Rates Of Emergency Department Research Articles

Hospital use for non-traumatic dental conditions among older adults in Florida.

Older Americans are at risk of many oral diseases and conditions, but limited access to dental care may lead to the use of hospital emergency departments (EDs) or inpatient admissions. This study examined the use of hospitals for non-traumatic dental conditions (NTDCs) among persons aged ≥65years in the Florida. We analysed hospital use for NTDCs in Florida in 2018 from health department data sets. We calculated frequencies and rates of ED visits and hospital inpatient admissions, overall and by county, age, sex, race/ethnicity and principal payer. We also examined the source of hospital admission, primary diagnoses and charges. In 2018, there were 4894 ED visits and 747 inpatient admissions for NTDCs among persons aged ≥65years in Florida. The rate for ED visits was 112.30 per 100000 population and for hospital inpatient admissions was 17.14; rates varied widely among counties. Medicare was the most common primary payer. Referrals from EDs accounted for 76.2% of inpatient admissions for NTDCs by older adults. Total charges were $21.4 million for ED visits and $40.2 million for inpatient admissions. The most common principal diagnosis for ED visits for NTDCs was "periapical abscess without sinus tract" (K04.7; 26.2%) and for inpatient admissions was "inflammatory conditions of the jaw" (M27.2; 19.1%). Of the 747 inpatient admissions, two people died. Hospital use for NTDCs in Florida among persons aged ≥65years is a clinical and financial challenge. Public coverage for basic adult dental services may lead to more effective use of funds and better health outcomes.

Associations between Source-Specific Particulate Matter and Respiratory Infections in New York State Adults.

The response of respiratory infections to source-specific particulate matter (PM) is an area of active research. Using source-specific PM2.5 concentrations at six urban sites in New York State, a case-crossover design, and conditional logistic regression, we examined the association between source-specific PM and the rate of hospitalizations and emergency department (ED) visits for influenza or culture-negative pneumonia from 2005 to 2016. There were at most N = 14 764 influenza hospitalizations, N = 57 522 influenza ED visits, N = 274 226 culture-negative pneumonia hospitalizations, and N = 113 997 culture-negative pneumonia ED visits included in our analyses. We separately estimated the rate of respiratory infection associated with increased concentrations of source-specific PM2.5, including secondary sulfate (SS), secondary nitrate (SN), biomass burning (BB), pyrolyzed organic carbon (OP), road dust (RD), residual oil (RO), diesel (DIE), and spark ignition vehicle emissions (GAS). Increased rates of ED visits for influenza were associated with interquartile range increases in concentrations of GAS (excess rate [ER] = 9.2%; 95% CI: 4.3%, 14.3%) and DIE (ER = 3.9%; 95% CI: 1.1%, 6.8%) for lag days 0–3. There were similar associations between BB, SS, OP, and RO, and ED visits or hospitalizations for influenza, but not culture-negative pneumonia hospitalizations or ED visits. Short-term increases in PM2.5 from traffic and other combustion sources appear to be a potential risk factor for increased rates of influenza hospitalizations and ED visits.

Construction and Validation of Risk-adjusted Rates of Emergency Department Visits for Long-stay Nursing Home Residents.

Long-stay nursing home (NH) residents are at high risk of having emergency department (ED) visits, but current knowledge regarding risk-adjusted ED rates is limited. To construct and validate 3 quarterly risk-adjusted rates of long-stay residents' ED use: any ED visit, ED visits without hospitalization or observation stay (outpatient ED), and potentially avoidable ED visits (PAED). The authors calculated quarterly NH risk-adjusted ED rates from 2011 Q2 to 2013 Q3 national Medicare claims and Minimum Data Set data. Using random-effect linear regressions, the authors validated these rates against Nursing Home Compare overall 5-star quality ratings and examined their associations with hospitalization rates to provide a quality context. Resident-quarter observations (7.3 million) from 15,235 unique NHs. Risk-adjusted rates of any ED, outpatient ED, and PAED averaged 9.7%, 3.4%, and 3.2%, respectively. Compared with NHs with 1 or 2 stars overall rating, NHs with ≥3 stars were significantly associated with lower rates of any ED visit, outpatient ED, and PAED (β, -0.23%, -0.16%, and -0.11%, respectively; all P<0.01). Pearson Correlation coefficients between hospitalization rates and rates of any ED visit, outpatient ED, and PAED were 0.74, 0.31, and 0.46, respectively. The moderately negative associations of 5-star ratings with ED rates provide supportive evidence to their validity. Outpatient ED and PAED were moderately correlated to hospitalizations suggesting they provided more information about quality than any ED.

