Emergency room visits by older patients living with HIV: an approach based on the EDEN registry.

The urban emergency department is an important site for the detection of HIV infection. Current research has focused on strategies to increase HIV testing in the emergency department. As more emergency department HIV cases are identified, there need to be well-defined systems for linkage to care. We conducted a retrospective study of rapid HIV testing in an urban public emergency department and level I trauma center from June 1, 2008, to March 31, 2010. The objectives of this study were to evaluate the increase in the number of tests and new HIV diagnoses resulting from the addition of targeted testing to clinician-initiated diagnostic testing, describe the demographic and clinical characteristics of patients with newly diagnosed HIV infection, and assess the effectiveness of an HIV clinic based linkage to care team. Of 96,711 emergency department visits, there were 5340 (5.5%) rapid HIV tests performed, representing 4827 (91.3%) unique testers, of whom 62.4% were male and 60.8% were from racial/ethnic minority groups. After the change in testing strategy, the median number of tests per month increased from 114 to 273 (p=0.004), and the median number of new diagnoses per month increased from 1.5 to 4 (p=0.01). From all tests conducted, there were 65 new diagnoses of HIV infection (1.2%, 95% confidence interval [CI] 0.9%, 1.5%). The linkage team connected over 90% of newly diagnosed and out-of-care HIV-infected patients to care. In summary, the addition of targeted testing to diagnostic testing increased new HIV case identification, and an HIV clinic-based team was effective at linkage to care.

Emergency Department Utilization and Readmissions Following Major Surgery: A Retrospective Study of Medicare Data

The Ontario Asthma Regional Variation Study: Emergency Department Visit Rates and the Relation to Hospitalization Rates

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

Decomposing Differences in Risk-Adjusted Rates of Emergency Department Visits Between Micropolitan and Urban Nursing Homes.

BackgroundPrevalence rates of HIV infection in KwaZulu-Natal are high, with a significant amount of those infected being women of reproductive age. A diagnosis of HIV infection has been associated with an increased risk for the development of depression. Antenatal depression is a serious health concern, having the potential to cause wide-reaching adverse consequences for mother and unborn child.AimTo compare depressive scores between newly diagnosed HIV-infected and HIV-uninfected pregnant women.SettingAntenatal clinics at two regional hospitals in KwaZulu-Natal, South Africa.MethodsA cross-sectional questionnaire-based analysis of 102 newly HIV-tested black African pregnant women (HIV infected: n = 40; HIV uninfected: n = 62) was conducted. Women’s socio-demographic and clinical data were recorded, before being assessed for depressive symptomology using an isiZulu version of the Edinburgh Depression Scale.ResultsAbout 9.8% of women suffered from significant depressive symptoms, irrespective of HIV status. Prevalence rates of antenatal depressive symptoms did not differ significantly between HIV-infected and HIV-uninfected cohorts (p = 0.79). A new diagnosis of HIV infection (p < 0.0001) and maternal age (p = 0.03) were risk factors for antenatal depression. Unemployment was a borderline risk factor (p = 0.09) for the development of antenatal depression.ConclusionPrevalence rates of depressive symptoms were low. Knowledge of a new diagnosis of HIV infection at the first antenatal visit places women at an increased risk for the development of depression during pregnancy. Younger age and unemployment influence depression. This study provides an important step in documenting the need for screening for antenatal depression in HIV-associated pregnancies in a South African population group.

