30-day Emergency Department Return Research Articles

Development of an Emergency Department Case Management Case-Finding Tool.

Identifying emergency department (ED) patients who are at high risk for return visits is an important goal for case management to improve patient care. This quality improvement study describes the development and evaluation of the Emergency Department Case Management Priority Score (EDCMPS), an electronic medical record (EMR)-based "case-finding" system, and its ability to identify these high-risk patients. In addition, the authors present data about its acceptability among emergency department case managers (ED CMs). Emergency departments with case management availability and staffing. A retrospective analysis at Duke University Hospital ED compared patient data pre- and postimplementation of the EDCMPS. The tool was developed using the LEAN and Plan-Do-Study-Act (PDSA) quality improvement methodologies, with ED CM participation. ED return and hospitalization rates within 7 and 30 days between both methods were compared, and a survey evaluated CM satisfaction with the EDCMPS. The 2-month preintervention period (July 1, 2022, to August 31, 2022) included 8,677 patients discharged from the ED, with 897 patients (10.3%) identified as at high risk for return based on the previous manual methodology. In the 3-month postintervention period (September 1, 2022, to November 30, 2022), there were 13,566 patients discharged, with 692 patients (5.1%) identified as at high risk for return using the EDCMPS. The EDCMPS outperformed the manual method, yielding a significantly higher odds ratio (OR) for 7- and 30-day ED return or hospitalization (e.g., 30-day any return OR = 4.21 vs. 1.69). The survey showed broad ED CM agreement on the tool's superior performance, especially in organizing outpatient resources and referring to support programs. However, challenges in securing primary care follow-up, housing, and health insurance applications were identified. The tool's collaborative development approach ensured its fit to ED CM needs, contributing to its success. The EDCMPS showcases promise in enhancing ED CM efficiency, with strong frontline staff endorsement. It pinpoints areas needing focus for patient support and has the potential to reduce ED revisits and therefore health care utilization. Its methodology offers insights for similar future implementations in health care institutions.

Nonspecific Diagnoses and Return Visits Among Children Discharged From the Emergency Department.

Previous work has suggested an association between diagnostic uncertainty and the use of nonspecific diagnostic billing codes. We sought to evaluate differences in emergency department (ED) return visits among children discharged from the ED with specific and nonspecific discharge diagnosis codes. We performed a retrospective study including children (aged <18 years) discharged from 40 pediatric EDs between July 2021 and June 2022. Our primary and secondary outcomes were 7-day and 30-day ED return visits, respectively. Our predictor of interest was diagnosis, classified as nonspecific (only signs/symptoms diagnoses, e.g., "cough") or specific (≥1 specific diagnosis, e.g., "pneumonia"). We evaluated for associations using Cox proportional hazard models adjusted for race/ethnicity, payer status, age, medical complexity, and neighborhood opportunity. Among 1870100 discharged children, 7-day return visits occurred in 73956 (4.0%); of these, 15.8% had nonspecific discharge diagnoses. The adjusted hazard ratio (aHR) of a return visit among children with a nonspecific diagnosis on their index visit was 1.08 (95% confidence interval, 1.06-1.10). Nonspecific diagnoses with the highest aHR of return visits were for fever, convulsions, digestive system, abdominal signs/symptoms, and headache. Respiratory and emotional/behavior signs or symptoms had a lower aHR of 7-day return visits. The aHR of nonspecific diagnosis on 30-day return visits was 1.01 (95% confidence interval 1.01-1.03). Children with nonspecific diagnoses discharged from the ED had distinct patterns of health care utilization compared with those having specific diagnoses. Further research is required to evaluate the role of diagnostic uncertainty with diagnosis code application in the ED.