Changes in the hospitalization and ED visit rates for respiratory diseases associated with source-specific PM2.5 in New York State from 2005 to 2016

Prior work found increased rates for emergency department (ED) visits for asthma and hospitalizations for chronic obstructive pulmonary disease per unit mass of PM2.5 across New York State (NYS) during 2014–2016 after significant reductions in ambient PM2.5 concentrations had occurred following implementation of various policy actions and major economic disruptions. The associations of source-specific PM2.5 concentrations with these respiratory diseases were assessed with a time-stratified case-cossover design and logistic regression models to identify the changes in the PM2.5 that have led to the apparently increased toxicity per unit mass. The rates of ED visits and hospitalizations for asthma and COPD associated with increases in source-specific PM2.5 concentrations in the prior 1, 4, and 7 days were estimated for 6 urban sites in New York State. Overall, there were similar numbers of significantly increased (n = 9) and decreased rates (n = 8) of respiratory events (asthma and COPD hospitalizations and ED visits) associated with increased source-specific PM2.5 concentrations in the previous 1, 4, and 7 days. Associations of source-specific PM2.5 concentrations with excess rates of hospitalizations for COPD for spark- and compression ignition vehicles increased in the 2014–2016 period, but the values were not statistically significant. Other source types showed inconsistent patterns of excess rates. For asthma ED visits, only biomass burning and road dust showed consistent positive associations with road dust having significant values for most lag times. Secondary nitrate also showed significant positive associations with asthma ED visits in the AFTER period compared to no associations in the prior periods. These results suggest that the relationships of asthma and COPD exacerbation with source-specific PM2.5 are not well defined and further work will be needed to determine the causes of the apparent increases in the per unit mass toxicity of PM2.5 in New York State in the 2014-16 period.

Adherence to Well-Child Care and Home Visiting Enrollment Associated with Increased Emergency Department Utilization.

Pediatric primary care and home visiting programs seek to reduce health disparities and promote coordinated health care use. It is unclear whether these services impact high-cost, emergency department (ED) utilization. We evaluated the association of well-child care (WCC) and home visiting with ED visit frequency for children < 1year with an established medical home. Retrospective cohort study using linked administrative data for infants ≥ 34weeks' gestation from 2010 to 2014, within a multisite, academic primary care system. Latent class analysis characterized longitudinal patterns of WCC. Multivariable negative binomial regression models tested the independent association between WCC patterns and home visiting enrollment with ED visits. Among 10,363 infants, three WCC latent classes were identified: "Adherent" (83.4% of the cohort), "Intermediate" (9.7%), and "Decreasing adherence" (7.0%). Sixty-one percent of the sample had ≥ 1 ED visit in the first 12months of life, and 73% of all ED visits were triaged as non-urgent. There was a significant interaction effect between WCC pattern and insurance status. Among Medicaid-insured infants, "Intermediate" and "Decreasing adherence" WCC patterns were associated with a lower incident rate of ED visits compared with the "Adherent" pattern (incident rate ratios (IRR) 0.88, p = 0.03 and 0.79, p < 0.001 respectively); this effect was not observed among privately-insured infants. Home visiting enrollment was independently associated with a higher rate of ED visits (IRR 1.24, p < 0.001). Among infants with an established medical home, adherence to recommended WCC and home visiting enrollment was associated with greater ED use for non-urgent conditions.

A Health Records Review of Outpatient Referrals from the Emergency Department.

Objectives Many patients discharged home from the emergency department (ED) require urgent outpatient consultation with a specialty service. We sought to identify the best- and worst-performing services with regard to time to outpatient consultation, the proportion of patients lost to follow-up, the rate of related return ED visits prior to consultation, and common strategies used by our top-performing clinics. Methods We conducted a health records review of The Ottawa Hospital ED visits during four 1-week periods. All consecutive adult outpatient consultation requests were included for chart review and were followed up to 12 months. Outcome measures included demographics, referral attendance rates, incomplete referrals, return ED visits, and time intervals. Services with at least 15 consultation requests were included for data analysis and qualitative mapping of their referral processes. Results Of the 963 patients who met inclusion criteria, 803 (83.4%) attended their appointment, while 160 (16.6%) were lost to follow-up. The overall median time to successful consultation was 9 days (IQR = 2–27). 92 (9.6%) patients returned to the ED with a related complaint. The top-performing clinics included ophthalmology, orthopedics, and thrombosis (median = 1, 8, 1 days; incomplete consultation = 3%, 4%, 6%; return ED visits = 0%, 6%, 2% respectively). The bottom-performing clinics included otorhinolaryngology, neurology, and gynecology (median = 47, 39, 27 days; incomplete consultation = 50%, 41%, 37%; return ED visits = 11%, 15%, 26%, respectively). Processes incorporated by top-performing clinics included reserving appointment slots for emergency referrals, structured referral forms, and centralized booking. Conclusions We found a substantial variability in both the waiting times and reliability of outpatient referrals from the ED. Top-performing clinics incorporate common referral processes.

