130 Meeting established canadian benchmarks for access to heart failure (HF) care following emergency department visit and association with outcome

131 Endothelial progenitor cells and functional capacity in heart failure patients

Access to heart failure care post emergency department visit: Do we meet established benchmarks and does it matter?

This study examined medical emergency department utilization for patterns among uninsured patients with psychiatric disorders. Billing records of 15,672 uninsured adult patients treated in the emergency department of an academic medical center in southeast Texas over a 12-month period were analyzed for information on demographic characteristics, diagnosis, number of emergency department visits, and hospitalization. Overall, 11.8% of the population was diagnosed as having at least one psychiatric disorder during an emergency department visit. Patients with psychiatric disorders had an increased risk of having multiple emergency department visits and hospitalization compared with patients without psychiatric disorders. The risk of multiple emergency department visits was particularly high for patients with either bipolar disorder or psychotic disorders. Uninsured patients with psychiatric disorders appear to be heavy users of medical emergency department services. These findings may be helpful in developing more efficient strategies to serve the mental health needs of the uninsured.

Hospital-Based, Acute Care Use Among Patients Within 30 Days of Discharge After Coronary Artery Bypass Surgery

Background: Community health workers (CHW) are specially trained lay-people often used as liaisons between underserved communities and the health care system. Prior studies suggest that use of CHWs can improve patient outcomes and reduce costs in a variety of illnesses. The role of CHW in managing patients with heart failure however has not been studied. This pilot study assesses the effect of CHW on hospital readmissions and Emergency Department (ED) visits for heart failure patients in an urban setting. Methods: Patients admitted to the hospital with a primary diagnosis of acute decompensated heart failure between April 2016 and March 2017 were screened for a pilot program to receive weekly home visits by a CHW. Visits included standardized assessment of overall well-being, vital signs, weight management, symptom control, medication compliance, diet education, and healthcare appointment reminders. Abnormal findings were reported to a cardiology nurse practitioner who triaged complaints and made appropriate changes. For this pilot study, enrolled patients were matched using 31 variables with retrospective control patients admitted with heart failure who did not receive a CHW. Hospital admissions and ED visits were compared for the 6 months following the index admission vs. the 6 months prior. Results: Sixteen patients received weekly visits from a CHW for 6 months after hospital admission. These were matched with 16 control patients who did not receive a CHW. Patients who received a CHW experienced a 36% decrease in Emergency Department (ED) visits in the 6 months after enrollment compared with the 6 months before. Control patients, however, experienced a 40% increase in ED visits over the same period. Similarly, patients with a CHW experienced a 42% decrease in hospital readmissions while control patients experienced a 28% increase. There was no significant difference in mortality between the groups. Conclusions: This pilot study suggests that CHW may reduce healthcare utilization for patients with heart failure without negatively impacting mortality. Based on these findings, a larger study is warranted to assess the efficacy and cost-efficiency of CHWs in helping to manage patients with heart failure.

Persons with heart failure (HF) at high risk for adverse events should be followed by specialized HF clinics, since follow-up by specialized HF clinics improves outcomes for HF patients. The objective was to determine whether there were disparities for gender and other factors associated with referral of patients to specialized HF clinics. In this prospective cohort study, patients with a confirmed primary diagnosis of HF were recruited by nurses at 8 hospital emergency departments (ED) in Québec, Canada. They were interviewed by telephone at 6 weeks post ED discharge and subsequently at 3 months and 6 months. Pertinent clinical variables were extracted from medical charts by trained nurses. Bivariate analysis and multiple logistic regression were used to identify whether gender and other potential factors were associated with referral to the HF clinic. We enrolled 549 patients (mean age 75.5±11.0 years; 51% males). By 6 months after their ED visit for HF, 37.6% of the cohort were referred to specialized HF clinics. Men were more likely to be referred (odds ratio [OR] 2.04; 95% confidence interval [CI] 1.12, 3.74). Other factors associated with referral were younger age (OR 0.95; 95% CI 0.92, 0.98), and systolic dysfunction HF (left ventricle ejection fraction <40%) (OR 3.08; 95% CI 1.77, 5.46). There are disparities in referral with respect to gender, age, and type of HF. These disparities in referral need to be addressed.

