baseline demographics, assessment of ejection fraction, time elapsed, net volume of fluid removed, and subjective degree of shortness of breath were recorded for each patient. RESULTS Forty of 45 patients completed full dialysis runs and had all three lung scans performed; 6 of 40 patients had zero or one B-line predialysis, and none of these 6 patients gained B-lines during dialysis. Thirty-four of 40 patients had statistically significant reductions in the number of B-lines from predialysis to the midpoint scan and from predialysis to postdialysis with a p value < 0.001. There was no association between subjective dyspnea scores and number of B-lines removed. CONCLUSIONS B-line resolution appears to occur real-time as fluid is removed from the body, and this change was statistically significant. These data support thoracic ultrasound as a useful method for evaluating real-time changes in EVLW and in assessing a patient's physiologic response to the removal of fluid. TRIAL REGISTRATION Massachusetts General Hospital trial registration protocol No. 2007P 002226.
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Affiliation(s)
- Vicki E Noble
- Department of Emergency Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA.
| | - Alice F Murray
- Department of Emergency Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Roberta Capp
- Department of Emergency Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Mary H Sylvia-Reardon
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - David J R Steele
- Department of Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
| | - Andrew Liteplo
- Department of Emergency Medicine, Division of Nephrology, Massachusetts General Hospital, Boston, MA
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Noble VE, Lamhaut L, Capp R, Bosson N, Liteplo A, Marx JS, Carli P. Evaluation of a thoracic ultrasound training module for the detection of pneumothorax and pulmonary edema by prehospital physician care providers. BMC Med Educ 2009; 9:3. [PMID: 19138397 PMCID: PMC2631015 DOI: 10.1186/1472-6920-9-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/21/2008] [Accepted: 01/12/2009] [Indexed: 05/15/2023]
Abstract
BACKGROUND While ultrasound (US) has continued to expedite diagnosis and therapy for critical care physicians inside the hospital system, the technology has been slow to diffuse into the pre-hospital system. Given the diagnostic benefits of thoracic ultrasound (TUS), we sought to evaluate image recognition skills for two important TUS applications; the identification of B-lines (used in the US diagnosis of pulmonary edema) and the identification of lung sliding and comet tails (used in the US diagnosis of pneumothorax). In particular we evaluated the impact of a focused training module in a pre-hospital system that utilizes physicians as pre-hospital providers. METHODS 27 Paris Service D'Aide Médicale Urgente (SAMU) physicians at the Hôpital Necker with varying levels of US experience were given two twenty-five image recognition pre-tests; the first test had examples of both normal and pneumothorax lung US and the second had examples of both normal and pulmonary edema lung US. All 27 physicians then underwent the same didactic training modules. A post-test was administered upon completing the training module and results were recorded. RESULTS Pre and post-test scores were compared for both the pneumothorax and the pulmonary edema modules. For the pneumothorax module, mean test scores increased from 10.3 +/- 4.1 before the training to 20.1 +/- 3.5 after (p < 0.0001), out of 25 possible points. The standard deviation decreased as well, indicating a collective improvement. For the pulmonary edema module, mean test scores increased from 14.1 +/- 5.2 before the training to 20.9 +/- 2.4 after (p < 0.0001), out of 25 possible points. The standard deviation decreased again by more than half, indicating a collective improvement. CONCLUSION This brief training module resulted in significant improvement of image recognition skills for physicians both with and without previous ultrasound experience. Given that rapid diagnosis of these conditions in the pre-hospital system can change therapy, especially in systems where physicians can integrate this information into treatment decisions, the further diffusion of this technology would seem to be beneficial and deserves further study.