Patient Experiences and Outcomes of a Telehealth Clinical Care Pathway for Postoperative Inflammatory Bowel Disease Patients.

Background:Despite advancements in treatment for inflammatory bowel disease (IBD), surgery remains inevitable for patients and IBD management is costly.Introduction:Frequent postoperative monitoring is needed for early detection of both short-term complications and long-term disease recurrence. We developed a care pathway for postoperative home monitoring of IBD patients using telehealth applications.Materials and Methods:We performed a retrospective cohort study with a matched control group to assess the efficacy of the Tight Control Surgery Scenario (TCSS), a 4-week postoperative care pathway. IBD patients aged 18 or older who underwent an IBD-related intestinal operation between October 2013 and December 2015 were eligible. Enrolled participants submitted postsurgical questionnaires and wound photos through e-mail. We measured patient satisfaction with the care pathway and assessed its impact on 30-day postoperative hospital readmission rates, emergency department (ED) visits, and gastroenterologist (GI)-related office visits.Results:Sixty-four (n) cases were enrolled in TCSS and matched to 64 historic controls. Patients who completed the additional evaluation survey expressed overall satisfaction. Readmissions, 30-day ED rates, and GI visits were numerically higher in cases compared with controls, but this difference was not statistically significant.Discussion:TCSS demonstrates the feasibility of implementing a telehealth care coordination platform for postsurgery IBD management. Patients with more complications may have sent in more photos due to greater concern for maintaining their health.Conclusions:Implementation of TCSS for easy home monitoring is feasible. While we did not see reductions in ED visits, GI follow-up visits, or readmissions, patient satisfaction was high, thus demonstrating its feasibility for telehealth applications.

Initiatives to reduce treatments in bronchiolitis in the emergency department and primary care

We performed a quality improvement initiative to reduce unnecessary treatments for acute bronchiolitis (AB) in primary care (PC) and the referral paediatric emergency department (ED). The quality improvement initiative involved...

Declining hospitalisation and surgical intervention rates in patients with Crohn's disease: a population-based cohort.

Lifetime risk of surgery in patients with Crohn's disease remains high. To assess population-level markers of Crohn's disease (CD) in the era of biological therapy. Population-based cohort study using administrative data from Ontario, Canada including 45235 prevalent patients in the Ontario Crohn's and Colitis Cohort (OCCC) from 1 April 2003 to 31 March 2014. CD-related hospitalisations declined 32.4% from 2003 to 2014 from 154/1000 (95% confidence interval (CI) [150, 159]) patients to 104/1000 (95% CI [101, 107]) (P<.001). There was a 39.6% decline in in-patient surgeries from 53/1000 (95% CI [50, 55]) to 32/1000 (95% CI [30, 34]) from 2003 to 2014 (P<.001). In-patient surgeries were mostly bowel resections. Out-patient surgeries increased from 8/1000 (95% CI [7, 9]) patients to 12/1000 (95% CI [10, 13]) (P<.001). Out-patient surgeries were largely related to fistulas and perianal disease and for stricture dilations/stricturoplasty. CD-related emergency department (ED) visits declined 28.4% from 141/1000 (95% CI [137, 146]) cases to 101/1000 (95% CI [99, 104]) from 2003 to 2014 (P<.001). Over the same time, patients receiving government drug benefits received infliximab or adalimumab at a combined rate of 2.2% in 2003 which increased to 18.8% of eligible patients by 2014. Rates of hospitalisations, ED visits and in-patient surgeries markedly declined in Ontario over the study period, while rates of biologic medication use increased markedly for those receiving public drug benefits.