A PROPENSITY-MATCHED COHORT STUDY TO ASSESS THE EFFECTIVENESS OF A COMMUNITY HOSPITAL BASED HEART FUNCTION CLINIC

There are no validated guidelines to guide physicians with difficult disposition decisions for emergency department (ED) patients with heart failure (HF). The authors sought to develop a risk scoring system to identify HF patients at high risk for serious adverse events (SAEs). This was a prospective cohort study at six large Canadian EDS that enrolled adult patients who presented with acute decompensated HF. Each patient was assessed for standardized clinical and laboratory variables as well as for SAEs defined as death, intubation, admission to a monitored unit, or relapse requiring admission. Adjusted odds ratios for predictors of SAEs were calculated by stepwise logistic regression. In 559 visits, 38.1% resulted in patient admission. Of 65 (11.6%) SAE cases, 31 (47.7%) occurred in patients not initially admitted. The multivariate model and resultant Ottawa Heart Failure Risk Scale consists of 10 elements, and the risk of SAEs varied from 2.8% to 89.0%, with good calibration between observed and expected probabilities. Internal validation showed the risk scores to be very accurate across 1,000 replications using the bootstrap method. A threshold of 1, 2, or 3 total scores for admission would be associated with sensitivities of 95.2, 80.6, or 64.5%, respectively, all better than current practice. Many HF patients are discharged home from the ED and then suffer SAEs or death. The authors have developed an accurate risk scoring system that could ultimately be used to stratify the risk of poor outcomes and to enable rational and safe disposition decisions.

Benefits Of An Interdisciplinary Nurse Practitioner And Clinical Pharmacy Specialist Heart Failure Access Clinic

Objective: The objective of this study was to document the frequency and clinical characteristics associated with repeat emergency department (ED) visits for asthma in an inner city population with a high burden of asthma. Methods: During an ED visit for asthma in an inner city hospital (‘index visit’), patients completed a valid survey addressing disease and behavioral factors. Hospital records were reviewed for information about ED visits and hospitalizations for asthma during the 12 months before and the 90 days after the index visit. Results: One hundred and ninety-two patients were enrolled; the mean age was 42 years, 69% were women, 36% were black, 54% were Latino, 69% had Medicaid, and 17% were uninsured. 100 patients (52%) were treated and released from the ED, 88 patients (46%) were hospitalized, and 4 patients (2%) left against medical advice. During the subsequent 90 days, 64 patients (33%) had at least one repeat ED visit for asthma and 27 (14%) were hospitalized for asthma. In a multivariate model, more past ED visits (OR 1.7, 95% CI 1.4, 2.1; p < 0.0001) and male gender (OR 2.5, 95% CI 1.2, 5.4; p = 0.02) remained associated with having a repeat ED visit. Most patients had the first repeat ED visit within 30 days and 18 returned within only 7 days. Among all patients with a repeat visit, those who were not hospitalized for the index visit were more likely to have a repeat visit within 7 days (37%) compared to those who were hospitalized (17%) (p = 0.05 in multivariate analysis). Conclusions: Repeat ED visits were prevalent among inner city asthma patients and most occurred shortly after the index visit. The strongest predictors of repeat visits were male gender and more ED visits in the 12 months before the index visit.

To assess the clinical efficacy and safety of neutralizing monoclonal antibodies (mABs) for outpatients with coronavirus disease 2019 (COVID‐19). PubMed, Embase, Web of Science, Cochrane Library, ClinicalTrials.gov, and World Health Organization International Clinical Trials Registry Platform (ICTRP) databases were searched from inception to July 19, 2021. Only randomized controlled trials (RCTs) that assessed the clinical efficacy and safety of neutralizing mABs in the treatment of COVID‐19 outpatients were included. The Cochrane risk‐of‐bias tool was used to assess the quality of the included RCTs. The primary outcome was the risk of COVID‐19‐related hospitalization or emergency department (ED) visits. The secondary outcomes were the risk of death and adverse events (AEs). Five articles were included, in which 3309 patients received neutralizing mAB and 2397 patients received a placebo. A significantly lower rate of hospitalization or ED visits was observed among patients who received neutralizing mABs than those who received a placebo (1.7% vs. 6.5%, odds ratios (OR): 0.26; 95% confidence interval (CI): 0.19–0.36; I 2 = 0%). In addition, the rate of hospitalization was significantly lower in the patients who received neutralizing mABs than in the control group (OR: 0.24; 95% CI: 0.17−0.34; I 2 = 0%). The mortality rate was also significantly lower in the patients who received neutralizing mABs than in the control group (OR: 0.16; 95% CI: 0.05−0.58; I 2 = 3%). Neutralizing mABs were associated with a similar risk of any AE (OR: 0.81; 95% CI: 0.64–1.01; I 2 = 52%) and a lower risk of serious AEs (OR: 0.37; 97% CI: 0.19–0.72; I 2 = 45%) compared with a placebo. Neutralizing mABs can help reduce the risk of hospitalization or ED visits in COVID‐19 outpatients. For these patients, neutralizing mABs are safe and not associated with a higher risk of AEs than a placebo.

