Avoidable Visits Research Articles

Medicaid Managed Care Lifts Barriers to Home Care

Medicaid Managed Care Lifts Barriers to Home Care

Asthma identification and medication administration forms in New York City schools

Asthma identification and medication administration forms in New York City schools

Avoidable and Unavoidable Visits to the Emergency Department Among Patients With Advanced Cancer Receiving Outpatient Palliative Care

ContextAdmissions to the emergency department (ED) can be distressing to patients with advanced cancer receiving palliative care. There is limited research about the clinical characteristics of these patients and whether these ED visits can be categorized as avoidable or unavoidable. ObjectivesTo determine the frequency of potentially avoidable ED visits (AvEDs) for patients with advanced cancer receiving outpatient palliative care in a large tertiary cancer center, identify the clinical characteristics of the patients receiving palliative care who visited the ED, and analyze the factors associated with AvEDs and unavoidable ED visits (UnAvEDs). MethodsWe randomly selected 200 advanced cancer patients receiving treatment in the outpatient palliative care clinic of a tertiary cancer center who visited the ED between January 2010 and December 2011. Visits were classified as AvED (if the problem could have been managed in the outpatient clinic or by telephone) or UnAvED. ResultsForty-six (23%) of 200 ED visits were classified as AvED, and 154 (77%) of 200 ED visits were classified as UnAvED. Pain (71/200, 36%) was the most common chief complaint in both groups. Altered mental status, dyspnea, fever, and bleeding were present in the UnAvED group only. Infection, neurologic events, and cancer-related dyspnea were significantly more frequent in the UnAvED group, whereas constipation and running out of pain medications were significantly more frequent in the AvED group (P < 0.001). In a multivariate analysis, AvED was associated with nonwhite ethnicity (odds ratio [OR] 2.66; 95% CI 1.26, 5.59) and constipation (OR 17.08; 95% CI 3.76, 77.67), whereas UnAvED was associated with ED referral from the outpatient oncology or palliative care clinic (OR 0.24; 95% CI 0.06, 0.88) and the presence of baseline dyspnea (OR 0.46; 95% CI 0.21, 0.99). ConclusionNearly one-fourth of ED visits by patients with advanced cancer receiving palliative care were potentially avoidable. Proactive efforts to improve communication and support between scheduled appointments are needed.

Resource utilization after gastrostomy tube placement: Defining areas of improvement for future quality improvement projects

BackgroundGastrostomy tube (GT) placement is a frequent procedure at a tertiary care children's hospital. Because of underlying patient illness and the nature of the device, patients often require multiple visits to the emergency room for GT-related concerns. We hypothesized that the majority of our patient visits to the ER related to gastrostomy tube concerns were not medically urgent. The purpose of this study was to characterize the incidence and indications for GT-related emergency room visits and readmission rates in order to develop family educational material that might allow for these nonurgent concerns to be addressed on an outpatient basis. MethodsWe reviewed the medical records of all patients with GT placement in the operating room from January 2011 to September 2012. We evaluated our primary outcome of ER visits at less than 30days after discharge and 30–365 days after discharge. The purpose of the ER visit was categorized as either mechanical (dislodgement, leaking) or wound-related (infection, granulation tissue). Additional outcomes assessed included readmission rates, reoperation rates, and the use of gastrostomy contrast studies. ResultsDuring the study period, 247 patients had gastrostomy tubes placed at our institution at a median age of 15.3months (range 0.03months–22years). Of the total patient population, 219 were discharged less than 30days after their operation (89%). Of these, 42 (20%) returned to the emergency room a total of 44 times within 30days of discharge for concerns related to their GT. Avoidable visits related to leaking, mild clogs, and granulation tissue were seen in 17/44 (39%). An additional 40 patients among the entire cohort of 247 (16%) presented to the ER a total of 71 times 31–365 days post-discharge; 59 (83%) of these visits were potentially avoidable. The readmission rate related to the GT was low (4%). ConclusionsFew studies have attempted to quantify the amount of postoperative resources utilized post-GT placement in children. Our findings indicated this is not an insignificant quantity. In response to these findings, we have developed a series of educational materials and identified a dedicated nurse to perform inpatient gastrostomy education to these patients prior to discharge.