Depression is one of the most common illnesses in the United States, with increased prevalence among people with lower socioeconomic status and chronic mental illness who often seek care in the emergency department (ED). We sought to estimate the rate and severity of major depressive disorder (MDD) in a nonpsychiatric ED population and its association with subsequent ED visits and hospitalizations. This prospective cohort study enrolled a convenience sample of English-speaking adults presenting to an urban academic medical center ED without psychiatric complaints between January 1, 2015, and September 21, 2015. Patients completed a computerized adaptive depression diagnostic screen (CAD-MDD) and dimensional depression severity measurement test (CAT-DI) via tablet computer. Primary outcomes included number of ED visits and hospitalizations assessed from index visit until January 1, 2016. Negative binomial regression modeling was performed to assess associations between depression, depression severity, clinical covariates, and utilization outcomes. Of 999 enrolled patients, 27% screened positive for MDD. The presence of MDD conveyed a 61% increase in the rate of ED visits (incidence rate ratio [IRR]=1.61, 95% confidence interval [CI]= 1.27 to 2.03) and a 49% increase in the rate of hospitalizations (IRR=1.49, 95% CI= 1.06-2.09). For each 10% increase in MDD severity, there was a 10% increase in the relative rate of subsequent ED visits (IRR=1.10, 95% CI= 1.04 to 1.16) and hospitalizations (IRR=1.10, 95% CI= 1.02 to 1.18). Across the range of the severity scale there was over a 2.5-fold increase in the rate of ED visits and hospitalization rates. Rates of depression were high among a convenience sample of English-speaking adult ED patients presenting with nonpsychiatric complaints and independently associated with increased risk of subsequent ED utilization and hospitalization. Standardized assessment tools that provide rapid, accurate, and precise classification of MDD severity have the potential to play an important role in identifying ED patients in need of urgent psychiatric resource referral.

This study compared two approaches for implementation of non-targeted HIV screening in the emergency department (ED): (1) designated HIV counselors screening in parallel with ED care and (2) nurse-based screening integrated into patient triage. A retrospective analysis was performed to compare parallel and integrated screening models using data from the first 12 months of each program. Data for the parallel screening model were extracted from information collected by HIV test counselors and the electronic medical record (EMR). Integrated screening model data were extracted from the EMR and supplemented by data collected by HIV social workers during patient interaction. For both programs, data included demographics, HIV test offer, test acceptance or declination, and test result. A Z-test between two proportions was performed to compare screening frequencies and results. During the first 12 months of parallel screening, approximately 120,000 visits were made to the ED, with 3,816 (3%) HIV tests administered and 65 (2%) new diagnoses of HIV infection. During the first 12 months of integrated screening, 111,738 patients were triaged in the ED, with 16,329 (15%) patients tested and 190 (1%) new diagnoses. Integrated screening resulted in an increased frequency of HIV screening compared with parallel screening (0.15 tests per ED patient visit vs. 0.03 tests per ED patient visit, p<0.001) and an increase in the absolute number of new diagnoses (190 vs. 65), representing a slight decrease in the proportion of new diagnoses (1% vs. 2%, p=0.007). Non-targeted, integrated HIV screening, with test offer and order by ED nurses during patient triage, is feasible and resulted in an increased frequency of HIV screening and a threefold increase in the absolute number of newly identified HIV-positive patients.

Background: To predict areas with a high concentration of long-term uninsured (LTU) and Emergency Department (ED) usage by uninsured patients in South Carolina. Methods: American Community Survey data was used to predict the concentration of LTU at the ZIP Code Tabulation Area (ZCTA) level. In a multivariate regression model, the LTU concentration was then modeled to predict ED visits by uninsured patients. ED data came from the restricted South Carolina Patient Encounter data with patients’ billing zip codes. A simulation was conducted to predict changes in the ED visit numbers and rates by uninsured patients if the LTU concentration was reduced to a lower level. Results: Overall, there was a positive relationship between ED visit rates by the uninsured patients and areas with higher concentrations of LTU. Our simulation model predicted that if the LTU concentration for each ZCTA was reduced to the lowest quintile, the ED visit rates by the uninsured would decrease significantly. The greatest reduction in the number of ED visits by the uninsured over a two-year period was for the following primary diagnoses: abdominal pain (15,751 visits), cellulitis and abscess (11,260 visits) and diseases for the teeth and supporting structures (10,525 visits). Conclusions: The provision of primary healthcare services to the LTU could help cut back inappropriate uses of ED resources and healthcare costs.

