Decrease In Emergency Department Visits Research Articles

Shift in emergency department utilization by frequent attendees with sickle cell disease during the COVID-19 pandemic: Amulticentre cohort study.

While the coronavirus disease-2019 (COVID-19) might have increased acute episodes in people living with sickle cell disease (SCD), it may also have changed their reliance on emergency department (ED) services. We assessed the impact of the COVID-19 pandemic and lockdowns on ED visits in adult SCD people followed in five French reference centres, with a special focus on 'high users' (≥10 visits in 2019). We analysed the rate of ED visits from 1 January 2015 to 31 December 2021, using a self-controlled case series. Among 1530 people (17 829 ED visits), we observed a significant reduction in ED visits during and after lockdowns, but the effect vanished over time. Compared to pre-pandemic, incidence rate ratios for ED visits were 0.59 [95% CI 0.52-0.67] for the first lockdown, 0.66 [95% CI 0.58-0.75] for the second and 0.85 [95% CI 0.73-0.99] for the third. High users (4% of people but 33.7% of visits) mainly drove the reductions after the first lockdown. COVID-19 lockdowns were associated with reduced ED visits. While most people returned to their baseline utilization by April 2021, high users had a lasting decrease in ED visits. Understanding the factors driving the drop in ED utilization among high users might inform clinical practice and health policy.

Association between stringency of lockdown measures and emergency department visits during the COVID-19 pandemic: A Dutch multicentre study.

The COVID-19 outbreak disrupted regular health care, including the Emergency Department (ED), and resulted in insufficient ICU capacity. Lockdown measures were taken to prevent disease spread and hospital overcrowding. Little is known about the relationship of stringency of lockdown measures on ED utilization. This study aimed to compare the frequency and characteristics of ED visits during the COVID-19 outbreak in 2020 to 2019, and their relation to stringency of lockdown measures. A retrospective multicentre study among five Dutch hospitals was performed. The primary outcome was the absolute number of ED visits (year 2018 and 2019 compared to 2020). Secondary outcomes were age, sex, triage category, way of transportation, referral, disposition, and treating medical specialty. The relation between stringency of lockdown measures, measured with the Oxford Stringency Index (OSI) and number and characteristics of ED visits was analysed. The total number of ED visits in the five hospitals in 2019 was 165,894, whereas the total number of visits in 2020 was 135,762, which was a decrease of 18.2% (range per hospital: 10.5%-30.7%). The reduction in ED visits was greater during periods of high stringency lockdown measures, as indicated by OSI. The number of ED visits in the Netherlands has significantly dropped during the first year of the COVID-19 pandemic, with a clear association between decreasing ED visits and increasing lockdown measures. The OSI could be used as an indicator in the management of ED visits during a future pandemic.

Inflicted violence-related injuries among children and youth in Ontario during the COVID-19 pandemic

BackgroundDuring the COVID-19 pandemic, it was hypothesized that stay-at-home policies would impact cases of violence, abuse, and neglect among children and youth due to increased familial stressors. ObjectiveWe examined the effect of the implementation of pandemic policies on violence-related emergency department (ED) visits and hospitalizations among youth. ParticipantsViolence-related ED visits and hospitalizations among children and youth ages 0–19 in Ontario, Canada were obtained from April 2015 until the most recent available date, March 31, 2022. MethodsWe used an interrupted time series design to model the change in monthly violence-related ED visits and hospitalizations before and during the pandemic. We used negative binomial models to estimate the immediate effect of the policy and the change in the number of injuries during the pandemic. ResultsAfter adjusting for seasonality and population changes over our study period, we observed a 56% decrease in violence-related ED visits (RR: 0.44, 95%CI: 0.38, 0.50) and a 35% decrease in hospitalizations (RR: 0.65, 95%CI: 0.52, 0.82) immediately after the implementation of the pandemic policy, followed by moderate increasing trends. We observed no difference in the effect of the pandemic policies on the rate of violence-related ED visits and hospitalizations by sex, age or material deprivation; however, males aged 10–19 years and those in higher quintiles of material deprivation had higher average rates of injuries compared to females, those in younger age groups and lower quintiles of deprivation over the study period. ConclusionsWe observed an abrupt decrease in the rate of violence-related ED visits and hospitalizations immediately after the onset of pandemic policies in Ontario. Following this, violence-related injuries increased, approaching pre-pandemic levels.