Avoidable and Unavoidable Visits to the Emergency Department Among Advanced Cancer Patients (AdCa) Followed by the Supportive Care (SCPC) Outpatient Clinic (S715)

1.Describe characteristics of advanced cancer patients who visit emergency room.2.Describe possible interventions to prevent avoidable visits to ER of advanced cancer patients. Admissions to ED are considered undesirable for patients receiving palliative care. There is limited research about the clinical characteristics of Advanced Cancer patients (AdCa) followed by SCPC who visited ED, and if these ED visits can be categorized as avoidable or unavoidable. Retrospective study of 200 consecutive AdCa evaluated by the Supportive Care physician who visited the ED between January 2010 and December 2011. All patients were instructed to call our main number if there was any change in symptoms. Based on pre-defined criteria patients were classified as having an avoidable (if the problem could have been managed at the outpatient center or by telephone) or unavoidable visit. Demographics and clinical characteristics were collected and analyzed. 47/200(23.5%) AdCa were classified as having had avoidable ED visits (AvED) while 153/200(76.5%) had unavoidable ED visits (NAvED). Main reasons for NAvED were: changes in mental status (24/153, 16%), infectious processes (32/153, 21%), new onset/worsening of pain and dyspnea (75/153, 49%), and severe worsening of other symptoms (22/153, 14%). Age, gender, marital status, and cancer types or stages, and reasons for referral to SCPC and time to ED visit after SCPC evaluation were not significantly different between AvED and NAvED patients. Baseline Edmonton Symptom Assessment Scale (ESAS) showed no significant difference in pain, dyspnea, fatigue, drowsiness, nausea, well-being, anxiety, and depression for AvED vs. NAvED; except for sleep ≥1: 141/153 (92%) vs. 37/47 (79%), p=0.01001, respectively. None of the patients phoned the SCPC before the ED visit. 17/153 (11%) of AdCa called their primary oncologist before NAvED visit vs. 1/46 (2%) having called before AvED, p=0.078. Multivariate analysis showed that NAvED was associated with worsening of pain (OR:2.485, p<0.0179), changes in mental status (OR:23.143, p<0.0098), and sleep disturbance (OR:3.611, p<0.0116). 0/47 (0%) AvED vs. 93/153 (51%) of NAvED were admitted to the hospital, p<0.0001. More than one in five of ED visits by AdCa are avoidable. Efforts to improve communication after the scheduled appointments through clinician initiated phone calls, electronic communication, and more frequent visits are needed.

Avoidable and unavoidable visits to the emergency department among advanced cancer patients (AdCa) followed by the supportive care (SCPC) outpatient clinic.