The Efficacy of Telemedicine Versus In-Person Education for High-Risk Patients Undergoing Primary Total Joint Arthroplasty

BackgroundWhile multiple studies have demonstrated the positive impact of preoperative education on total joint arthroplasty (TJA) outcomes, the traditional method of conducting in-person individualized counseling or group education may limit access to these resources for a subset of the population. This study aimed to evaluate the use of preoperative telemedicine and in-person educational programs for primary TJA patients to determine if the utilization of telemedicine is inferior to in-person education in high-risk populations. MethodsA retrospective chart review of all “high-risk” patients undergoing primary unilateral TKA or THA by 1 of 10 board-certified surgeons at a single institution over 1 year was performed. Patients were prospectively classified as high-risk based on race/ethnicity, comorbidities, and socioeconomic and psychosocial factors. Demographics, comorbidities, and hospital outcomes were compared between patients receiving preoperative nurse navigator education via telemedicine versus those receiving face-to-face education. ResultsWhen comparing the interventions, telemedicine education was noninferior to face-to-face visits. No significant differences between postoperative length of stay, discharge home, 30-day emergency department return, or 30-day readmission rates were noted. Within the telemedicine group, patients who received video consultations were found to be 6 times more likely to be discharged home after surgery (odds ratio (OR): 5.95, 95% confidence interval (CI): 2.00 to 25.49; P = .004) and less likely to have a 30-day readmission than the phone consultations (OR: 0.36, 95% CI: 0.12 to 0.94: P = .050). ConclusionThis study demonstrates that telemedicine is not inferior to in-person preoperative education for patients undergoing unilateral TJA, although video-based consultation may improve outcomes over phone-only education.

Evaluation of the BEAT Meth Intervention for Emergency Department Patients with Methamphetamine Psychosis.

Methamphetamine is the second leading cause of overdose death in America and a leading cause of emergency department (ED) visits. Methamphetamine-induced psychosis is a dangerous and difficult-to-treat consequence of methamphetamine use. We describe the pilot implementation and outcomes of a multimodal treatment intervention for ED patients with methamphetamine psychosis, Beginning Early and Assertive Treatment for Methamphetamine Psychosis (BEAT Meth). BEAT Meth was implemented in an urban safety net health system. The protocol includes early identification and treatment of methamphetamine psychosis, a protocolized hospitalization, and support for transitioning patients to specialty addiction treatment. Patients receiving BEAT Meth were compared with ED patients with methamphetamine psychosis who were discharged. Implementation fidelity was measured to assess feasibility. BEAT Meth patients were nearly 3 times more likely to attend an outpatient specialty addiction appointment in the 30 days after discharge than comparison patients (32% vs 11%, P < 0.01). Subsequent ED utilization was common among all patients, and there was no significant difference in 30-day ED return rates between BEAT Meth and comparison patients (28% vs 37%, P = 0.10). Exploratory analyses suggested that increased attendance at outpatient treatment reduced ED utilization. BEAT Meth is an intervention framework to support identification, management, and treatment engagement of ED patients with methamphetamine psychosis. Treatment strategies like BEAT Meth are necessary to manage the unique challenges of methamphetamine addiction. These findings will guide clinical care, program development, and research.

Treatment of Acute Bronchitis and its Impact on Return Emergency Department Visits

BackgroundAntibiotics are not recommended in healthy, uncomplicated adults for the treatment of acute bronchitis, yet are still often prescribed. No randomized studies have examined whether prescribing antibiotics in the emergency department (ED) impacts hospital return rates. ObjectiveOur aim was to compare hospital return rates between those who were prescribed an antibiotic vs. those who were not prescribed an antibiotic for the treatment of acute bronchitis. MethodsA retrospective cohort study was completed evaluating patients aged 18–64 years who presented to a community teaching hospital ED with acute bronchitis between January 2017 and December 2019. The primary outcomes were 30-day ED return and hospital admissions from initial ED visit. The rates of ED return or readmitted were compared for patients prescribed an antibiotic for treatment of acute bronchitis vs. those patients who were not prescribed an antibiotic. ResultsOf the 752 patients included, 311 (41%) were prescribed antibiotics. Baseline demographics were similar between both groups. Of those prescribed an antibiotic, 26 of 311 (8.4%) returned to the hospital within 30 days compared with 33 of 441 patients (7.5%) who were not prescribed an antibiotic (odds ratio 1.13; 95% confidence interval 0.66–1.92). ConclusionsThere was no association found between antibiotic therapy for treatment of acute bronchitis and return to the hospital.

Social Determinants of Health Influence Early Outcomes Following Lumbar Spine Surgery.