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Affiliation(s)
- Vicki E Noble
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, Massachusetts, USA
| | - Lionel Lamhaut
- SAMU de Paris, Hôpital Necker – Enfants Malades, 149 Rue de Sèvres, 75743 Paris Cedex 15, France
| | - Roberta Capp
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, Massachusetts, USA
| | - Nichole Bosson
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, Massachusetts, USA
| | - Andrew Liteplo
- Department of Emergency Medicine, Massachusetts General Hospital, 55 Fruit St., Boston, Massachusetts, USA
| | - Jean-Sebastian Marx
- SAMU de Paris, Hôpital Necker – Enfants Malades, 149 Rue de Sèvres, 75743 Paris Cedex 15, France
| | - Pierre Carli
- SAMU de Paris, Hôpital Necker – Enfants Malades, 149 Rue de Sèvres, 75743 Paris Cedex 15, France
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Capp R, Murray A, Noble V, Steele D, Liteplo A. 62: The Dynamics of B-lines: A Useful Tool in the Evaluation of Pulmonary Fluid Status as Fluid Shifts Occur in the Body. Ann Emerg Med 2008. [DOI: 10.1016/j.annemergmed.2008.06.128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Capp R, Bosson N, Noble V, Lamhaut L, Marx J, Liteplo A, Carli P. 341: Can Physicians Who Work in the Out-of-Hospital System Accurately Interpret Chest Ultrasound Images for Pneumothorax and Pulmonary Edema Following Focused Training? Ann Emerg Med 2008. [DOI: 10.1016/j.annemergmed.2008.06.367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Otegui MS, Capp R, Staehelin LA. Developing seeds of Arabidopsis store different minerals in two types of vacuoles and in the endoplasmic reticulum. Plant Cell 2002; 14:1311-27. [PMID: 12084829 PMCID: PMC150782 DOI: 10.1105/tpc.010486] [Citation(s) in RCA: 83] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/06/2001] [Accepted: 03/01/2002] [Indexed: 05/18/2023]
Abstract
Mineral-accumulating compartments in developing seeds of Arabidopsis were studied using high-pressure-frozen/freeze-substituted samples. Developing seeds store minerals in three locations: in the protein storage vacuoles of the embryo, and transiently in the endoplasmic reticulum (ER) and vacuolar compartments of the chalazal endosperm. Energy dispersive x-ray spectroscopy and enzyme treatments suggest that the minerals are stored as phytic acid (myo-inositol-1,2,3,4,5,6-hexakisphosphate) salts in all three compartments, although they differ in cation composition. Whereas embryo globoids contain Mg, K, and Ca as cations, the chalazal ER deposits show high levels of Mn, and the chalazal vacuolar deposits show high levels of Zn. The appearance of the first Zn-phytate crystals coincides with the formation of network-like extensions of the chalazal vacuoles. The core of these networks consists of a branched network of tubular ER membranes, which are separated from the delineating tonoplast membranes by a layer of cytosolic material. Degradation of the networks starts with the loss of the cytosol and is followed by the retraction of the ER, generating a network of collapsed tonoplast membranes that are resorbed. Studies of fertilized fis2 seeds, which hyperaccumulate Zn-phytate crystals in the chalazal vacuolar compartments, suggest that only the intact network is active in mineral sequestration. Mineral determination analysis and structural observations showed that Zn and Mn are mobilized from the endosperm to the embryo at different developmental stages. Thus, Zn appears to be removed from the endosperm at the late globular stage, and Mn stores appear to be removed at the late bent-cotyledon stage of embryo development. The disappearance of the Mn-phytate from the endosperm coincides with the accumulation of two major Mn binding proteins in the embryo, the 33-kD protein from the oxygen-evolving complex of photosystem II and the Mn superoxide dismutase. The possible functions of transient heavy metal storage in the chalazal endosperm are discussed. A model showing how phytic acid, a potentially cytotoxic molecule, is transported from its site of synthesis, the ER, to the different mineral storage sites is presented.
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Affiliation(s)
- Marisa S Otegui
- Department of Molecular, Cellular, and Developmental Biology, University of Colorado, Boulder, CO 80309-0347, USA.
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Norris DG, Bruce DA, Byrd RL, Schut L, Littman P, Bilaniuk LT, Zimmerman RA, Capp R. Improved relapse-free survival in medulloblastoma utilizing modern techniques. Neurosurgery 1981; 9:661-4. [PMID: 7322331 DOI: 10.1227/00006123-198112000-00008] [Citation(s) in RCA: 47] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023] Open
Abstract
Between 1969 and 1979, 22 patients with medulloblastoma were treated by the same surgical group and radiation therapy group. The patients were divided into two groups because of the clinical availability in December 1974 of the computed tomographic (CT) scanner and of the operating microscope used in the initial surgical procedure. There were 11 patients in each group. The percentage of patients with a relapse-free survival in the group treated between 1969 and 1974 (Group 1) was 38% at 4 years. The survival in the 11 patients treated between 1974 and 1979 (Group 2) was 84% at 4 years. This improvement is statistically significant (P less than or equal to 0.001). All patients received the same dose of radiation. Efforts to minimize the tumor burden by total surgical resection did not increase postoperative morbidity or mortality. These results are discussed, along with the relative impact of the CT scan, total resection at operation, and increased focus for radiation therapy on the improved outcome.
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