Family and Neighborhood Resilience Are Associated with Children's Healthcare Utilization

OBJECTIVE

To evaluate the association of external factors of resilience, neighborhood, and family resilience with healthcare use.

STUDY DESIGN

A cross-sectional, observational study was conducted using data from the 2016-2017 National Survey of Children's Health. Children aged 4-17 years were included. Multiple logistic regression was used to determine aOR and 95% CIs for association between levels of family resilience, neighborhood resilience and outcome measures: presence of medical home, and ≥2 emergency department (ED) visits per year while adjusting for adverse childhood experiences (ACEs), chronic conditions, and sociodemographic factors.

RESULTS

We included 58 336 children aged 4-17 years, representing a population of 57 688 434. Overall, 8.0%, 13.1%, and 78.9% lived in families with low, moderate, and high resilience, respectively; 56.1% identified their neighborhood as resilient. Of these children, 47.5% had a medical home and 4.2% reported ≥2 ED visits in the past year. A child with high family resilience had 60% increased odds of having a medical home (OR, 1.60; 95% CI, 1.37-1.87), and a child with moderate family resilience or resilient neighborhood had a 30% increase (OR, 1.32 [95% CI, 1.10-1.59] and OR, 1.31 [95% CI, 1.20-1.43], respectively). There was no association between resilience factors and ED use, although children with increased ACEs had increased ED use.

CONCLUSIONS

Children from resilient families and neighborhoods have an increased odds of receiving care in a medical home after adjusting for the effects of ACEs, chronic conditions, and sociodemographic factors, but no association was seen with ED use.

Emergency department use and geospatial variation in social determinants of health: a pilot study from South Carolina

BACKGROUND

Health systems are increasingly addressing patients' social determinants of health (SDoH)-related needs and investigating their effects on health resource use. SDoH needs vary geographically; however, little is known about how this geographic variation in SDoH needs impacts the relationship between SDoH needs and health resource use.

METHODS

This study uses data from a SDoH survey administered to a pilot patient population in a single health system and the electronic medical records of the surveyed patients to determine if the impact of SDoH needs on emergency department use varies geospatially at the US Census block group level. A Bayesian zero-inflated negative binomial model was used to determine if emergency department visits after SDoH screening varied across block groups. Additionally, the relationships between the number of emergency department visits and the response to each SDoH screening question was assessed using Bayesian negative binomial hurdle models with spatially varying coefficients following a conditional autoregressive (CAR) model at the census block group level.

RESULTS

Statistically important differences in emergency department visits after screening were found between block groups. Statistically important spatial variation was found in the association between patient responses to the questions concerning unhealthy home environments (e.g. mold, bugs/rodents, not enough air conditioning/heat) or domestic violence/abuse and the mean number of emergency department visits after the screen.

CONCLUSIONS

Notable spatial variation was found in the relationships between screening positive for unhealthy home environments or domestic violence/abuse and emergency department use. Despite the limitation of a relatively small sample size, sensitivity analyses suggest spatially varying relationships between other SDoH-related needs and emergency department use.

Emergency Department Use, Hospitalization, and Their Sociodemographic Determinants among Patients with Substance-Related Disorders: A Worldwide Systematic Review and Meta-Analysis

Background: Identifying the determinants of emergency department (ED) use and hospitalization among patients with substance-related disorders (SRD) can help inform healthcare services and case management regarding their unmet health needs and strategies to reduce their acute care. Objectives: The present study aimed to identify sociodemographic characteristics, type of used drug, and risky behaviors associated with ED use and hospitalization among patients with SRD. Methods: Studies in English published from January 1st, 1995 to April 30th, 2022 were searched from PubMed, Scopus, Cochrane Library, and Web of Science to identify primary studies on ED use and hospitalization among patients with SRD. Results: Of the 17,348 outputs found, a total of 39 studies met the eligibility criteria. Higher ED use and hospitalization among patients with SRD were associated with a history of homelessness (ED use: OR = 1.93, 95%CI = 1.32-2.83; hospitalization: OR = 1.53, 95%CI = 1.36-1.73) or of injection drug use (ED use: OR = 1.34, 95%CI = 1.13-1.59; hospitalization: OR = 1.42, 95%CI = 1.20-1.69). Being female (OR = 1.24, 95%CI = 1.14-1.35), using methamphetamine (OR = 1.99, 95%CI = 1.24-3.21) and tobacco (OR = 1.25, 95%CI = 1.11-1.42), having HIV (OR = 1.70, 95%CI = 1.47-1.96), a history of incarceration (OR = 1.90, 95%CI = 1.27-2.85) and injury (OR = 2.62, 95%CI = 1.08-6.35) increased ED use only, while having age over 30  years (OR = 1.40, 95%CI = 1.08-1.81) and using cocaine (OR = 1.60, 95%CI = 1.32-1.95) increased hospitalization only among patients with SRD. Conclusions: The finding outline the necessity of developing outreach program and primary care referral for patients with SRD. Establishing a harm reduction program, incorporating needle/syringe exchange programs, and safe injection training with the aim of declining ED use and hospitalization, is likely be another beneficial strategy for patients with SRD.