Background: Disparities among social determinants of health (SDoH) can impact overall well-being and surgical outcomes. The purpose of this study was to identify SDoH for patients who underwent lumbar spine surgery and evaluate their relationship to the postoperative outcomes of length of stay (LOS), discharge disposition, and readmissions. Methods: We conducted a retrospective observational study of patients who underwent lumbar spine surgery from July 2017 to January 2021. We used a self-reported SDoH survey in conjunction with the electronic medical record to gather patient information. Multivariate analysis was used to evaluate the relationships between patient demographics, SDoH, and postoperative outcomes. Results: A total of 951 patients underwent lumbar spine surgery: 484 (50.9%) had decompressive laminectomy alone without fusion, and 467 (49.1%) had decompressive laminectomy with instrumented posterolateral fusion. When controlling for age, American Society of Anesthesiologists physical status classification, and surgery type, the SDoH of being currently married or having a life partner was associated with shorter LOS and decreased likelihood of discharge to a skilled nursing facility. Financial strain was associated with longer LOS, while attending church was associated with a decreased likelihood of 30-day emergency department (ED) return. Conclusion: This study identified various SDoH that may influence postoperative lumbar spine surgery outcomes of LOS, discharge disposition, 30-day ED return, and 30-day readmission. Patients at risk for suboptimal outcomes appear to be those with lower financial resources, less in-home support, and lower social connectivity. Routine screening of SDoH may enable care teams to effectively allocate resources for at-risk patients.

405 Crisis Stabilization Unit Reduces Admission Rates for Suicidal Patients in a Midwest Emergency Department

In an attempt to improve patient care and hospital operations, our institution implemented a crisis stabilization unit (CSU) to provide psychiatric stabilization and treatment in a setting other than the emergency department (ED). After initial evaluation and medical clearance by an emergency medicine provider, patients transfer from the ED to the CSU. The CSU aims to decrease the time, space, and monetary burdens on the ED, and to preserve the limited inpatient psychiatry beds for patients who truly need admission, as patients may discharge home from the CSU. The purpose of this study is to determine the effect on hospital admission rates for suicidal patients in the emergency department after the opening of the CSU in a rural academic medical center. We performed a before-and-after analysis of introducing the CSU within a Midwestern tertiary referral center. We evaluated study periods of November 15, 2017 to May 15, 2018 and November 15, 2018 to May 15, 2019 to examine patients pre- and post-CSU implementation. Adult patients presenting with suicidal ideation or suicidal attempt were included. The primary outcome was difference in proportion of inpatient psychiatric admission of suicidal patients presenting to the ED. Secondary outcomes compared were changes in proportion of any admission, use of code greens (code activated in cases where patient poses a threat, requiring immediate attention by psychiatry and security), incomplete admission (a bed request is made but the patient leaves prior to admission), restraint use, scheduling of follow-up within 30 days of discharge, ED returns within 30 days, and mean difference in ED boarding hours. We performed a descriptive analysis of patient visit characteristics presenting before and after CSU implementation. Association between categorical outcomes was determined to estimate relative risks (RR) and 95% confidence intervals (CI). Continuous outcomes were examined as the mean difference (MD) by time period. There were 962 patients presenting with suicidality (n=435 pre-CSU, n=527 post-CSU). There were no differences in population during the two study periods by age, sex, race, homelessness, or insurance. Compared to the pre-CSU period, there was a reduction in psychiatric admission (RR: 0.48; 95% CI: 0.40-0.56), any admission (RR: 0.65; 95% CI: 0.58-0.73), discharge after bed request (RR: 0.22; 95% CI: 0.11-0.43), 30-day return to the ED (RR: 0.74; 95% CI: 0.56-0.98), ED boarding time among admitted patients (MD: -9.0 hours; 95% CI: -13.5, -4.6) and incomplete admissions (MD: -12.5 hours; 95% CI: -21.3, -3.7). There was no significant difference in restraint use or code green use in the ED. There was a 60% increase in a 30-day follow-up being scheduled (RR: 1.60; 95% CI: 1.40-1.82). This study showed that the rate of any inpatient admission, discharge after bed request, 30-day ED return, and ED boarding time decreased after the implementation of the CSU.

Predictors of return visits to the emergency department among different age groups of older adults.