Assessing Care Value for Older Patients Receiving Radiotherapy With or Without Cisplatin or Cetuximab for Locoregionally Advanced Head and Neck Cancer

Clinicians frequently use radiotherapy with cetuximab over radiotherapy only or radiotherapy with cisplatin because of a perceived survival and tolerability advantage, but scant data are available to support this perception. To measure the 3 aspects of value (quality, outcomes, and cost) in older patients receiving radiotherapy only, radiotherapy with cisplatin, or radiotherapy with cetuximab for locoregionally advanced head and neck cancer. For this cohort study, patient records were obtained from the Surveillance, Epidemiology, and End Results Program (SEER)-Medicare outcomes and claims database from January 1, 2004, to December 31, 2014. Participants were 65 years or older; received a diagnosis between 2006 and 2013 of stages III to IVB head and neck cancer; had only 1 cancer on record; and did not undergo surgical intervention. Data analysis was conducted from February 5, 2018, to March 27, 2019. Patients were divided into exposure arms on the basis of their first-line therapy or identified chemoradiotherapy and radiotherapy regimen. Overall survival was analyzed by propensity score matching Cox proportional hazards regression models, quality by measuring 90-day emergency department (ED) visit and inpatient admission rates, and costs by assessing 90-day total Medicare spending. The overall cohort included 1091 patients, of whom 815 (74.7%) were male; the mean (SD) age was 73.9 (6.6) years. Patients receiving radiotherapy with cisplatin had higher overall survival compared with those receiving radiotherapy only (adjusted hazard ratio [HR], 0.64; 95% CI, 0.47-0.87). This finding was not seen in patients receiving radiotherapy with cetuximab (adjusted HR, 0.95; 95% CI, 0.75-1.20), compared with the radiotherapy only group, and it persisted after stratifying patients by age. The ED visit (adjusted incidence rate ratio [IRR], 1.72; 95% CI, 1.30-2.30) and inpatient admission (adjusted IRR, 1.48; 95% CI, 1.12-1.98) rates in the 90 days after treatment start were higher in patients receiving radiotherapy with cisplatin compared with those treated with radiotherapy only. Patients receiving radiotherapy with cetuximab had a higher rate of ED visits (adjusted IRR, 1.38; 95% CI, 1.05-1.82) compared with those in the radiotherapy only group. The 90-day after-treatment spending for patients receiving radiotherapy with cetuximab was $48 620 (95% CI, $46 466-$50 775) compared with $33 009 (95% CI, $31 499-$34 519) for radiotherapy with cisplatin and $27 622 (95% CI, $25 118-$30 126) for radiotherapy only. In this cohort study, no survival difference, a higher rate of ED visits but not of inpatient admissions, and higher spending were observed in patients receiving radiotherapy with cetuximab compared with patients receiving radiotherapy only. The findings suggest that radiotherapy alone should be maintained as a treatment arm in evaluation of novel therapeutics for locoregionally advanced head and neck cancer in older and sicker patients.

Depression, Anxiety, and Emergency Department Use for Asthma.

Asthma is responsible for ∼1.7 million emergency department (ED) visits annually in the United States. Studies in adults have shown that anxiety and depression are associated with increased asthma-related ED use. Our objective was to assess this association in pediatric patients with asthma. We identified patients aged 6 to 21 years with asthma in the Massachusetts All-Payer Claims Database for 2014 to 2015 using International Classification of Diseases, Ninth and 10th Revision codes. We examined the association between the presence of anxiety, depression, or comorbid anxiety and depression and the rate of asthma-related ED visits per 100 child-years using bivariate and multivariable analyses with negative binomial regression. Of 65 342 patients with asthma, 24.7% had a diagnosis of anxiety, depression, or both (11.2% anxiety only, 5.8% depression only, and 7.7% both). The overall rate of asthma-related ED use was 17.1 ED visits per 100 child-years (95% confidence interval [CI]: 16.7-17.5). Controlling for age, sex, insurance type, and other chronic illness, patients with anxiety had a rate of 18.9 (95% CI: 17.0-20.8) ED visits per 100 child-years, patients with depression had a rate of 21.7 (95% CI: 18.3-25.0), and patients with both depression and anxiety had a rate of 27.6 (95% CI: 24.8-30.3). These rates were higher than those of patients who had no diagnosis of anxiety or depression (15.5 visits per 100 child-years; 95% CI: 14.5-16.4; P < .001). Children with asthma and anxiety or depression alone, or comorbid anxiety and depression, have higher rates of asthma-related ED use compared with those without either diagnosis.

Sex differences in health services and medication use among older adults with asthma.