The maturation of emergency medicine (EM) as a specialty has coincided with dramatic increases in emergency department (ED) visit rates, both in the United States and around the world. ED crowding has become a public health problem where periodic supply and demand mismatches in ED and hospital resources cause long waiting times and delays in critical treatments. ED crowding has been associated with several negative clinical outcomes, including higher complication rates and mortality. This article describes emergency care systems and the extent of crowding across 15 countries outside of the United States: Australia, Canada, Denmark, Finland, France, Germany, Hong Kong, India, Iran, Italy, The Netherlands, Saudi Arabia, Catalonia (Spain), Sweden, and the United Kingdom. The authors are local emergency care leaders with knowledge of emergency care in their particular countries. Where available, data are provided about visit patterns in each country; however, for many of these countries, no national data are available on ED visits rates or crowding. For most of the countries included, there is both objective evidence of increases in ED visit rates and ED crowding and also subjective assessments of trends toward higher crowding in the ED. ED crowding appears to be worsening in many countries despite the presence of universal health coverage. Scandinavian countries with robust systems to manage acute care outside the ED do not report crowding is a major problem. The main cause for crowding identified by many authors is the boarding of admitted patients, similar to the United States. Many hospitals in these countries have implemented operational interventions to mitigate crowding in the ED, and some countries have imposed strict limits on ED length of stay (LOS), while others have no clear plan to mitigate crowding. An understanding of the causes and potential solutions implemented in these countries can provide a lens into how to mitigate ED crowding in the United States through health policy interventions and hospital operational changes.

Epidemiological trends of HIV infection in Spain

The UK is described by the Department of Health in London as “a relatively low prevalence country for HIV infection.” The word “relatively” is the key. By comparison with the huge numbers of cases seen in much of sub-Saharan Africa, for example, HIV/AIDS is a minor problem in the UK. However, that is no grounds for complacency, as shown by the need for an official target for further reduction, which is a 25% decrease in new diagnoses of HIV infection by the end of 2007. To see how achievable this might be, we need to look at the ways in which new cases are currently arising. Last year saw 7,750 new diagnoses of HIV infection in the UK, but the more detailed breakdown is available up to the end of 2004.1 As of Dec 31, 2004, there were an estimated 58,300 people over the age of 15 years living with HIV in the UK, and this number is rising not only because of new diagnoses but also because of successful anti-HIV drug regimens. Male-to-male transmission remains an issue, at a plateau of around 1,800 new diagnoses annually. Heterosexual intercourse accounts for 4,000 new diagnoses each year, but most of those are acquired outside the UK. Injecting drug use accounts for just 150 new cases; mother-to-child transmissions number only 130 or so (the introduction of antenatal testing as a routine will have helped here); HIV infection due to blood transfusions or blood products is now very rare, most cases being acquired overseas; occupational HIV exposure is also very uncommon. Clearly the 2007 target (i.e., 25% decrease in new diagnoses) can be met only by making a significant impact on the two main sources, which are HIV transmission via same sex or heterosexual intercourse. The early willingness of British health officials and politicians to recognise the potential danger of HIV and do something about it when the world found out about this virus more than 20 years ago explains much of the early success. Still, as elsewhere in the world, pendulums swing back and prevention messages need repeating, especially now that anti-retroviral drugs mean that HIV infection is no longer seen as a death sentence, at least in countries such as the UK where such treatment is affordable. However, public health guidance and policy needs sensitive handling because so many British cases of HIV infection are either acquired outside the country or arise in ethnic minority groups, and more generally, it is difficult to see how prevention can be further enhanced in the UK other than by reinforcement of existing advice. The budget statement in April 2006 did contain a tax concession on condoms, by which the value added tax (a sort of sales tax) would be only 5% instead of the typical 17.5%. Though generally welcomed, this looks like a cosmetic gesture. The non-use of condoms is hardly likely to be based on price. More controversial is post-exposure prophylaxis (PEP). When exposure has been occupational (eg, a needlestick accident involving a healthcare worker) the British PEP guideline is clear, but the same document1 appears more tentative when it comes to exposure via sexual intercourse. This guidance, from February 2004, is currently being revised, but the British Association for Sexual Health and HIV has lately issued its own advice. That guideline2 recommends, provided the source individual is known to be HIV positive, PEP where the exposure has been due to receptive or insertive anal or vaginal sex. As with the U.S. guidelines,3 a further proviso is that the exposure is not more than 72 hours old. The indications for PEP are still being debated, and there is the potential to make some impact on prevention. However, any impression on national HIV statistics will be lessened by the simple fact that so many people who are HIV positive are not aware of their status.