To identify predictors of 30-day emergency department (ED) return visits in patients age 65-79years and age≥80years. This was a cohort study of older adults who presented to the ED over a 1-year period. A mixed-effects logistic regression model was used to identify predictors for returning to the ED within 30days. We stratified the cohort into those aged 65-79years and aged ≥80years. Adjusted odds ratios (aORs) with 95% confidence intervals (CI) were reported. This study adhered to the STROBE reporting guidelines. A total of 21,460 ED visits representing 14,528 unique patients were included. The overall return rate was 15% (1998/13,300 visits) for age 65-79years, and 16% (1306/8160 visits) for age≥80years. A history of congestive heart failure (CHF), dementia, or prior hospitalization within 2years were associated with increased odds of returning in both age groups (for age 65-79: CHF aOR 1.36 [CI 1.16-1.59], dementia aOR 1.27 [CI 1.07-1.49], prior hospitalization aOR 1.36 [CI 1.19-1.56]; for age≥80: CHF aOR 1.32 [CI 1.13-1.55], dementia aOR 1.22 [CI 1.04-1.42], and prior hospitalization aOR 1.27 [CI 1.09-1.47]). Being admitted from the ED was associated with decreased odds of returning to the ED within 30days (aOR 0.72 [CI 0.64-0.80] for age 65-79years and 0.72 [CI 0.63-0.82] for age≥80). Age alone was not an independent predictor of return visits. Prior hospitalization, dementia and CHF were predictors of 30-day ED return. The identification of predictors of return visits may help to optimize care transition in the ED.

LO38: Reducing inappropriate urine culture testing in the emergency department

Background: Urinary tract infections (UTI) are a common emergency department (ED) presentation. Urine cultures (UC) are frequently ordered to confirm the diagnosis, however, it can be challenging to differentiate between a true infection and asymptomatic bacteriuria (ASB) which does not generally benefit from antibiotics. This over-treatment of ASB leads to serious adverse side effects, growing antimicrobial resistance and increased healthcare costs. By reducing inappropriate ED urine culture testing, we can concomitantly avoid the false positives that contribute to this large-scale problem. Aim Statement: We aimed to reduce ED urine culture testing at Credit Valley Hospital, a large community hospital based in Mississauga, Ontario by 30%, from a baseline average of 97 cultures per 1000 ED visits in 2017, to 68 cultures per 1000 ED visits by year end 2019. Measures &amp; Design: Multiple PDSA cycles were ran with our multi-disciplinary ED team. Our interventions to encourage rational urine culture testing are three-fold, including (1) medical directive optimization (removal of routine sending of UC), (2) individualized physician feedback and (3) physician education with introduction of a clinical decision aid. Our outcome measure is rate of UC per 1000 ED patient visits with a balance measure of rate of 30-day ED return visit of hospital admission for patients with a UTI. Evaluation/Results: Despite a parallel surge in ED volumes, we observed a significant decrease in urine culture testing, from an annual average of 97 cultures per 1000 ED visits to 60 cultures per 1000 ED visits in 2019 year-to-date. There was no increase in the rate of ED 30-day return visit or admission for UTI or a diagnostic equivalent. Discussion/Impact: Our multipronged approach effectively decreased the rate of UC testing during the study period. ED physicians provide higher quality care with judicious use of resources to guide diagnosis and management. Active ongoing interventions include our transition to a 2-step UC order protocol (uncoupling urinalysis with culture) using BD vacutainer urine collection products, which will allow for 48 hour storage of uncompromised urine. Further work will leverage our knowledge and experience with optimizing urine culture testing to other culture specimens.