140 Background: Admissions to ED are considered undesirable for AdCa receiving palliative care. There is limited research about clinical characteristics of AdCa followed by SCPC who visited ED, and if these ED visits can be categorized as avoidable or unavoidable. Methods: Retrospective study of 200 consecutive AdCa evaluated by the SCPC physician who visited ED between January 2010 and December 2011. All patients were instructed to call to our main number if any change in symptoms. Based on pre-defined criteria AdCa were classified as having an avoidable (if the problem could have been managed at the outpatient center or by telephone) or unavoidable visit. Demographics and clinical characteristics were collected and analyzed. Results: 47/200 (23.5%) AdCa had avoidable ED-visits (AvED) and 153/200 (76.5%) had unavoidable ED-visits (NAvED). Main reasons for NAvED: changes in mental statu s(24/153, 16%), infectious processes (32/153, 21%), new onset/worsening of pain and dyspnea (75/153,49%), and severe worsening others symptoms (22/153,14%). Age, gender, marital status, and cancer types, reasons for referral to SCPC, and time to ED-visit after SCPC visit were not significantly different between AvED and NAvED patients. Baseline Edmonton Symptom Assessment Scale showed no significant difference in pain, dyspnea, fatigue, drowsiness, nausea, well-being, anxiety, and depression for AvED vs. NAvED; except for sleep ≥1: 141/153 (92%) vs. 37/47 (79%), p=0.01001, respectively. None of the patients phoned the SCPC before to ED visit. 17/153 (11%) of AdCa called their primary oncology before NAvED visit vs. 1/46(2%) call before AvED, p=0.078. Multivariate analysis showed that NAvED was associated with worsening of pain (OR:2.485, p&lt;0.0179), changes in mental status (OR:23.143, p&lt;0.0098), and sleep disturbance(OR:3.611, p&lt;0.0116). 0/47(0%) AvED vs. 93/153 (51%) of NAvED were admitted to the hospital, p&lt;0.0001. Conclusions: More than one in five of ED visits by AdCa are avoidable. Efforts through to improve communication after the scheduled appointments, through clinician initiated phone calls, electronic communication and more frequent visits are needed.

How to Improve Dose Administration Aids for Aged Care Facilities

During transitions of care, older adults are at risk of adverse drug events which could lead to avoidable hospital visits. Pharmacists are increasingly involved in care teams at various stages of the continuum of care. The types and frequency of clinical interventions performed by pharmacists in the geriatric practice setting remain poorly documented.This study aimed to describe the current integration of pharmacist interventions during transitions of care of older adults admitted in short-term geriatric units (STGUs) and to explore barriers and facilitators to their implementation in clinical practice. The secondary objective was to explore associations between certain patient characteristics and pharmacist-led interventions during transitional care.A mixed methods study was conducted with pharmacists practicing in STGUs in the Montreal area, Canada. The application of 8 pharmaceutical interventions was assessed using a self-administered questionnaire, along with as a retrospective chart review. Four semi-structured group interviews were conducted in order to identify perceived barriers and facilitators.Thirteen pharmacists participated in the study. In the questionnaire, medication reconciliation on admission and at discharge was reported as being performed at least half the time by 12 (92%) and 7 (54%) pharmacists, respectively. The retrospective chart review revealed that these interventions were documented in 95 (98%) and 25 (26%) files, respectively. While 35% of patients had a documented pharmaceutical care plan on admission, none was documented at discharge. Several barriers to implementing clinical interventions were identified such as lack of time, technical support, communication and standardization.Pharmacists are involved at different periods of transitional care; however, certain barriers should be addressed in order to expand their role in discharge planning. Providing guidelines on what is expected at discharge and post-discharge, and having a practice focused on delegation and collaboration would help pharmacists increase their role throughout the transition of care of older adults.

Chen, colleagues provide MTM in L.A.’s most vulnerable neighborhoods

Chen, colleagues provide MTM in L.A.’s most vulnerable neighborhoods

Do Free Clinics Reduce Unnecessary Emergency Department Visits?: The Virginian Experience

As part of the safety net, free clinics (FCs) increase access to preventive and primary care for the uninsured. This study compared a group of uninsured FC users and a group of uninsured non-FC users to explore the impact of FC enrollment on the pattern of ED visits, as characterized by (1) level of complexity of care received at the ED, and (2) avoidable vs. unavoidable as classified by an existing clinical algorithm. Emergency department visits by FC users were less likely to be low-level-of-care than visits by non-FC users (OR 0.89, 95% CI 0.84-0.93). Free clinic enrollment was not a statistically significant predictor of avoidable visits (p=.6465). We found that the group of individuals who had access to primary care at the local FCs were significantly less likely than the group of uninsured individuals who were not enrolled in a FC to use the ED for care with lower levels of clinical complexity. Thus, the cost of increasing the primary care workforce as the Medicaid population expands may be worth it in the long run. Further exploration into what characterizes an effective FC is needed.