Healthcare Utilization (HCU) Reduction with High-Frequency (10 kHz) Spinal Cord Stimulation (SCS) Therapy.

Spinal cord stimulation (SCS) is a well-established treatment for patients with chronic pain. With increasing healthcare costs, it is important to determine the benefits of SCS in healthcare utilization (HCU). This retrospective, single-center observational study involved 160 subjects who underwent implantation of a high-frequency (10 kHz) SCS device. We focused on assessing trends in HCU by measuring opioid consumption in morphine milligram equivalents (MME), as well as monitoring emergency department (ED) and office visits for interventional pain procedures during the 12-month period preceding and following the SCS implant. Our results revealed a statistically significant reduction in HCU in all domains assessed. The mean MME was 51.05 and 26.52 pre- and post-implant, respectively. There was a 24.53 MME overall decrease and a mean of 78.2% statistically significant dose reduction (p < 0.0001). Of these, 91.5% reached a minimally clinically important difference (MCID) in opioid reduction. Similarly, we found a statistically significant (p < 0.01) decrease in ED visits, with a mean of 0.12 pre- and 0.03 post-implant, and a decrease in office visits for interventional pain procedures from a 1.39 pre- to 0.28 post-10 kHz SCS implant, representing a 1.11 statistically significant (p < 0.0001) mean reduction. Our study reports the largest cohort of real-world data published to date analyzing HCU trends with 10 kHz SCS for multiple pain etiologies. Furthermore, this is the first and only study evaluating HCU trends with 10 kHz SCS by assessing opioid use, ED visits, and outpatient visits for interventional pain procedures collectively. Preceding studies have individually investigated these outcomes, consistently yielding positive results comparable to our findings.

Decreasing Emergency Department Visits After Surgery Among Patients at Risk for Postoperative Urinary Retention.

Decreasing Emergency Department Visits After Surgery Among Patients at Risk for Postoperative Urinary Retention.

Trends in hallucinogen-associated emergency department visits and hospitalizations in California, USA, from 2016 to 2022.

Hallucinogens encompass a diverse range of compounds of increasing scientific and public interest. Risks associated with hallucinogen use are under-researched and poorly understood. We aimed to compare the trends in hallucinogen-associated health-care use with alcohol- and cannabis-associated health-care use. We conducted an ecological study with publicly available data on International Classification of Diseases, 10th Revision (ICD-10) diagnosis codes associated with emergency department (ED) visits and hospitalizations from the California Department of Healthcare Access and Information (HCAI). HCAI includes primary and secondary ICD-10 codes reported with ED or hospital discharge from every non-federal health-care facility licensed in California, United States, from 2016 to 2022. ICD-10 codes were classified as hallucinogen-, cannabis- or alcohol-associated if they were from the corresponding category in the ICD-10 block 'mental and behavioral disorders due to psychoactive substance use'. Observed hallucinogen-associated ED visits increased by 54% between 2016 and 2022, from 2260 visits to 3476 visits, compared with a 20% decrease in alcohol-associated ED visits and a 15% increase in cannabis-associated ED visits. The observed hallucinogen-associated hospitalizations increased by 55% during the same period, from 2556 to 3965 hospitalizations, compared with a 1% increase in alcohol-associated hospitalizations and a 1% increase in cannabis-associated hospitalizations. This rise in hallucinogenic ED visits was significantly different from the trend in cannabis-associated (P < 0.001) and alcohol-associated (P = 0.005) ED visits. The hallucinogen-associated hospitalizations trend also significantly differed when compared with cannabis- (P < 0.001) and alcohol-associated (P < 0.001) hospitalizations. Hallucinogen-associated emergency department visits and hospitalizations in California, USA, showed a large relative but small absolute increase between 2016 and 2022.