MP27-20 CAN A SIMPLE PHONE CALL IMPROVE POST-URETEROSCOPY OUTCOMES IN PATIENTS WITH PSYCHIATRIC DISEASE? 6.3.6

INTRODUCTION AND OBJECTIVE: A recent publication from our institution demonstrated that among the 12.6% of patients that return to the emergency department (ED) within 30 days of ureteroscopy (URS) for stone disease, approximately 60% have a history of psychiatric disease (PD). Small-scale quality improvement studies have suggested that postoperative nursing telephone calls reduce unplanned care encounters after URS for all patients. We sought to determine if a postoperative phone call by a urology nurse targeted to this high-risk group would reduce the rate of post-URS ED returns. METHODS: PD was defined as having a DSM-5 psychiatric diagnosis, a prescription for a psychoactive medication, or documentation by a clinician regarding the diagnosis and management of either. Our cohort was identified by prospectively screening the medical record of all patients undergoing URS for stone disease between August 2018 and August 2019. Patients with a history of chronic pain syndromes or substance abuse were excluded. Patients who met inclusion criteria were called by urology triage nurses between postoperative days 1-4. Nurses reviewed a standardized script with the patient and then used a templated form to document information regarding symptomatology and medication usage. Information regarding ED presentation was obtained by chart review, and outcomes were compared with our previously published retrospective population. RESULTS: At 12-months follow-up, 42% of 360 patients undergoing URS were identified as having PD. The overall 30-day ED return rate following URS for stone disease was 10.8%, and 56% of the patients who returned had PD. PD patients had an ED return rate of 14.4% (previously 16.7%), and 56% of these visits resulted in admission (previously 36%). The proportion of PD patients returning to the ED with a chief complaint of pain was 32%, whereas previously it was 46%. CONCLUSIONS: PD is a risk factor for post-op ED presentation and is prevalent in patients undergoing URS. Our findings demonstrate that phone calls targeted to these patients may lead to a reduction in 30-day ED returns for reasons that do not require admission, such as pain. Compared with our published retrospective data, the findings of this study reflected an overall reduction in ED returns for PD patients following initiation of postoperative phone calls. Source of Funding: NA

Unplanned Emergency Department Visits within 30 Days of Mastectomy and Breast Reconstruction.

Unplanned emergency department visits are often overlooked as an indicator of care quality. The authors' objectives were to (1) determine the rate of 30-day emergency department visits following mastectomy with or without immediate reconstruction, (2) perform a risk analysis of potential factors associated with emergency department return, and (3) assess for potentially preventable visits with a focus on returns for pain. Using the Healthcare Cost and Utilization Project data, the authors identified adult women who underwent mastectomy with or without reconstruction. Multivariable logistic regression was performed to evaluate risk of unplanned emergency department visits. The authors identified and sorted diagnostic codes to investigate why patients were seeking emergency department care. In addition, the authors performed a subgroup analysis on patients returning with a pain-related diagnosis to evaluate risk. Of 159,275 cases of mastectomy with or without immediate reconstruction, 4917 (3.1 percent) experienced an unplanned return to the emergency department within 30 days of operation. A substantial proportion of those who returned (23 percent) presented with a pain-related diagnosis. Only 0.9 percent of cases with a 30-day emergency department return were readmitted. Numerous patients return to the emergency department within 30 days of mastectomy with or without immediate reconstruction. There is a need for policy makers and physicians to implement strategies to reduce discretionary emergency department use, specifically among younger or publicly insured patients. Combining unplanned emergency department visits with readmission rates as a care quality indicator warrants consideration. Risk, III.

Anxiety Associated With Increased Risk for Emergency Department Recidivism in Patients With Low-Risk Chest Pain

Anxiety contributes to the chest pain symptom complex in 30% to 40% of patients with low-risk chest pain seen in the emergency department (ED). The validated Hospital Anxiety Depression Scale-Anxiety subscale (HADS-A) has been used as an anxiety screening tool in this population. The objective was to determine the prevalence of abnormal HADS-A scores in a cohort of low-risk chest pain patients and test the association of HADS-A score with subsequent healthcare utilization and symptom recurrence. In a single-center, prospective, observational cohort study of adult ED subjects with low-risk chest pain, the HADS-A was used to stratify participants into 2 groups: low anxiety (score <8) and high anxiety (score ≥8). At 45-day follow-up, chest pain recurrence was assessed by patient report, whereas ED utilization was assessed through chart review. Of the 167 subjects enrolled, 78 (47%) were stratified to high anxiety. The relative risk for high anxiety being associated with at least one 30-day ED return visit was 2.6 (95% confidence interval 1.4 to 4.7) and this relative risk increased to 9.1 (95% confidence interval 2.18to38.6) for 2 or more ED return visits. Occasional chest pain recurrence was reported by more subjects in the high anxiety group, 68% vs 47% (p = 0.029). In conclusion, 47% of low-risk chest pain cohort had abnormal levels of anxiety. These patients were more likely to have occasional recurrence of their chest pain and had an increased risk multiple ED return visits.