Characteristics of people with epilepsy who attend emergency departments: Prospective study of metropolitan hospital attendees

One fifth of people with established epilepsy attend hospital emergency departments (EDs) and one half are admitted each year. These ED visits are not necessarily required, and unplanned hospitalizations are costly. Reducing avoidable ED visits and admissions is a target in most health services. The development of interventions is, however, challenging. Policymakers lack information about users' characteristics, factors associated with ED use, as well as quality of care. This study provides this information. We prospectively recruited patients attending three London EDs for seizures. They completed questionnaires on service use and psychosocial state. Eighty-five patients were recruited. The mean age was 41; 53% were male. The average number of ED attendances in the prior year (mean 3.2; median 2) exceeded that of other ED users and those with most chronic conditions. ED use was not homogenous, with some patients attending frequently. Compared to the wider epilepsy population, ED attendees experienced more seizures, anxiety, had lower knowledge of epilepsy and its management and greater perceived epilepsy-related stigma. In the previous 12 months, most patients' epilepsy outpatient care was consistent with standard criteria for quality. In descending order, lower knowledge, higher perceived stigma, poorer self-medication management, and seizure frequency were associated with more emergency visits. People with epilepsy presenting to EDs reattend frequently. Interventions aiming at reduced ED use by this population should address lower knowledge, stigma, suboptimal self-management, and frequent seizures reported by patients.

Context and significance of emergency department visits and readmissions after pediatric appendectomy

Background The readmission rate after pediatric appendectomy is frequently reported in clinical outcomes studies and quality improvement initiatives without proper description. Our aim was to delineate the context and significance of these encounters. Methods Patients (<18 years old) who underwent appendectomy for acute appendicitis at a tertiary children's hospital from January 2007 through June 2010 were reviewed. Emergency department (ED) visits and inpatient readmissions within 90 days were identified and classified as unrelated, related surgical complications, or potentially avoidable visits for minor related concerns. Results Of 629 patients, 119 (18.9%) had 141 ED visits or readmissions within 90 days after discharge. Eighty-three (58.9%) encounters were limited to the ED, and 58 (41.1%) required inpatient hospitalization. Eighty-seven percent of encounters within the first 30 days after discharge, but only 26% of those occurring beyond 30 days, were related to the operation ( P < .001). Overall, 45 (31.9%) ED visits or readmissions were totally unrelated to the appendectomy, 36 (25.5%) represented true surgical complications requiring inpatient hospitalization, and 60 (42.6%) were minor, potentially avoidable visits related to the appendectomy. Potentially avoidable encounters were more common in Spanish-speaking patients ( P < .01). Conclusions Emergency department visits and inpatient readmissions after pediatric appendectomy are frequent but not uniformly indicative of surgical complications or suboptimal care. Opportunities exist to reduce avoidable ED visits related to minor postoperative concerns.

Abstract 2095: Health Policy: Can an Open Access Model for Intravenous Diuretics in an Outpatient Heart Failure Disease Management Program Reduce Hospital Costs?

Background: Heart failure (HF) is the most frequent discharge diagnosis for patients older than 65 and one of the most expensive diseases to treat for CMS. Patients with early symptoms of decompensated HF may need access to IV diuretics when oral medications used in a sliding scale dosage are no longer effective. Indigent patients without access to a private physician are at particular risk of having to use the emergency room (ER) for this reason. This model results in more costs and potential admissions. We sought to reduce ER use and improve quality of care and service to indigent patients followed in a Heart Failure Disease Management Program (HFDMP). Methods: Grant funding was procured to provide free furosemide IVP, potassium and metolazone for patients enrolled in a HFDMP at Jackson Memorial Hospital. The HFDM program consist of intense patient education using DVD’s in both English and Spanish, written material, log books for weight, activity, blood pressure and diuretic use. Patients are instructed to weight daily and add an additional oral dose of furosemide at home for weight gain of greater than 2 pounds. For weight gain of greater than 5 pounds unresponsive to oral therapy, patients were given access to the clinic without an appointment for “walk-in” IVP furosemide, potassium and metolazone. Results: 173 new patients were enrolled into program in 3 months (10/07 through 12/31/07). Of these, 115 visits for IVP furosemide were recorded from 54 patients. 16 patients used it multiple times (range 2–11). Average ER cost for all CHF patient seen and discharged after diuresis at JMH is $25,692. Therefore, an estimated cost savings of 115 avoidable ER visits is $2,954,586. In the last three quarters of 2007, of all CHF patients seen in the ER, 96.6% are admitted. The average inpatient cost for a primary diagnosis of CHF was $26,404.05 (LOS 5.25 days). The average for a CHF patient seen and discharged from the ER was $5,295 (LOS &lt;48hrs). All monetary values are Billed Charges. Conclusion: An open access IVP furosemide program is cost effective alternative to ER and inpatient treatment for CHF patients requiring diuresis.