Medical advice lines offering on-demand access to providers reduced emergency department visits.

Instant access to clinicians through virtual care is designed to allow patients to receive care they need while avoiding high-cost visits in acute-care settings. This study investigates the effect of offering patients the option to instantly connect with emergency care providers instead of being referred to the emergency department (ED) following calls to a medical advice line. We used a staggered rollout design to assess the effects of implementing this program on key outcomes among Veterans Affairs enrollees. Analyzing over 1 million calls from 2019 to 2022, we found that access to a provider reduced the proportion of patients who subsequently visited the ED compared with those with access to the standard medical advice line (38% vs 36%). There was no significant difference observed in subsequent inpatient admissions or 30-day mortality. We found that a majority of callers (65%) achieved issue resolution or were directed to lower acuity settings for further evaluation. Although substantial direct cost savings were not evident, our findings demonstrate that on-demand access to a virtual provider can effectively decrease ED visits.

Outpatient Management of Sickle Cell Vaso-Occlusive Crisis As a Strategy of Decreasing Emergency Department Visits

Background: Complications of sickle cell disease (SCD), including vaso-occlusive crises (VOC), usually require emergency room visits or even hospitalization for management. Outpatient treatment programs have been developed for management of VOC, however the literature is limited as to the efficacy of these models. Previously, patients in Edmonton, Canada followed by the Hemoglobinopathy Clinic would have to present to the emergency department (ED) for assessment of and management of VOC. Since 2019, patients experiencing early VOC symptoms were able to present to the Medical Outpatient Unit (MOU), an infusion clinic shared with other benign and malignant hematology conditions, to be assessed and receive treatment. This study retrospectively evaluated the outcomes of this treatment strategy. Hypothesis: Outpatient management of VOC is an effective way to assess patients and provide appropriate treatment, thereby reducing the frequency of ED presentations for SCD patients. Methods: Patients were able to schedule their own appointments and were encouraged to present early before they developed severe symptoms. They would be assessed by a nurse, who could then release orders from their personalized pain plan, which is a standing set of orders from an SCD clinic physician. Examples of orders include intravenous fluids and pain medications. Based on the severity of symptoms, patients could also be referred to the ED or for assessment by a physician or nurse practitioner. Chart review of patients aged 18 years or older with SCD followed by the Edmonton Hemoglobinopathy Clinic and who presented to MOU from November 2019 to December 2022 for management of VOC was completed. Information gathered included if the patient was on hydroxyurea at the time, investigations ordered, treatments administered, if NP or physician assessment was required, and disposition following the encounter. Encounters within 7 days were counted as one episode and assumed to be the same VOC event. Visits to ED for this cohort were counted and compared to the number of ED visits from 2016 to 2018. Results: 26 SCD patients had at least one MOU encounter for VOC or prophylaxis resulting in a total of 136 encounters (median 2, maximum 25). These accounted for 96 separate episodes of VOC (median 2, maximum 19), with a median of 1 encounter to MOU per episode (maximum 5). Patient demographics had a mean age of 32 years as of the beginning of the study (maximum 65, minimum 16) with 14 males (54%) and 12 females (46%). Patient diagnoses included 10 with HbSS (38%), 12 with HbSC (46%), 3 with HbSD (12%), and 1 with HbSB° (4%). 21 of 26 patients (81%) were on hydroxyurea at some point during this time period. IV fluids were administered in 129 encounters (95%), and pain medications were given in 64 encounters (47%), with opioid medications being given in 24 encounters (18%). 109 encounters had assessment by a nurse only (80%), while 24 were also assessed by a nurse practitioner (18%) and only 3 required assessment by a physician (2%). Patients were discharged home in 134 of 136 encounters (99%), with only 2 encounters resulting in assessment in ED. 70 of 96 episodes of VOC treated in MOU did not have presentation to ED within 30 days (73%). Total ED visits for this cohort decreased from 59 in 2016-2018 to 38 during the time of this study. Conclusion: Treatment of VOC in an outpatient setting was effective for assessment and treatment and decreased ED visits in our cohort. While retrospective, these results suggest outpatient treatment of VOC can be completed safely and efficiently in a shared infusion unit and may be generalized to other centres with outpatient IV infusion programs.