LO72: A randomized controlled trial of electronic clinical decision support to reduce unnecessary CT imaging for patients with mild traumatic brain injury

Introduction: Utilization of CT imaging has risen dramatically with increases in availability, but without corresponding improvements in patient outcomes for many clinical scenarios. Previous attempts to improve imaging appropriateness have met with limited success, with commonly cited barriers including a lack of confidence in patient outcomes, medicolegal risk, and patient expectations. The objective of this study was to assess the impact of an electronic clinical decision support (CDS) intervention to reduce CT utilization for emergency department (ED) patients with mild traumatic brain injury (MTBI). Methods: This was a cluster-randomized, controlled trial with physicians as the unit of randomization. All emergency physicians (EPs) at 4 urban adult EDs and 1 urgent care center were randomly assigned to receive evidence-based imaging CDS (intervention) or no CDS (control) for patients with MTBI over a 1-year study period. CDS was launched in an external web browser whenever an intervention EP ordered a non-enhanced head CT from the computerized physician order entry (CPOE) system for ED patients CTAS 2-5 with a CEDIS chief complaint of head injury; however, interaction with CDS was voluntary. The CDS tool provided detailed information to physicians about the Canadian CT Head Rule, including patient eligibility, exclusion criteria, risk factors and probability of serious injury, as well as an imaging recommendation (yes/no). CDS recommendations could be printed for the medical record as could educational patient handouts to support physician decision making. The primary outcome was CT utilization for patients with MTBI on the index visit. Secondary outcomes included ED length of stay (LOS), and return visits, CT use, hospital admission and traumatic head injury diagnoses over the next 30-days. This study was REB approved. Results: Physician demographics and baseline CT utilization for MTBI patients were similar among intervention and control EPs during a 2-year pre-intervention period. In the first 8-months following CDS implementation, 102 intervention EPs saw 2,189 eligible patients while 100 control EPs saw 1,707 patients. Intervention EPs voluntarily interacted with CDS on 36.2% of eligible encounters. Head CT utilization was lower among intervention EPs than controls (38.5% vs 45.1%, p&lt;0.0001) as was ED LOS (201 vs 218.5 minutes, p&lt;0.001). There was no difference in 30-day ED return visits, head CT utilization, hospital admission or traumatic head injury diagnoses. Conclusion: In one of the largest RCTs of CDS to date, exposure to CDS was associated with decreased head CT utilization and shorter LOS on the index visit, and no difference in 30-day head CT use, return ED visits or hospital admission. These results suggest that a comprehensive CDS implementation may be able to overcome several barriers to use of decision rules and may contribute to improved clinical decision making and decreased CT utilization.

Association of socioeconomic status with outcomes in older adult community-dwelling patients after visiting the emergency department: a retrospective cohort study

ObjectivesOlder adults frequently visit the emergency department (ED). Socioeconomic status (SES) has an important impact on health and ED utilisation; however, the association between SES and ED utilisation in elderly...

Sex differences in outcomes after discharge from Alberta emergency departments for asthma: A large population-based study

ABSTRACTObjective: Asthma exacerbations frequently result in emergency department (ED) visits. While sex differences have been identified in some asthma studies, there is a paucity of literature on sex differences in the ED setting, especially population-based ones. This study examines sex differences in important outcomes of patients discharged from EDs for acute asthma in Alberta, Canada. Methods: Alberta residents aged from 2 to 55 years discharged from EDs with a primary diagnosis of asthma during 1999–2011 were identified from administrative databases from a single-payer health care system for the entire geographic region of Alberta. Multivariable Cox regression models analyzed time to first follow-up physician or specialist visit, and logistic regression models analyzed the binary outcome of ED return within 30 days for asthma. Results: There were 115,853 discharged patients analyzed (40.4% and 59.1% female in pediatric and adult groups, respectively). Approximately 26% of patients revisited the ED during 1999–2011 and 5.1% did so within 30 days. Women had higher odds of a 30-day ED return after ED discharge than men (unadjusted odds ratio [uOR] = 1.26; 95% confidence interval [CI] 1.17–1.36). Time to first non-ED physician follow-up was shorter for girls (unadjusted hazard ratio [uHR] = 1.05; 95%CI 1.03–1.07) and women (uHR = 1.62; 95%CI 1.59–1.64) than for boys and men, respectively. Significant interactions between sex and age, socio-economic status, area of residence, and comorbidities were identified and changed the effect of sex on outcomes. Conclusions: In conclusion, women return to EDs within 30 days of discharge for acute asthma more often than men. Time to first non-ED physician follow-up for children and adults differed by sex. Multiple factors likely contribute to these differences; however, identifying these differences is critical to understand the influence of sex on health behaviors and outcomes.