Sex differences are well documented in chronic disease populations with cardiovascular disease and diabetes. Although recent research has suggested that asthma is more severe in older women compared to men, the extent of this difference remains poorly understood. The objective of this study was to compare rates of asthma-specific health services use (HSU) and medication use, between older women and men with asthma.This population-based cohort study included 209 054 individuals aged ≥66 years with asthma from health administrative data in Ontario, Canada. The primary exposure was sex. Outcomes included asthma-specific HSU (spirometry, emergency department (ED), hospitalisation, physician office and specialist visits) and medication use (asthma controller and reliever prescriptions). Negative binomial regression models adjusted for age, socioeconomic status and comorbidities were used to ascertain outcomes by sex from 2010 to 2016.Compared to men, women had lower rates of spirometry (adjusted relative rate (ARR) 0.87, 95% CI 0.85–0.89) and specialist visits for asthma (ARR 0.93, 95% CI 0.90–0.96), but higher rates of asthma-specific ED (ARR 1.43, 95% CI 1.33–1.53) and physician office visits (ARR 1.03, 95% CI 1.01–1.05). Women also had lower asthma controller (ARR 0.98, 95% CI 0.97–0.99) but higher asthma reliever (ARR 1.03, 95% CI 1.02–1.05) prescription fill rates, compared to men.These findings may indicate poorer disease control, greater asthma severity and poorer access to specialist asthma care in women.

Visualizing Carbon Monoxide Poisoning Surveillance Data on the US CDC National Environmental Public Health Tracking Network

TPS 683: Short-term health effects of air pollutants 2, Exhibition Hall, Ground floor, August 28, 2019, 3:00 PM - 4:30 PM Background: CDC’s National Environmental Public Health Tracking Program (Tracking Program) aims to provide information from a nationwide network of integrated unintentional carbon monoxide (CO) poisoning data that could inform relevant public health action and prevention. Methods: The Tracking Program has developed dynamic environmental health surveillance system that includes standard visualization tools such as charts, interactive maps, and tables, and displays a variety of measures of morbidity and mortality (e.g., crude, and age-adjusted rates per 100,000) for unintentional CO poisoning. Users also can explore these measures by cause (i.e., fire, non-fire, unknown intent or mechanism). The hospitalization and emergency department (ED) data are obtained by the Tracking Program from funded state recipients (26 states); mortality data are from the National Vital Statistics System. We pooled the CO poisoning data from 2010-2014, and examined the proportion of unintentional non-fire CO poisonings, and compared state-specific age-adjusted rates during the same period. Results: During 2010-2014, there were more than 4,500 unintentional CO poisoning deaths with an average of 916 deaths annually. Deaths and hospitalizations categorized as non-fire comprised of 41.4%, and 55.4% of cases respectively. During the same period, states that had the two highest annual age-adjusted rate of ED visits for unintentional CO poisoning were Connecticut (AR: 21.4 in 2011) and Vermont (AR=15.7 in 2013), and the highest hospitalization rate were observed in New Mexico (AR: 2.1 in 2011) and Maryland (AR=1.8 in 2009). Conclusions: The Tracking Program demonstrates the opportunity to visualize environmental and health data on one data platform. This allows users to examine temporal and spatial trends and to identify communities at greater risk for CO poisoning. The Tracking Program’s CO poisoning data can be used to drive public health policy and actions that ultimately will reduce the burden of mortality and morbidity for CO poisoning.

1 Risk of Emergency Department Revisit or Hospitalization in Older Adults Discharged With Potentially Inappropriate Medications: A Retrospective Cohort Study

Vulnerable elderly patients are prone to multiple co-morbidities that warrant the need for several long-term prescriptions or “polypharmacy.” Polypharmacy strongly correlates with higher risk of prescribing potentially inappropriate medications (PIMs). In 1991 Mark H. Beers, a geriatrician, led the first published consensus on guidelines for PIMs commonly prescribed nationwide (Beers criteria). Geriatric emergency physicians’ question if Beers criteria are equally as effective in an emergency department (ED) setting where prescriptions are intended for short term use only. In other words, do short-term PIMs pose the same risks of ED returns and hospitalization as PIMs prescribed for 3 months or longer? To determine whether PIMs prescribed to older adults discharged from the ED increases the risk of subsequent ED revisits or hospital admissions within 3 and 30 days from ED discharge. A retrospective cohort observational study of adults 65 years and older discharged with prescription(s) from the Mount Sinai Hospital ED in New York City, January 2012 to November 2015. Hospital electronic medical records were identified for unique subjects prescribed PIMs at ED discharge versus those prescribed non PIMs from 2012 to 2015. PIMs are defined following the 2015 Beers criteria. For ED returns to hospitals other than Mount Sinai, patient records were linked up to their Medicare claims 30 days following their index visit. Primary outcomes were frequency and incident rates of ED revisits and hospitalization within 3 and 30 days (D) post index ED discharge. Secondary outcomes were rates and reasons of hospital admissions over 3 and 30 days in both groups. Descriptive and bivariate analysis, including Chi-square test, are currently underway. A total of 31,521 unique patients made a total of 71,484 ED visits during the study period. Mean age was 76.1 years (8.52 SD), 57.44% were female. Of these, 7,659(20.45%) were discharged from the ED with a medication prescription: 1,567 (20.46%) were considered PIM prescriptions (vs. 79.54% were non-PIMs). There were 39,962 return visits to Mount Sinai Hospital (MSH), 55.9%. 112 patients died during the study period. Though extensively reported in geriatric care literature, studies on PIM prescriptions that focus on the short term yet urgent ED setting are rare. This study addresses a hotly debated topic in geriatric emergency practice today.