Prospective Cohort Study of Emergency Department Visit Frequency and Diagnoses Before and During COVID-19 Pandemic in Urban, Low-Income, US- and Foreign-Born Mothers in Boston, MA.

The coronavirus 2019 (COVID-19) pandemic fundamentally changed how populations interface with the healthcare system. Despite historical spikes in US mortality during the pandemic, emergency department (ED) visits were paradoxically low. This is a concerning phenomenon that raises a red flag regarding access to care, especially among vulnerable populations. In this study we sought to understand how ED utilization evolved during the COVID-19 pandemic among traditionally understudied, low-income, racially diverse US- and foreign-born mothers. This is a secondary analysis of a pre-existing dataset of 3,073 participants enrolled in the Boston Birth Cohort at birth and followed prospectively. We obtained ED visit diagnoses from 2019 and 2020 via electronic health records, categorized according to the International Classification of Diseases, 10th Revision, and compared them using graph plots, chi-square, and negative binomial regression. The number of ED visits decreased by 29.1% (P < 0.001) from 2019 (1,376) to 2020 (976). However, visits for infectious and parasitic diseases, including COVID-19, increased by 90.6% (32:61) with COVID-19 accounting for 77% of those visits in 2020 (47/61). Mental health-related visits increased by 40.9% (44:62), with diagnoses of alcohol use disorder increasing by 183% (6:17). Regression analysis showed 50% less ED utilization among foreign- vs US-born participants; however, the increase in infectious diseases visits was greater among foreign-born compared to US-born mothers (185% vs 26%, P = 0.01), while the increase in mental health diagnoses was greater among US-born mothers (69% vs -33%, P = 0.10). Despite a decrease in total ED visits during the pandemic, there was an increase in COVID-19- (immigrant > US born) and mental health- (US-born only) related visits. Our findings demonstrate that EDs remain a critical access point for care for minority populations and have implications for preparedness, resources, and services of EDs in urban settings to better address the needs of communities. However, alternative avenues for healthcare services for these populations, particularly during health crises, warrant further investigation.

Effect of extended pharmacist involvement in discharge transitions of care on hospital readmission rates: Prospective, randomized, parallel arm design trial

AbstractPharmacist involvement in transitions of care has been shown to improve patient outcomes and reduce readmission rates. Pharmacists reduce medication errors at discharge by ensuring all home medications continued are appropriate, provide pharmacist discharge patient medication education on new and existing medications therapies, and evaluate the safety and efficacy of the patient's medication therapy in order to decrease readmission rates. Results from this study may provide a financial benefit for hospital reimbursement by reducing 30 day readmission rates. The primary outcome was the comparison of composite emergency department (ED) and hospital 30 day readmission rates for patients that have extended pharmacist intervention at discharge versus standard of care. Patients 18 years of age and older with a readmission risk score of 25 or greater, and admitted on general medicine floors from November 1, 2022 through February 28, 2023 were included. Patients were randomized into a standard of care (SOC) or extended SOC group. The primary outcome was the comparison of composite ED and hospital 30 day readmission rates for patients that have extended pharmacist intervention at discharge versus SOC. A key secondary outcome included number of drug‐related problems identified and resolved. The primary outcome was analyzed using chi‐squared analysis (alpha of 0.05) and secondary outcomes as descriptive statistics. Data was analyzed using Stata® 16.1 statistical software. Two hundred and ninety‐six patients were included for analysis with 148 patients in both extended SOC and SOC groups. Extended SOC decreased the composite 30 day ED visit and hospital readmission rate by 7% (p = 0.63). Extended SOC group decreased 30 day ED visits by 4.9% and inpatient 30 day readmissions by 8.2% analyzed using descriptive statistics. Patients in extended SOC group resulted in a non‐statistical decrease in ED visits and inpatient readmissions 30 days after discharge compared to SOC group.