Improvements in Patient and Health System Outcomes Using an Integrated Oncology and Palliative Medicine Approach on a Solid Tumor Inpatient Service.

Early palliative care (PC) improves outcomes for outpatients with advanced cancer. Its effect on hospitalized patients with cancer is unknown. Herein, we report on the influence of a novel, fully integrated inpatient medical oncology and PC partnership at a tertiary medical center during its first year of implementation. We conducted a retrospective, longitudinal, pre- and postintervention cohort study at Duke University Hospital. Pre- and postintervention cohorts were defined as all patients admitted to the solid tumor inpatient service from September 1, 2009, to June 30, 2010, and September 1, 2011 to June 30, 2012, respectively. We extracted patient data, including demographics, cancer diagnosis, disease status, length of stay, intensive care unit transfer rate, discharge disposition, time to emergency department return, time to readmission, and 7- and 30-day emergency department return and readmission rates. Nursing and physician surveys assessed satisfaction. Descriptive statistics, and Kruskal-Wallis and Χ2 tests were used to describe and compare cohorts. A generalized estimating equation accounted for repeated measures. Pre- and postintervention analysis cohorts included 731 and 783 patients, respectively, representing a total of 1,514 patients and 2,353 encounters. Cohorts were similar in baseline characteristics. Statistically significant lower odds in 7-day readmission rates were observed in the postintervention cohort (adjusted odds ratio, 0.76; 95% CI, 0.58 to 1.00; P = .0482). Patients in the postintervention group had a decrease in mean length of stay (-0.30 days; 95% CI, -0.62 to 0.02); P = .0651). We observed a trend for increasing hospice referrals ( P = .0837) and a 15% decrease in intensive care unit transfers ( P = .61). Physicians and nurses universally favored the model. A fully integrated inpatient partnership between PC and medical oncology is associated with significant and clinically meaningful improvements in key health system-related outcomes and indicators of quality cancer care.

Wide Variability in Emergency Physician Admission Rates: A Target to Reduce Costs Without Compromising Quality.

IntroductionAttending physician judgment is the traditional standard of care for emergency department (ED) admission decisions. The extent to which variability in admission decisions affect cost and quality is not well understood. We sought to determine the impact of variability in admission decisions on cost and quality.MethodsWe performed a retrospective observational study of patients presenting to a university-affiliated, urban ED from October 1, 2007, through September 30, 2008. The main outcome measures were admission rate, fiscal indicators (Medicaid-denied payment days), and quality indicators (15- and 30-day ED returns; delayed hospital admissions). We asked each Attending to estimate their inpatient admission rate and correlated their personal assessment with actual admission rates.ResultsAdmission rates, even after adjusting for known confounders, were highly variable (15.2%–32.0%) and correlated with Medicaid denied-payment day rates (p=0.038). There was no correlation with quality outcome measures (30-day ED return or delayed hospital admission). There was no significant correlation between actual and self-described admission rate; the range of mis-estimation was 0% to 117%.ConclusionEmergency medicine attending admission rates at this institution are highly variable, unexplained by known confounding variables, and unrelated to quality of care, as measured by 30-day ED return or delayed hospital admission. Admission optimization represents an important untapped potential for cost reduction through avoidable hospitalizations, with no apparent adverse effects on quality.

Is polypharmacy an independent risk factor for adverse outcomes after an emergency department visit?