488 National Trends and Outcomes of Irritable Bowel Syndrome Presenting to Emergency Departments: Results From the Nationwide Emergency Department Sample (NEDS) Database

INTRODUCTION: Irritable bowel syndrome (IBS) is a chronically relapsing disease that causes gastrointestinal discomfort with diarrhea and/or constipation in a large group of Americans. Estimates of IBS disease burden in emergency departments (ED) are lacking. We sought to investigate IBS emergency department visits nationally, patient demographics and hospitalization trends from 2009-2014 using Nationwide Emergency Department Sample (NEDS) database. METHODS: The Nationwide Emergency Department Sample database was used to extract data from 2009 to 2014 for patients who visited the ED with a primary diagnosis of irritable bowel syndrome. International Classification of Diseases (ICD-9-CM) were used to identify patients; Irritable bowel syndrome (ICD-9-CM: 564.1). The 2009-2014 NEDS data was used to study the incidence of ED visits, patient/hospital factors, inpatient charges, length of hospitalization and discharge from hospital to home. RESULTS: There were 189,210 (0.02%) ED visits identified with a diagnosis of IBS among a total of 795,980,104 ED visits between 2009-2014 in the NEDS database. Most patients were female (n = 143247.6, 75.8%) with a mean age of 42.4 years. The rate of ED visits decreased from 10.2 per 100,000 in 2009, to 9.4 per 100,000 in 2014 (decrease of 8%; z = -1.691, P = 0.091). The majority of patients had private insurance (n = 68687, 36.3%) followed by Medicare (n = 43272, 22.9%) and Medicaid (n = 41737, 22.1%). Uninsured patients presenting with IBS to the ED constituted 15% (n = 28392) of the study population. Patients presented with IBS in far greater numbers to urban EDs (n = 150148, 79.4%) compared to rural EDs (n = 39062, 20.6%). Most were discharged from the ED (n = 134616.9, 71.1%) while 28.9% (n = 54593.5) patients were admitted. Hospitalized patients had a decrease in mean length of stay from 3.64 days in 2009 to 3.53 days in 2014; however, the mean inpatient charges increased from $20,823 in 2009 to $27,649 in 2014 (increase of 32.8%). CONCLUSION: Irritable bowel syndrome emergency department visits remained relatively constant between 2009 and 2014 while nearly 30% of patients were admitted. Despite unchanged hospital length of stay, hospitalization costs appear to be increasing. Better outpatient management of irritable bowel syndrome is needed to avoid emergency department visits and rising inpatient costs.

Temporal Trends and Predictors of Thirty-Day Readmissions and Emergency Department Visits Following Total Knee Arthroplasty in Ontario Between 2003 and 2016