Frequencies of emergency department use and hospitalization comparing patients with different types of substance or polysubstance-related disorders

Background

This study measured emergency department (ED) use and hospitalization for medical reasons among patients with substance-related disorders (SRD), comparing four subgroups: cannabis-related disorders, drug-related disorders other than cannabis, alcohol-related disorders and polysubstance-related disorders, controlling for various clinical, sociodemographic and service use variables.

Methods

Clinical administrative data for a cohort of 22,484 patients registered in Quebec (Canada) addiction treatment centers in 2012-13 were extracted for the years 2009-10 to 2015-16. Using negative binomial models, risks of frequent ED use and hospitalization were calculated for a 12-month period (2015-16).

Results

Patients with polysubstance-related disorders used ED more frequently than other groups with SRD. They were hospitalized more frequently than patients with cannabis or other drug-related disorders, but less frequently than those with alcohol-related disorders. Patients with alcohol-related disorders used ED more frequently than those with cannabis-related disorders and underwent more hospitalizations than both patients with cannabis-related and other drug-related disorders. Co-occurring SRD-mental disorders or SRD-chronic physical illnesses, more years with SRD, being women, living in rural territories, more frequent consultations with usual general practitioner or outpatient psychiatrist, and receiving more interventions in community healthcare centers increased frequency of ED use and hospitalization, whereas both adverse outcomes decreased with high continuity of physician care. Behavioral addiction, age less than 45 years, living in more materially deprived areas, and receiving 1-3 interventions in addiction treatment centers increased risk of frequent ED use, whereas living in semi-urban areas decreased ED use. Patients 25-44 years old receiving 4+ interventions in addiction treatment centers experienced less frequent hospitalization.

Conclusion

Findings showed higher risk of ED use among patients with polysubstance-related disorders, and higher hospitalization risk among patients with alcohol-related disorders, compared with patients affected by cannabis and other drug-related disorders. However, other variables contributed substantially more to the frequency of ED use and hospitalization, particularly clinical variables regarding complexity and severity of health conditions, followed by service use variables. Another important finding was that high continuity of physician care helped decrease the use of acute care services. Strategies like integrated care and outreach interventions may enhance SRD services.

Supplementary Information

The online version contains supplementary material available at 10.1186/s13011-021-00421-7.

Emergency department visits in African Americans with mild cognitive impairment and diabetes

AIMS

Dementia, diabetes, and African American race are three factors that are independently associated with emergency department (ED) use. This study tested the hypothesis that ED use is associated with worse cognitive function in African Americans with Mild Cognitive Impairment (MCI) and poorly controlled diabetes.

METHODS

This study examined differences in ED use among African Americans with MCI and diabetes in a secondary data analysis of baseline data from a one-year randomized controlled trial (N = 101).

RESULTS

Over one year, 49/92 participants (53.3%) had at least one ED visit. At baseline, participants who had an incident ED visit had significantly fewer years of education; lower scores on neuropsychological tests assessing working memory, psychomotor speed, and complex scanning; higher diabetes-related interpersonal distress scores; lower adherence to a diabetes medication; and higher hemoglobin A1c levels compared to participants with no ED visits (p ≤ 0.05 for all comparisons).

CONCLUSIONS

This study identified multiple risk factors for ED visits in older African Americans with MCI and diabetes. Targeted interventions may be necessary to reduce the need for ED care in high risk populations.