This study aimed at verifying the role of polypharmacy as an independent risk factor for adverse health outcomes in older emergency department (ED) patients. This was a large (n=2057) sample of older ED patients (≥65years) participating in an observational cohort study. Polypharmacy and excessive polypharmacy were defined as having 6-9 drug prescriptions and 10 or more drug prescriptions in the last 3months, respectively. The total number of medication prescriptions was also available. Outcome measures were in-hospital mortality; 30-day ED return; ED revisit, hospital admission, and mortality at 6months. Logistic and Cox regression models as well as receiver operating characteristic curves using the Youden index and the area under the curve were calculated. Polypharmacy and excessive polypharmacy were present in 624 (30.3%) and 367 (17.8%) subjects, respectively. The mean number of prescriptions in the last 3months was 5.7 (range 0-25) drugs. Polypharmacy and, particularly, excessive polypharmacy were constantly and independently associated with worse outcomes. A cut-off of 6 had the highest value of the Youden Index in predicting the majority of the adverse outcomes considered. Polypharmacy and excessive polypharmacy are independent risk factors for adverse health outcomes after an ED visit. Further studies are needed to clarify whether drug related issues (such as non-compliance, inappropriate or suboptimal prescribing, adverse drug reactions, and drug-drug or drug-disease interactions) or underlying multimorbidity and disease severity, as well as clinical complexity and frailty, are responsible for the negative outcomes associated with polypharmacy.

Cardiac Acute Care Nurse Practitioner and 30-Day Readmission

The utilization outcomes of nurse practitioners (NPs) in the acute care setting have not been widely studied. The purpose of this study was to determine the impact on utilization outcomes of NPs on medical teams who take care of patients admitted to a cardiovascular intensive care unit. A retrospective 2-group comparative design was used to evaluate the outcomes of 185 patients with ST- or non ST-segment elevation myocardial infarction or heart failure who were admitted to a cardiovascular intensive care unit in an urban medical center. Patients received care from a medical team that included a cardiac acute care NP (n = 109) or medical team alone (n = 76). Patient history, cardiac assessment, medical interventions, discharge disposition, discharge time, and 3 utilization outcomes (ie, length of stay, 30-day readmission, and time of discharge) were compared between the 2 treatment groups. Logistic regression was used to identify predictors of 30-day readmission. Patients receiving care from a medical team that included an NP were rehospitalized approximately 50% less often compared with those receiving care from a medical team without an NP. Thirty-day hospital readmission (P = .011) and 30-day return rates to the emergency department (P = .021) were significantly lower in the intervention group. Significant predictors for rehospitalization included diagnosis of heart failure versus myocardial infarction (odds ratio [OR], 3.153, P = 0.005), treatment by a medical team without NP involvement (OR, 2.905, P = 0.008), and history of diabetes (OR, 2.310, P = 0.032). The addition of a cardiac acute care NP to medical teams caring for myocardial infarction and heart failure patients had a positive impact on 30-day emergency department return and hospital readmission rates.

A Clinical Prediction Model to Estimate Risk for 30-Day Adverse Events in Emergency Department Patients With Symptomatic Atrial Fibrillation

Atrial fibrillation affects more than 2 million people in the United States and accounts for nearly 1% of emergency department (ED) visits. Physicians have little information to guide risk stratification of patients with symptomatic atrial fibrillation and admit more than 65%. Our aim is to assess whether data available in the ED management of symptomatic atrial fibrillation can estimate a patient's risk of experiencing a 30-day adverse event. We systematically reviewed the electronic medical records of all ED patients presenting with symptomatic atrial fibrillation between August 2005 and July 2008. Predefined adverse outcomes included 30-day ED return visit, unscheduled hospitalization, cardiovascular complication, or death. We performed multivariable logistic regression to identify predictors of 30-day adverse events. The model was validated with 300 bootstrap replications. During the 3-year study period, 914 patients accounted for 1,228 ED visits. Eighty patients were excluded for non-atrial-fibrillation-related complaints and 2 patients had no follow-up recorded. Of 832 eligible patients, 216 (25.9%) experienced at least 1 of the 30-day adverse events. Increasing age (odds ratio [OR] 1.20 per decade; 95% confidence interval [CI] 1.06 to 1.36 per decade), complaint of dyspnea (OR 1.57; 95% CI 1.12 to 2.20), smokers (OR 2.35; 95% CI 1.47 to 3.76), inadequate ventricular rate control (OR 1.58; 95% CI 1.13 to 2.21), and patients receiving β-blockers (OR 1.44; 95% CI 1.02 to 2.04) were independently associated with higher risk for adverse events. C-index was 0.67. In ED patients with symptomatic atrial fibrillation, increased age, inadequate ED ventricular rate control, dyspnea, smoking, and β-blocker treatment were associated with an increased risk of a 30-day adverse event.