Association of serotonin reuptake inhibitors with asthma control.

Background: Clinical trials demonstrated that selective serotonin reuptake inhibitors (SSRI) can improve asthma control in patients with comorbid major depressive disorder (MDD) and that this effect may be greater than the effect of SSRIs on depression. These findings suggest that SSRIs may improve asthma control in patients without MDD. Objective: The current retrospective study examined the effect of SSRIs and serotonin and norepinephrine reuptake inhibitors (SNRI) on asthma control in adult patients. We hypothesized that patients would have fewer asthma exacerbations after treatment with an SSRI or SNRI. Methods: Electronic health record data of adult patients (N = 592) who were seen at a University of Texas Southwestern (UTSW) hospital or clinic and had (1) an SSRI or SNRI prescription, (2) a previous asthma diagnosis, and (3) no mood disorder diagnosis were extracted by using the UTSW Clinical Data Exchange Network. Wilcoxon signed rank tests were used to compare oral corticosteroid prescriptions and asthma-related emergency department (ED) visits and hospitalizations in the 12 months before and after the start of an SSRI/SNRI. Results: Therapy with SSRIs/SNRIs was associated with a significant decrease in oral corticosteroid use (p = 0.003), ED visits (p = 0.002), and hospitalizations (p < 0.001). Conclusion: Results from the current study add to the existing literature by demonstrating a reduced rate of severe exacerbations in patients with asthma by using an SSRI/SNRI without limiting the analytic sample to a high-illness-severity subgroup defined by symptoms of asthma or depression. Future work should include a prospective, placebo controlled study with individuals who have asthma and no comorbid mental health condition, verified by a mental health professional.

Impact of the COVID-19 pandemic on emergency department alcohol intoxication presentations and positive screens for problem drinking.

Our aim was to assess the changes in patients presenting with acute alcohol intoxications or positive screens for problem drinking during the COVID-19 pandemic compared to before the pandemic in a seven-hospital health system. A retrospective chart review of emergency department (ED) visits from seven hospitals in the Washington, DC/Baltimore, and MD area from January 2019 to June 2021 is provided. The health system utilizes a validated system for Screening, Brief Intervention, and Referral to Treatment (SBIRT) for ED patients. We evaluated trends in patients who had a positive SBIRT screen for problem drinking (AUDIT-C score ≥ 3 in women, 4 in men), alcohol misuse (≥5), and those presenting with acute alcohol intoxication before March 2020 and during the early COVID pandemic period. There were 510648 patients who were screened, ranging from ages of 16 to 95years during the study period. There was an overall increase in patients who screened positive for problem drinking, alcohol misuse, and acute intoxications. While there was an overall decrease in the total number of ED visits during the start of the pandemic, which later increased near prepandemic levels, alcohol-related presentations as a percentage of total visits increased during the early pandemic period. There was an overall decrease in ED visits during the COVID-19 pandemic study period; problem drinking and acute intoxication presentation held steady, leading to an overall increase in proportion compared to pre-COVID-19 levels. Future research should focus on lessons learned during this time and should navigate the postpandemic care of patients with AUD. There was an increase in the proportion of ED visits for alcohol intoxications and positive screens for problem drinking during the COVID-19 pandemic in our seven-hospital system.