Association of Follow-Up After an Emergency Department Visit for Mental Illness with Utilization Based Outcomes

Follow-up within 30 days of an emergency department (ED) visit for mental illness is a new and widely-used quality measure. However, no empirical evidence validates associations between follow-up and subsequent utilization based outcomes. Using Massachusetts all payer claims data, we identified insured individuals with an ED visit for mental illness. Multivariate regression analysis estimated associations between follow-up within 30 days after an ED visit for mental illness with costs, hospitalizations, and additional ED visits in 180 days following the index visit. 63,814 index ED visits were included (56.5% female, mean [SD] age 38.0 [12.1] years, 48% Medicaid covered). 31% of index ED principal diagnoses were for major depressive disorder, 3% schizophrenia, 5% bipolar disorder, 34% anxiety disorder, 0.6% post-traumatic stress disorder, 8% other psychoses, and 19% other mental illness diagnoses. Only 33% of patients had a follow-up visit for mental illness within 30 days. Adjusted regression analyses show timely follow-up is associated with increased costs in the 180 days after (average marginal effect = $1622; 95% confidence interval [CI] 1459, 1786), an increased probability of inpatient hospitalization (2.7 percentage points; 95% CI 0.021, 0.032), and a small reduction in the probability of at least one additional ED visit (- 1.7 percentage points; 95% CI - 0.026 to 0.009). Overall follow-up rates are low; follow-up within 30 days of an ED visit for mental illness is associated with increased costs and increased probability of hospitalization in the follow-up period. It is not known whether increased rates of utilization improve patient outcomes, potentially by receiving appropriate more intensive care.

Effect of socio-demographic and health factors on the association between multimorbidity and acute care service use: population-based survey linked to health administrative data

BACKGROUND

This study explores how socio-demographic and health factors shape the relationship between multimorbidity and one-year acute care service use (i.e., hospital, emergency department visits) in older adults in Ontario, Canada.

METHODS

We linked multiple cycles (2005-2006, 2007-2008, 2009-2010, 2011-2012) of the Canadian Community Health Survey (CCHS) to health administrative data to create a cohort of adults aged 65 and older. Administrative data were used to estimate one-year service use and to identify 12 chronic conditions used to measure multimorbidity. We examined the relationship between multimorbidity and service use stratified by a range of socio-demographic and health variables available from the CCHS. Logistic and Poisson regressions were used to explore the association between multimorbidity and service use and the role of socio-demographic factors in this relationship.

RESULTS

Of the 28,361 members of the study sample, 60% were between the ages of 65 and 74 years, 57% were female, 72% were non-immigrant, and over 75% lived in an urban area. Emergency department visits and hospitalizations consistently increased with the level of multimorbidity. This study did not find strong evidence of moderator or interaction effects across a range of socio-demographic factors. Stratified analyses revealed further patterns, with many being similar for both services - e.g., the odds ratios were higher at all levels of multimorbidity for men, older age groups, and those with lower household income. Rurality and immigrant status influenced emergency department use (higher in rural residents and non-immigrants) but not hospitalizations. Multimorbidity and the range of socio-demographic variables remained significant predictors of service use in the regressions.

CONCLUSIONS

Strong evidence links multimorbidity with increased acute care service use. This study showed that a range of factors did not modify this relationship. Nevertheless, the factors were independently associated with acute care service use, pointing to modifiable risk factors that can be the focus of resource allocation and intervention design to reduce service use in those with multimorbidity. The study's results suggest that optimizing acute care service use in older adults requires attention to both multimorbidity and social determinants, with programs that are multifactorial and integrated across the health and social service sectors.

Implementation of three innovative interventions in a psychiatric emergency department aimed at improving service use: a mixed-method study

Background

Emergency department (ED) use is often viewed as an indicator of health system quality. ED use for mental health (MH) reasons is increasing and costly for health systems, patients, and their families. Patients with mental disorders (MD) including substance use disorders (SUD) and suicidal behaviors are high ED users. Improving ED services for these patients and their families, and developing alternatives to ED use are thus key issues. This study aimed to: (1) describe the implementation of three innovative interventions provided by a brief intervention team, crisis center team, and family-peer support team in a Quebec psychiatric ED, including the identification of implementation barriers, and (2) evaluate the impacts of these ED innovations on MH service use and response to needs.

Method

Using mixed methods with data triangulation, the implementation and impact of the three above-named ED interventions were studied. Quantitative data were collected from 101 participants (81 patients, 20 family members) using a user questionnaire and patient medical records. Qualitative data were gathered from focus groups (n = 3) with key intervention staff members (n = 14). The user questionnaire also included open-ended questions. Descriptive, comparative and content analyses were produced.