Caractéristiques, consommation de ressources des usagers des services d’urgences de plus de 75 ans en France: Résultats d’une enquête nationale

Because the elderly tend to have complex and multiple diseases, they are likely to use emergency department (ED) resources at higher rates than other age groups. This study sought to determine the characteristics and resource use of the elderly patients (>or=75 years old) visiting EDs in France and assessed the effect of age on resource use.The sample was selected from the DREES prospective study of 150 French EDs for one week in 2002. A case report form was completed for each patient, stating the reasons for consultation, method of arrival, treatment, and outcome. Data were weighted to produce a representative national description.Of the 9801 patients seen that week, the elderly (n=1153) accounted for 11.8% of all ED visits, that is, 26 676 ED visits weekly nationwide. In this group, the mean age was 83 years and 60.9% were women. Most patients arrived by medical transportation: 55.6% by nonemergency ambulances and 24.6% by emergency medical transport. More than 75% were referred by their general practitioner (GP). Medical problems (69.5%) were much more frequent than trauma (24.8%). Clinical status was stable in 62% of cases. Use of ED resources was high: radiographs for 74.0%, laboratory testing for 71.0% and electrocardiography for 64.0%. The percentage of unnecessary or avoidable visits was small: 8.7% were not admitted, were clinically stable, and came for diagnostic tests that could have been performed on an outpatient basis. Age was an independent factor of pre-ED and ED resource use.Unplanned health care of the elderly uses substantial ED resources. Elderly patients appear to use available resources appropriately. Demographic trends show that their ED use will increase. Accordingly, analysis of the organization and funding of ED services for this population is indispensable.

Emergency department revisits.

We reviewed the charts of patients returning within 72 hours to our emergency department to determine whether monitoring revisits is a useful quality assurance indicator. Patient visits for June and December 1987 were selected to eliminate a potential seasonal difference. Of the 13,261 visits during these two months, 455 (3.4%) were revisits within 72 hours. Charts were available on 444 patients, of whom 407 (91.7%) represented cases in which the return and the initial visits were clearly related. Charts were reviewed for deficiencies in medical management, appropriate prescribed follow-up, patient education, and patient compliance. Suspected medical management problems were discussed by the three senior authors, and a consensus decision was made. Return visits were considered avoidable if a deficiency was noted in at least one of the areas listed above. There were 297 unscheduled related return visits, 96 (32.3%) of which were avoidable. Of these avoidable visits, 38 (39.6%) had medical management deficiencies, 14 (14.6%) had inappropriate prescribed follow-up, 20 (20.8%) had not been given proper education, and 35 (36.5%) were due to patient noncompliance. Of the 110 scheduled return visits, there was one (0.9%) deficiency in medical management and none in the other categories. Of the unscheduled return visits, 146 (49.2%) returned within 24 hours; 89 (30.0%) between 24 and 48 hours; and 62 (20.8%) between 48 and 72 hours. Of the avoidable visits, 85% returned within 48 hours, as did 92% of those with medical management deficiencies.(ABSTRACT TRUNCATED AT 250 WORDS)