Drivers that decrease hospital-delivered care in children with medical complexity: Parental perspectives

Abstract Background and objective Children with medical complexity (CMC) have chronic and severe conditions leading to medical fragility. CMC represent less than 1% of children but account for one-third of paediatric healthcare expenditures. Enrollment to a complex care program (CCP) decreases health care resource utilization while improving parental satisfaction. An in-depth understanding of how these changes operate in real-world setting is needed to further support CMC and their families. This study aimed at assessing the possible reasons for a decrease in emergency department (ED) visits and hospitalization length of stay related to enrollment to a CCP, based on parental perspectives. Study design Using a qualitative approach, data were collected using in-depth, semi-structured interviews with parents of CMC enrolled in a CCP from a university hospital centre in Montreal, Canada. The interview guide was co-constructed by an interdisciplinary team, including a parent partner and a clinical nurse coordinator. Themes have been identified inductively, using thematic analysis. Results Parents identified personalized care, family empowerment and guidance as enablers arising from the CCP that contributed to the decrease in hospital-delivered care utilization. Improvement in medical baseline condition was also identified as a contributing factor, while not necessarily related to program’s support. Conclusions In this study, we identified personalized care, parental empowerment, and guidance as three strategies for a CCP to potentially decrease ED visits and hospital length of stay, from the parents’ perspective. Parents identified the clinical nurse coordinator as playing a central role in supporting the implementation of these strategies.

Implementation of a heart failure educational intervention for patients with recent admissions for acute decompensated heart failure.

This study examined whether implementation of a heart failure (HF) education class targeted at patients and their caregivers decreased worsening HF, emergency department (ED) visits and hospital admissions, and improved patient quality of life and confidence in disease state management. Patients with HF and a recent hospital admission for acute decompensated heart failure (ADHF) were offered an educational course covering HF pathophysiology, medications, diet, and lifestyle modifications. Patients completed surveys before and 30 days after completion of the educational course. Outcomes of participants at 30 and 90 days after class completion were compared against outcomes for the same patients at 30 and 90 days prior to course attendance. Data was collected using electronic medical records, in-person during the class, and during a phone follow-up. The primary outcome was a composite of hospital admission, ED visit, and/or outpatient visit for HF at 90 days. A total of twenty-six patients attended classes between September 2018 and February 2019 and were included in the analysis. Median age was 70 years, and most patients were white. All patients were American College of Cardiology/American Heart Association (ACC/AHA) Stage C and a majority had New York Heart Association (NYHA) Class II or III symptoms. Median left ventricular ejection fraction (LVEF) was 40%. The primary composite outcome occurred significantly more frequently in the 90 days prior to class attendance than in the 90 days following attendance (96% vs. 35%, p < 0.01). Likewise, the secondary composite outcome occurred significantly more frequently in the 30 days before class attendance than in the 30 days following (54% vs. 19%, p = 0.02). These results were driven by a decrease in admissions and ED visits for HF symptoms. Survey scores related to patient HF self-management practices and patient confidence in ability to self-manage HF increased numerically from baseline to 30 days after class attendance. Implementation of an educational class for HF patients improved patient outcomes, confidence, and ability to self-manage HF. Hospital admissions and ED visits also decreased. Adoption of such a course might help to decrease overall health care costs and improve patient quality of life.

Evaluating the impact of a virtual outpatient care programme in preventing hospitalizations, emergency department visits and mortality for patients with COVID-19: a matched cohort study