Results

Key implementation issues were identified in relation to system, organizational and patient profiles, similar to results identified in most studies in the ED implementation literature aimed at improving responsiveness to patients with MD. Results were encouraging, as the innovations had a significant impact for improved patient MH service use and adequacy of care. Services also seemed adapted to patient profiles. Family members were grateful for the help received in the ED.

Conclusions

Before implementing innovations, managers need to recognize the basic issues common to all new healthcare interventions: the need for staff training and strong involvement, particularly among physicians, development of collaborative tools especially in cases of potential cultural clash between staff and organizations, and continuous quality assessment. Future research needs to confirm the pertinence of these interventions, especially use of family-peer support teams in ED, as a highly innovative intervention. Broader ED strategies could also be deployed to improve MH services and decrease ED use for MH reasons.

A comprehensive assessment for community-based, person-centered care for older adults

Background

Many health and social needs can be assessed and met in community settings, where lower-cost, person-centered, preventative and proactive services predominate. This study reports on the development and implementation of a person-centered care model integrating dental, social, and health services for low-income older adults at a community dental clinic co-located within a senior wellness center.

Methods

A digital comprehensive geriatric assessment (CGA) and referral system linking medical, dental, and psychosocial needs by real-time CGA-derived metrics for 996 older adults (age ≥ 60) was implemented in 2016–2018 as part of a continuous quality improvement project. This study aims to describe: 1) the development and content of a new CGA; 2) CGA implementation, workflows, triage, referrals; 3) correlations between CGA domains, and adjusted regression models, assessing associations with self-reported recent hospitalizations, emergency department (ED) visits, and clinically-assessed dental urgency.

Results

The multidisciplinary team from the senior wellness and dental centers planned and implemented a CGA that included standard medical history along with validated instruments for functional status, mental health and social determinants, and added oral health. Care navigators employed the CGA with 996 older adults, and made 1139 referrals (dental = 797, care coordination = 163, social work = 90, mental health = 32). CGA dimensions correlated between oral health, medical status, depressive symptoms, isolation, and reduced quality of life (QoL). Pain, medical symptoms, isolation and depressive symptoms were associated with poorer self-reported health, while general health was most strongly correlated with lower depressive symptoms, and higher functional status and QoL. Isolation was the strongest correlate of lower QoL.

Adjusted odds ratios identified social and medical factors associated with recent hospitalization and ED visits. General and oral health were associated with dental urgency. Dental urgency was most strongly associated with general health (AOR = 1.78,95%CI [1.31, 2.43]), dental symptoms (AOR = 2.39,95%CI [1.78, 3.20]), dental pain (AOR = 2.06,95%CI [1.55–2.74]), and difficulty chewing (AOR = 2.80, 95%CI [2.09–3.76]). Dental symptoms were associated with recent ED visits (AOR = 1.61, 95%CI [1.12–2.30]) or hospitalizations (AOR = 1.47, 95%CI [1.04–2.10]).

Conclusion

Community-based inter-professional care is feasible with CGAs that include medical, dental, and social factors. A person-centered care model requires coordination supported by new workflows. Real-time metrics-based triage process provided efficient means for client review and a robust process to surface needs in complex cases.

Opening the door: inviting youth and parent perspectives on youth mental health emergency department use

BACKGROUND

Canadian Emergency Departments (EDs) have seen increasing use by children and youth for mental health concerns in recent years. This trend is likely a result of several complex factors, and researcher-posed potential explanations include gaps or access problems in primary care or mental health services, increasing prevalence or awareness of mental disorders and fear of potentially harmful outcomes, or expectations of need for urgent specialist care. Youth, parent, or caregiver perceptions and reasons for increasing mental health ED use may differ, and to date have been underrepresented in informing research directions. We sought to engage with youth and parents or caregivers served by a Canadian tertiary paediatric health centre to: 1) inform research directions for an emerging program of research in child and youth ED use for mental health care; and 2) develop strategies to support ongoing patient engagement in our research.

METHODS

Youth and parents were consulted to inform the development of a research engagement strategy. Partnerships with local community agencies facilitated supported engagement with both youth and parents. Group and individual in-person engagement opportunities were offered, as well as opportunities for written submissions and information sharing.