295 The Forgotten Emergency Department Visit When Assessing Hospital Readmissions

Background: Payment reforms and other policy initiatives are accelerating the shift of risk from payers to providers. As a result, population health management is playing an increasing role in decision making by providers, guided by the Medicare Triple Aim. Reducing avoidable hospitalizations is an important tool for achieving this aim, by increasing quality of care and containing hospital costs. Previous studies have examined the trends over time of emergency department (ED) visits for major diseases. However, there is very little data assessing ED visits related to the symptoms of these major diseases. This study examined the trends of ED visits for chest pain (CP), a symptom suggestive of coronary artery disease (CAD), and of shortness of breath (SOB), a symptom suggestive of congestive heart failure (CHF). Methods: We conducted a population-based cross-sectional study to estimate ED visits for CP suggestive of CAD and for SOB suggestive of CHF in the US for the years 2006 through 2013 at encounter level, using the Nationwide Emergency Department Sample (NEDS) database. We defined CP suggestive of CAD as a principal diagnosis of CP for the ED visit (ICD-9-CM code: 786.5), with a CAD code (410-414) as a secondary diagnosis but no diagnosis for other serious conditions that may trigger CP (e.g., aortic dissection). We defined SOB suggestive of CHF as a principal diagnosis of SOB (ICD-9-CM code: 786.05) for the ED visit with a CHF code (428.0-428.4) as a secondary diagnosis but no diagnosis for other conditions that may trigger SOB (e.g., pneumothorax). Outcome measures included annual number of ED visits and subsequent admissions, weighted for national estimates (2006-2013). We performed a trend analysis in rates over time, which accounted for US census population, for ED visits and subsequent admissions, using a generalized linear regression model with a Poisson distribution and a Wald test. Results: The number of ED visits for CP suggestive of CAD per 100,000 population increased 24.3% from 197 in 2006 to 245 in 2013 (p&lt;0.01), while subsequent admissions for CP suggestive of CAD decreased by 36.1% from 90 in 2006 to 58 in 2013 (p&lt;0.01). However, we found a consistently small number of ED visits for SOB suggestive of CHF over time, from 4 ED visits in 2006 to 5 ED visits in 2013 (p&gt;0.1). Similarly, subsequent admissions for SOB suggestive of CHF were relatively low and stable, from 0.61 admissions per 100,000 in 2006 to 0.72 admissions in 2013 (p&gt;0.1). Conclusions: Our results showed an increasing trend for ED visits and a decreasing trend for subsequent admissions over time for CP suggestive of CAD. However, there appeared no change for ED visits and subsequent admissions over time for SOB suggestive of CHF. Future research is warranted to examine possible reasons for the different ED visit rates for symptoms associated with major diseases such as CAD and CHF.

Partnering to Improve Pediatric Asthma Quality.

Minnesota has shown relatively high growth of mortality from diabetes mellitus (DM) and dementia in recent years, especially in rural areas. Analysis of medical care utilization patterns may reveal the reasons for this trend. The goal of the present study was to characterize the Minnesota dementia and diabetes care landscape by rurality and geographic region. Specifically, we compared the Metro region to five other rural-urban regions. Disease-specific 2017 hospital admission and emergency department (ED) visit data was obtained from the State Center for Health Statistics and the Healthcare Cost and Utilization Project. We used the logistic regression analysis adjusted by multiple covariates to evaluate rural-urban differences in hospital admissions and ED visits. Age-adjusted rates of ED visits for both DM and dementia were significantly higher in rural zip code areas, especially in northeast regions. Rural areas had elevated odds for dementia hospital admissions (OR=1.05, p<0.0001) and ED visits (OR=1.24, p<0.0001), but decreased odds for DM hospital admission (OR=0.96, p<0.0001) and ED visits (OR=0.96, p<0.0001). This was particularly true in the northeast region (relative to Metro regions) where ED visits were less likely due to DM (OR=0.89, p<0.0001) but more likely related to dementia (ORs=1.42, p<0.0001). Geographic differences for ED visits due to DM were greater than those for dementia, with higher rates for rural as compared to urban regions (northeast MN compared to a large metropolitan region). This geographical mismatch between mortality rates and ED visit rates may illustrate the relative lack of access to health services in rural MN.