ObjectivesTo evaluate the impact of virtual care in preventing unnecessary healthcare visits for patients with SARS-CoV-2. MethodsWe conducted a retrospective matched cohort study, evaluating the COVID-19 Expansion to Outpatients (COVIDEO) programme involving virtual assessments for all positive patients in the Sunnybrook assessment centre from January 2020 to June 2021, followed by risk-stratified routine follow-up, couriering of oxygen saturation devices, and 24 hour/day direct-to-physician pager for urgent questions. We linked COVIDEO data to province-wide datasets, matching each eligible COVIDEO patient to ≤10 other Ontario SARS-CoV-2 patients on age, sex, neighbourhood, and date. The primary outcome was emergency department (ED) visit, hospitalization or death within 30 days. Multivariable regression accounted for comorbidities, vaccination, and pre-pandemic healthcare utilization. ResultsAmong 6508 eligible COVIDEO patients, 4763 (73.1%) were matched to ≥1 non-COVIDEO patient. COVIDEO care was protective against the primary composite outcome (adjusted odds ratio [aOR] 0.91, 95% CI, 0.82–1.02), with a reduction in ED visits (7.8% vs. 9.6%; aOR 0.79, 95% CI, 0.70–0.89), but increase in hospitalizations (3.8% vs. 2.7%, aOR 1.37, 95% CI, 1.14–1.63) reflecting more direct-to-ward admissions (1.3% vs. 0.2%, p < 0.0001). Results were similar when matched comparators were limited to patients who had not received virtual care elsewhere with a decrease in ED visits (7.8 vs. 8.6%, aOR 0.86, 95% CI, 0.75–0.99) and an increase in hospitalizations (3.7 vs. 2.4%, aOR 1.45, 95% CI, 1.17–1.80). DiscussionAn intensive remote care programme can prevent unnecessary ED visits and facilitate direct-to-ward hospitalizations and thereby mitigate the impact of COVID-19 on the healthcare system.

Effects of a Nurse-Initiated Telephone Care Path for Pain Management in Patients With Head and Neck Cancer Receiving Radiation Therapy.

This quality improvement project aimed to determine whether a nurse-initiated telephone care path could decrease emergency department visits, hospital admissions, and pain levels for patients with head and neck cancer receivi.

Standard nurse phone triage versus tele-emergency care pilot on Veteran use of in-person acute care: An instrumental variable analysis.

Use of acute care telemedicine is growing, but data on quality, utilization, and cost are limited. We evaluated a Veterans Affairs (VA) tele-emergency care (tele-EC) pilot aimed at reducing reliance on out-of-network (OON) emergency department (ED) care, a growing portion of VA spending. With this service, an emergency physician virtually evaluated selected Veterans calling a nurse triage line. Calls to the triage line occurring January-December 2021 and advised to seek care acutely within 24 h were included. We described tele-EC user characteristics, common triage complaints, and patterns in referral to and management by tele-EC. The primary outcome was acute care visits (ED, urgent care, and hospitalizations at VA and OON sites) within 7 days of the index call. Secondary outcomes included mortality, OON acute care spending, and the effect of tele-EC visit modality (phone vs. video). We used both standard regression and instrumental variable (IV) analysis, using the tele-EC physician schedule as the instrument. Of 7845 eligible calls, 15.5% had a tele-EC visit, with case resolution documented in 57%. Compared to standard nurse triage, tele-EC users were less likely to be Black, had more prior ED visits, and were triaged as higher acuity. Calls concerning dizziness/syncope, blood in stool, and chest pain were most likely to have a tele-EC visit. Tele-EC was associated with fewer ED visits than standard nurse triage in both regression (average marginal effect [AME] -16.8%, 95% confidence interval [CI] -19.2 to -14.4) and IV analyses (AME -17.5%, 95% CI -25.1 to -9.8), lower hospitalization rate (AME -3.1%, 95% CI -6.2 to -0.0), and lower OON spending (AME -$248, 95% CI -$458 to -$38). Among Veterans initially advised to seek care within 24 h, use of tele-EC compared to standard phone triage led to decreased ED visits,hospitalizations, and OON spending within 7 days.

Implementation of Coach McLungsSM into primary care using a cluster randomized stepped wedge trial design