RESULTS

Youth and parents identified specific mechanisms to support engagement and for sharing ongoing opportunities and progress, including providing multiple platforms for engagement, offering separate opportunities for youth and parents or caregivers, and minimizing the potential for distress by ensuring appropriate supports and providing alternative opportunities for feedback, including written submissions. They identified lack of timely access to mental health care in primary care and community mental health settings, and accessibility, dependability, and familiarity of the ED as areas for further research.

CONCLUSIONS

Strategies to mitigate potential concerns regarding distress, readiness for participation, literacy, and protection of privacy were highlighted as important considerations. Youth and parents were interested in ongoing research engagement through consultation and information sharing. Youth and parents identified areas of interest for research and refined the research team's proposed research directions by adding contextualizing information.

TRIAL REGISTRATION

Not applicable.

Interventions to improve emergency department use for mental health reasons: protocol for a mixed-methods systematic review

BACKGROUND

Healthcare resources are limited and unnecessary, and inappropriate emergency department use is now a highly visible healthcare priority. Individuals visiting the emergency department for mental health-related reasons are often amongst the most frequent presenters. In response, researchers and clinicians have created interventions to streamline emergency department use and several primary studies describe the effects of these interventions. Yet, no consensus exists on the optimal approach, and information on the quality of development, effectiveness, acceptability, and economic considerations is hard to find. The purpose of this study is to systematically review interventions designed to improve appropriate use of the emergency department for mental health reasons.

METHOD

A mixed-method systematic review using Joanna Briggs Methodology. Search combining electronic databases (EMBASE, MEDLINE, PsycINFO, CINAHL, HealthSTAR, PROQUEST, Cumulative Index to Nursing and Allied Health) and secondary searches (grey literature and hand search with consultation). Two independent reviewers will screen titles and abstracts using predetermined eligibility criteria and a third reviewer will resolve conflicts. Full texts will also be screened by two independent reviews and conflicts resolved in a consensus meeting with a third reviewer. A pilot-tested data extraction form will be used to retrieve data relevant to the study objectives. We will assess the quality and of all included studies. Data describing interventions will be summarized using logic models and reported narratively. Quality of development will be assessed using the Oxford Implementation Index. For data on intervention effectiveness, we will assess statistical heterogeneity and conduct a meta-analysis using a random effects method, if appropriate. For interventions that cannot be pooled, we will report outcomes narratively and descriptively. Qualitative data on acceptability will be synthesized using meta-aggregation and an economic evaluation of interventions will be done. The reporting of this protocol follows the PRISMA-P statement.

DISCUSSION

Using a combined systematic review methodology and integrated knowledge translation plan, the project will provide decision makers with concrete evidence to support the implementation and evaluation of interventions to improve emergency department use for mental health reasons. These interventions reflect widespread priorities in the area of mental health care.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018087430.

Emergency department utilization and resuscitation rate among patients receiving maintenance hemodialysis

BACKGROUND

End-stage renal disease (ESRD) is a growing global health concern with increased disease burden and high medical costs. Utilization of the emergency department (ED) among dialyzed patients and the associated risk factors remain unknown.

METHODS

Participants of this study, selected from the National Health Insurance Database in Taiwan, were aged 19-90 years and received maintenance hemodialysis from January 1, 2010, to December 31, 2010. A control group consisting of individuals who did not receive dialysis, selected from the same data source, were matched for age, sex, and the Charlson Comorbidity Index (CCI). Subgroup analysis with hemodialysis frequency was also performed. ED utilization among enrolled individuals was assessed in 2012. Generalized estimating equations with multiple variable adjustments were used to identify risk factors associated with resuscitation during ED visits.

RESULTS

One group of 2985 individuals who received maintenance hemodialysis, and another group of 2985 patients that did not receive hemodialysis, between January 1, 2010, and December 31, 2010, were included in this study. There were 4822 ED visits in the hemodialysis group, and 1755 ED visits in the non-dialysis group between January 1, 2012, and December 31, 2012. Analysis of multivariable generalized estimating equations identified the risk associated with resuscitation during ED visits to be greater in individuals who were receiving maintenance hemodialysis, aged older than 55 years, hospitalized in the past year, and assigned first and second degree of triage.

CONCLUSION

Patients receiving maintenance hemodialysis had higher ED utilization and a significantly higher risk of resuscitation during ED visits than those without hemodialysis.