Higher risk-adjusted rate of emergency department (ED) visits might reflect poor quality of nursing home (NH) care; however, existing evidence is limited regarding rural-urban differences in ED rates of NHs, especially for long-stay residents. To determine and quantify sources of rural-urban differences in NH risk-adjusted rates of any ED visit, ED without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED) of long-stay residents. We calculated quarterly NH risk-adjusted rates using 2011-2013 national Medicare claims and Minimum Data Set 3.0, and then implemented Generalized Estimating Equation models to examine rural-urban differences in ED rates and Blinder-Oaxaca decomposition to quantify the contributions of NH and market factors. Privately owned, free-standing NHs in the United States (N=13,260). Over the study period, risk-adjusted rates averaged 9.8% for any ED, 3.3% for outpatient ED, and 3.2% for PAED. Compared with urban NHs, rural NHs were associated with significantly lower rates of any ED, outpatient ED, and PAED (β=-1.67%, -0.44%, and -0.28%; all P<0.01). Observable differences in market factors (nursing home bed concentration, hospital beds, and the existence of a critical access hospital) explained about half of the rural-urban differences in rates of any ED and PAED, but not outpatient ED. Decomposition analyses suggested that lower ED rates in rural NHs appear to be related to market availability of hospital resources. Policymakers may focus on not only reducing unnecessary ED visits but also ensuring equitable hospital access in rural areas.

The association between pre-tonsillectomy education and postoperative emergency department returns: A retrospective cohort pilot study

The potential effects of increasing numbers of uninsured and underinsured persons on US emergency departments (EDs) is a concern for the health care safety net. To describe the changes in ED visits that occurred from 1997 through 2007 in the adult and pediatric US populations by sociodemographic group, designation of safety-net ED, and trends in ambulatory care-sensitive conditions. Publicly available ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 through 2007 were stratified by age, sex, race, ethnicity, insurance status, safety-net hospital classification, triage category, and disposition. Codes from the International Classification of Diseases, Ninth Revision (ICD-9), were used to extract visits related to ambulatory care-sensitive conditions. Visit rates were calculated using annual US Census estimates. Total annual visits to US EDs and ED visit rates for population subgroups. Between 1997 and 2007, ED visit rates increased from 352.8 to 390.5 per 1000 persons (rate difference, 37.7; 95% confidence interval [CI], -51.1 to 126.5; P = .001 for trend); the increase in total annual ED visits was almost double of what would be expected from population growth. Adults with Medicaid accounted for most of the increase in ED visits; the visit rate increased from 693.9 to 947.2 visits per 1000 enrollees between 1999 and 2007 (rate difference, 253.3; 95% CI, 41.1 to 465.5; P = .001 for trend). Although ED visit rates for adults with ambulatory care-sensitive conditions remained stable, ED visit rates among adults with Medicaid increased from 66.4 in 1999 to 83.9 in 2007 (rate difference, 17.5; 95% CI, -5.8 to 40.8; P = .007 for trend). The number of facilities qualifying as safety-net EDs increased from 1770 in 2000 to 2489 in 2007. These findings indicate that ED visit rates have increased from 1997 to 2007 and that EDs are increasingly serving as the safety net for medically underserved patients, particularly adults with Medicaid.