BackgroundTotal knee arthroplasty (TKA) is the second most common surgery performed in Canada. Understanding and improving quality metrics associated with such high-volume procedures is of utmost importance to maximize value within the healthcare system, which is a balance between cost and quality. Although rates and predictors of hospital readmission and emergency department (ED) visits following TKA have previously been described in privatized healthcare settings, few studies have evaluated trends in length of stay (LOS), hospital readmissions, and ED visits following TKA in a universal single-payer system. MethodsUsing data from a provincially held and validated registry, the Institute for Clinical and Evaluative Sciences, we undertook a review of all 205,152 TKAs performed in the province of Ontario, Canada, between 2003 and 2016. We determined temporal trends in utilization, LOS, readmissions, and ED visits and evaluated patient and provider predictors of hospital readmissions and ED visits using multivariate logistic regression modeling. We also grouped and described the most common reasons for readmission and ED visits based on the available International Classification of Diseases, Ninth Revision and Tenth Revision coding information. ResultsLOS decreased significantly over the study period (P < .0001), from a median of 5 days (10th percentile 3 days, 90th percentile 8 days) in 2003 to a median of 3 days (10th percentile 2 days, 90th percentile 4 days) in 2016. All-cause 30-day readmissions did not change significantly over the study period, but the rate of ED visits increased significantly over time. Predictors of 30-day readmission following TKA included older age, male gender, lower income quartile, not having a postoperative visit with a primary care physician (PCP), increased comorbidities, longer LOS, urgent or revision surgery, admission to a teaching hospital, and discharge to an inpatient rehabilitation facility. Variables that predicted increased odds of an ED visit included older age, male gender, lower income quartile, not having a postop visit with a PCP, increasing comorbidities, year of surgery, longer LOS, and revision surgery. Admission to a teaching hospital and discharge to an inpatient rehabilitation facility showed a trend toward increased odds of an ED visit. ConclusionsWe identified a significant increase in ED visits following TKA in Ontario between 2003 and 2016, with no corresponding increase in hospital readmissions despite a significant temporal trend toward shorter LOS. Predictors of ED visits and readmissions were similar, including male gender, lower income, higher comorbidities, and lacking a PCP visit postoperatively. Increased rates of ED visits following TKA in Ontario represent a quality problem, as they are associated with increased cost to the public healthcare system without any substantial benefit. Interventions aimed at redirecting patients from the ED for minor postoperative concerns should be investigated, as this is likely to improve care by reducing costs, improving efficiency, and enhancing patient experience.

Trends in United States emergency department visits and associated charges from 2010 to 2016

BackgroundDemographic shifts and care delivery system evolution affect the number of Emergency Department (ED) visits and associated costs. Recent aggregate trends in ED visit rates and charges between 2010 and 2016 have not been evaluated. MethodsData from the National Emergency Department Sample, comprising approximately 30 million annual patient visits, were used to estimate the ED visit rate and charges per visit from 2010 to 2016. ED visits were grouped into 144 mutually exclusive clinical categories. Visit rates, compound annual growth rates (CAGRs), and per visit charges were estimated. ResultsFrom 2010 to 2016, the number of ED visits increased from 128.97 million to 144.82 million; the cumulative growth was 12.29% and the CAGR was 1.95%, while the population grew at a CAGR of 0.73%. Expressed as a population rate, ED visits per 1000 persons increased from 416.92 in 2010 to 448.19 in 2016 (p value <0.001). The mean charges per visit increased from $2061 (standard deviation $2962) in 2010 to $3516 (standard deviation $2962) in 2016; the CAGR was 9.31% (p value <0.001). Of 144 clinical categories, 140 categories had a CAGR for mean charges per visit of at least 5%. ConclusionThe rate of ED visits per 1000 persons and the mean charge per ED visit increased significantly between 2010 and 2016. Mean charges increased for both high- and low-acuity clinical categories. Visits for the 5 most common clinical categories comprise about 30% of ED visits, and may represent focus areas for increasing the value of ED care.

Emergency department visits and hospitalizations among hemodialysis patients by day of the week and dialysis schedule in the United States.

Background and objectivePrevious reports indicated that patients on thrice-weekly hemodialysis (HD) had higher mortality rates after the 3-day interdialytic interval. However, day-of-the-week patterns of emergency department (ED) visits and hospitalizations remain under-investigated.MethodsWe conducted a retrospective cohort study of HD patients on thrice-weekly dialysis, using 2013 data from the United States Renal Data System (USRDS). We estimated crude incidence rates of ED visits and hospitalizations by day of the week and dialysis schedule (Monday, Wednesday, Friday or Tuesday, Thursday, Saturday). Using Poisson regression, we estimated case-mix adjusted rate ratios of all-cause ED visits and hospitalizations, and adjusted rates of cause-specific ED visits and hospitalizations.ResultsWe identified 241,093 eligible HD patients in 2013, who had 514,773 ED visits and 301,674 hospitalizations that year. Three distinct but related patterns of outcome events were observed. Crude and adjusted incidence rates of all-cause, cardiovascular, and infection-related ED visits and hospitalizations, but not vascular-access-related events, were higher on all three HD treatment days (“dialysis-day effect”). Rates for ED visits and hospitalizations were lower on weekends than weekdays, rising appreciably from Sunday to Monday for both dialysis schedules (“post-weekend effect”); and rates were highest after the long 3-day interval between dialysis sessions for both dialysis schedules (“interdialytic-gap effect”). In contrast, rates of hospitalizations not preceded by an ED visit were nearly the same Monday through Friday and lower on weekends for both dialysis schedules.ConclusionsHigher rates of ED visits and hospitalizations on the days of HD sessions and early in the week are a public-health concern that should stimulate research to explain these patterns and reduce the excessive morbidity and associated costs among patients on thrice-weekly HD, while improving quality of care and patient experience with dialysis.