BackgroundAsthma is a prevalent chronic disease that is difficult to manage and associated with marked disparities in outcomes. One promising approach to addressing disparities is shared decision making (SDM), a method by which the patient and provider cooperatively make a decision about asthma care. SDM is associated with improved outcomes for patients; however, time constraints and staff availability are noted implementation barriers. Use of health information technology (IT) solutions may facilitate the utilization of SDM. Coach McLungsSM is a collaborative web-based application that involves pediatric patients, their caregivers, and providers in a personalized experience while gathering patient-reported data. Background logic provides decision support so both audiences can develop a well-informed treatment plan together. The goal of this study is to evaluate the implementation of the Coach McLungsSM intervention into primary care.MethodsImplementation will be evaluated using a stepped wedge randomized control study design at 21 pediatric and family medicine practices within a large, integrated, nonprofit healthcare system. We will measure changes in emergency department visits, hospitalizations, and oral steroid use, which serve as surrogate measures for patient-centered asthma outcomes. We will use a generalized linear mixed models with logit link to test the hypothesis for the reduction in exacerbation rates specifying the fixed effects of intervention and time and random effects for practice and practice*time. This design achieves 84% power to detect the hypothesized effect size difference of 10% in overall exacerbation between control (40%) and intervention (30%) periods (two-sided, p = 0.05). Implementation will be guided using the Expert Recommendations for Implementing Change (ERIC), a compilation of implementation strategies, and evaluated using the CFIR (Consolidated Framework for Implementation Research) and RE-AIM (Reach Effectiveness, Adoption, Implementation, Maintenance).DiscussionWe anticipate that a tailored implementation of Coach McLungsSM across diverse primary care practices will lead to a decrease in emergency department visits, hospitalizations, and oral steroid use for patients in the intervention group as compared to the control condition.Trial Registration: Clincaltrials.gov, NCT05059210. Registered 28 September 2021, https://www.clinicaltrials.gov/ct2/show/NCT05059210

The association between vacant housing demolition and safety and health in Baltimore, MD

We measured the association between vacant housing demolitions and changes in crime and emergency department (ED) visits in Baltimore, MD. We included 646 block groups in Baltimore, 224 of which experienced at least one demolition from 2012 to 2019. The exposure was the number of demolitions completed in a block group during the previous quarter. Crime (all, property, and violent) and ED visits (all, adults, children, and for specific causes) were examined as the change in the rate per 1000 people from the previous quarter to the current quarter and analyzed using multivariable mixed effects regression models. Demolitions were associated with a small decrease in total ED visits (difference = −0.068 per 1000 people from the previous quarter to the current quarter, 95% CI -0.119, −0.018) but no significant change in crime. For each demolition, the rate of total child ED visits was 0.452 lower compared to the previous quarter (95% CI -0.777, −0.127). Demolitions were associated with small decreases in adult injury-related ED visits in the short term.

The Impact of Reimbursement for Non-Face-to-Face Chronic Care Management on Health Utilization Among Patients With Type 2 Diabetes in Louisiana

ObjectivesWe evaluated the impact of reimbursement for non-face-to-face chronic care management (NFFCCM) on healthcare utilization among Medicare beneficiaries with type 2 diabetes in Louisiana. MethodsWe implemented group-based trajectory balancing and propensity score matching to obtain comparable treatment (with NFFCCM) and control (without NFFCCM) groups at baseline. Patients with diabetes with Medicare as their primary payer at baseline were extracted using electronic health records of 3 health systems from Research Action for Health Network, a Clinical Research Network. The study period is from 2013 to early 2020. Our outcomes include general healthcare utilization (outpatient, emergency department, and inpatient encounters) and health utilization related to diabetic complications. We tested each of these outcomes according to multiple treatment definitions and different subgroups. ResultsReceiving any NFFCCM was associated with an increase in outpatient visits of 657 (95% confidence interval [CI] 626-687; P < .001) per 1000 patients per month, a decrease in inpatient admissions of 5 (95% CI 2-7; P < .001) per 1000 patients per month, and a decrease in emergency department visits of 4 (95% CI 1-7; P = .005) per 1000 patients per month after 24-month follow-up from initial NFFCCM encounter. Both complex and noncomplex NFFCCM significantly increased visits to outpatient services and inpatient admissions per month. Receiving NFFCCM has a dose-response association with increasing outpatient visits per month. ConclusionsPatients with diabetes in Louisiana who received NFFCCM had more low-cost primary healthcare and less high-cost healthcare utilization in general. The cost savings of NFFCCM in diabetes management could be further explored in the future.