Emergency Department Visits in a Cohort of Persons with Substance Use: Incorporating the Role of Social Networks

BACKGROUND

Frequent emergency department (ED) visits often suggest inappropriate use for low acuity needs and multiple comorbidities, including substance use disorders.

OBJECTIVE

This study examines associations of individuals and their social networks with high frequency ED use among persons reporting substance use.

METHODS

Information was obtained from interview responses from the first 6-month follow-up visit of a longitudinal. Prevalence ratios for the outcome of high frequency ED visits (≥2 in 6 months) were determined with a generalized linear model, log link, Poisson distribution and robust standard errors.

RESULTS

Of 653 participants, 131 (20%) had ≥2 ED visits. In multivariable analysis, greater likelihood of high frequency ED visits over 6 months was associated with being homeless (PR: 1.58; 95% CI: 1.19, 2.10), taking ≥3 medications (PR: 1.58; 95% CI: 1.19, 2.10) and having had a hospitalization over the same period (PR: 4.33; 95% CI: 3.26, 7.56). Among social network factors, lower likelihood of high frequency visits was associated with each increasing year of mean alter age (PR: 0.98; 95% CI: 0.6, 0.99) and greater likelihood with having received health-related informational support from ≥2 alters (PR: 1.62; 95% CI: 1.04, 2.53). Conclusions/Importance: Social network factors may play an important role in ED use. Interventions to promote health behaviors through social influence may be helpful in reducing high frequency ED visits.

Use of Group Concept Mapping to Identify Patient Domains of Uncertainty That Contribute to Emergency Department Use

INTRODUCTION

Prior research suggests that uncertainty related to symptoms is a driver of emergency department (ED) use, and that patients often leave the ED with uncertainty not being addressed. Our objective was to engage patients to identify domains that contribute to feelings of uncertainty and decisions to use the ED.

METHODS

We used Group Concept Mapping, a quasi-qualitative/quasi-quantitative method, to elicit patients' views on how uncertainty related to experiencing symptoms contributes to decisions to access the ED. Purposive sampling was used to recruit participants who either sought treatment at the ED twice within a 30-day period, or visited both the ED and a primary care provider at least once within the past year.

RESULTS

Thirty-four participants engaged in two rounds of Group Concept Mapping during which participants participated in structured brainstorming of ideas, followed by ranking and clustering of ideas into domains. The first round generated 47 idea statements reflecting uncertainty about consequences, severity, emergency room services, primary care options, finances, and psychologic concerns. The second round generated 52 idea statements reflecting uncertainty about self-management, causation, diagnosis and treatment plan, trust in the provider and institution, accessibility, and alternative care options.

DISCUSSION

Factors that contribute to uncertainty and decision-making about ED use are both intrinsic (ie, cause, symptom severity) and extrinsic (ie, finances, accessibility). These domains can inform approaches to measure the uncertainty that patients experience, and to design and test interventions for nurses and other providers to help manage patient uncertainty during acute illness.

Contested Ownership of Disease and Ambulatory-Sensitive Emergency Department Visits for Type 2 Diabetes

BACKGROUND

Approximately 21 million persons have diabetes and account for 11.9% of all emergency department (ED) visits for a total cost of $14.1 billion. Nonemergent visits for ambulatory-sensitive conditions that could be managed by the primary care provider make up almost one-third of the ED visits. African Americans comprise approximately 30% of South Carolina's population but make up approximately 50% of the ED visits for diabetes. The purpose of the research was to explore the experiences of 20 African-American adults with diabetes with ambulatory-sensitive ED use.

RESEARCH DESIGN AND METHODS

The research design for this study is grounded theory with dimensional analysis methods. Following ethics approval and informed consent, interviews were conducted, recorded and transcribed verbatim, and themes were analyzed to form the explanatory framework or matrix for ED use. The framework of context, conditions, processes and consequences provides a key for understanding the themes of the story embedded in the descriptive narratives.

RESULTS

The contested ownership of diabetes was the overarching perspective--"doing what I got to do," "it's always on mind… wishing not to be a diabetic" and "it's a constant burden." And handling diabetes involved taking decisions "into your hands." The context of perceived urgency of symptoms included all the reasons that precipitated ED visit--personal experience, primary care access and services and social network support for decisions--influenced ownership of these decisions.