Physician Availability in Long-Term Care and Resident Hospital Transfer: A Retrospective Cohort Study

ObjectivesTo investigate whether same-day physician access in long-term care homes reduces resident emergency department (ED) visits and hospitalizations. DesignRetrospective cohort study. Setting and participants161 long-term care homes in Ontario, Canada, and 20,624 residents living in those homes. MethodsWe administered a survey to Ontario long-term care homes from March to May 2017 to collect their typical wait time for a physician visit. We linked the survey to administrative databases to capture other long-term care home characteristics, resident characteristics, hospitalizations, and ED visits. We defined a cohort of residents living in survey-respondent homes between January and May 2017 and followed each resident for 6 months or until discharge or death.We estimated negative binomial regression models on counts of hospitalizations and ED visits with random intercepts for long-term care homes. We controlled for residents' sociodemographic and illness characteristics, long-term care home size, chain status, rurality, and nurse practitioner access. ResultsFifty-two homes (32%) reported same-day physician access. Among residents of homes with same-day physician access, 9% had a hospitalization and 20% had an ED visit during follow-up. In contrast, among residents in homes without same-day access, 12% were hospitalized and 22% visited an ED.The adjusted hospitalization and ED rates among residents of homes with same-day physician access were 21% lower (rate ratio = 0.79, P = .02) and 14% lower (rate ratio = 0.86, P = .07), respectively, than residents of other homes. We estimate that nearly 1 in 6 resident hospitalizations could be prevented if all long-term care homes had same-day physician access. Conclusions and implicationsResidents of long-term care homes with same-day physician access experience lower hospitalization and ED visit rates than residents in homes that wait longer for physicians, even after adjusting for important resident and home characteristics. Improved on-demand access to physicians has the potential to reduce hospital transfer rates.

Association of an Emergency Department–Based Intensive Care Unit With Survival and Inpatient Intensive Care Unit Admissions

Increased patient acuity, decreased intensive care unit (ICU) bed availability, and a shortage of intensivist physicians have led to strained ICU capacity. The resulting increase in emergency department (ED) boarding time for patients requiring ICU-level care has been associated with worse outcomes. To determine the association of a novel ED-based ICU, the Emergency Critical Care Center (EC3), with 30-day mortality and inpatient ICU admission. This retrospective cohort study used electronic health records of all ED visits between September 1, 2012, and July 31, 2017, with a documented clinician encounter at a large academic medical center in the United States with approximately 75 000 adult ED visits per year. The pre-EC3 cohort included ED patients from September 2, 2012, to February 15, 2015, when the EC3 opened, and the post-EC3 cohort included ED patients from February 16, 2015, to July 31, 2017. Data analyses were conducted from March 2, 2018, to May 28, 2019. Implementation of EC3, an ED-based ICU designed to provide rapid initiation of ICU-level care in the ED setting and seamless transition to inpatient ICUs. The main outcomes were 30-day mortality among ED patients and rate of ED to ICU admission. A total of 349 310 visits from a consecutive sample of ED patients (mean [SD] age, 48.5 [19.7] years; 189 709 [54.3%] women) were examined; the pre-EC3 cohort included 168 877 visits and the post-EC3 cohort included 180 433 visits. Implementation of EC3 was associated with a statistically significant reduction in risk-adjusted 30-day mortality among all ED patients (pre-EC3, 2.13%; post-EC3, 1.83%; adjusted odds ratio, 0.85; 95% CI, 0.80-0.90; number needed to treat, 333 patient encounters; 95% CI, 256-476). The risk-adjusted rate of ED admission to ICU decreased with implementation of EC3 (pre-EC3, 3.2%; post-EC3, 2.7%; adjusted odds ratio, 0.80; 95% CI, 0.76-0.83; number needed to treat, 179 patient encounters; 95% CI, 149-217). Implementation of a novel ED-based ICU was associated with improved 30-day survival and reduced inpatient ICU admission. Additional research is warranted to further explore the value of this novel care delivery model in various health care systems.