Emergency Department Visit Rates Research Articles

Gaps during Pediatric to Adult Care Transfer Escalate Acute Resource Utilization in Sickle Cell Disease.

Guidelines recommend transfer to adult healthcare within six months of completing pediatric care, however this has not been studied in sickle cell (SCD). We hypothesized that longer transfer gaps are associated with increased resource utilization. Transfer gaps were defined as the time between the last pediatric and first adult visits. We estimated the association between varying transfer gaps and the rate of inpatient, emergency department (ED), and outpatient visits using negative binomial regression. Healthcare utilization was evaluated in a mid-south comprehensive program for a follow-up period of up to eight years (2012-2020) and also restricted to the first two years of adult healthcare. In total, 183 young adults (YAs) with SCD (51% male, 67% HbSS/HbSβ0-thalassemia) transferred to adult healthcare between 2012-2018. YAs with transfer gaps ≥6 months compared to <2 months had 2.01 (95%CI: 1.31, 3.11) times the rate of hospitalizations in the 8-year follow-up and 1.89 (95%CI: 1.17, 3.04) when restricted to the first two years of adult healthcare. In the first two years of adult care, those with transfer gaps ≥6 months compared to <2 months, had 1.75 (95%CI: 1.10, 2.80) times the rate of ED encounters. Those with gaps ≥2 to <6 months compared to <2 months had 0.71 (95%CI: 0.53, 0.95) times the rate of outpatient visits. Among YAs with SCD, a longer transfer gap was associated with increased inpatient and decreased outpatient encounters in adult healthcare and more ED encounters in the first two years of adult healthcare. Strategies to reduce transfer gaps are needed.

The association between alcohol retail access and health care visits attributable to alcohol for individuals with and without a history of alcohol-related health-care use.

Alcohol retail access is associated with alcohol use and related harms. This study measured whether this association differs for people with and without heavy and disordered patterns of alcohol use. The study used a repeated cross-sectional analysis of health administrative databases. All residents of Ontario, Canada aged 10-105 years with universal health coverage (n = 10 677 604 in 2013) were included in the analysis. Quarterly rates of emergency department (ED) and outpatient visits attributable to alcohol in 464 geographic regions between 2013 and 2019 were measured. Quarterly off-premises alcohol retail access scores were calculated (average drive to the closest seven stores) for each geographic region. Mixed-effect linear regression models adjusted for area-level socio-demographic covariates were used to examine associations between deciles of alcohol retail access and health-care visits attributable to alcohol. Stratified analyses were run for individuals with and without prior alcohol-attributable health-care use in the past 2years. We included 437 707 ED visits and 505 271 outpatient visits attributable to alcohol. After adjustment, rates of ED visits were 39% higher [rate ratio (RR) = 1.39, 95% confidence interval (CI) = 1.20-1.61] and rates of outpatient visits were 49% higher (RR = 1.49, 95% CI = 1.26-1.75) in the highest versus lowest decile of alcohol access. There was a positive association between alcohol access and outpatient visits attributable to alcohol for individuals without prior health-care attributable to alcohol (RR = 1.65, 95% CI = 1.39-1.95 for the highest to lowest decile of alcohol access) but not for individuals with prior health-care attributable to alcohol (RR = 1.08, 95% CI = 0.90-1.30). There was a positive association between alcohol access and ED visits attributable to alcohol for individuals with and without prior health-care for alcohol for ED visits. In Ontario, Canada, greater alcohol retail access appears to be associated with higher rates of emergency department (ED)and outpatient health-care visits attributable to alcohol. Individuals without prior health-care for alcohol may be more susceptible to greater alcohol retail access for outpatient but not ED visits attributable to alcohol.

F.6 Opportunities for improvement: understanding drivers of emergency department visits within 90 days of posterior spinal decompression surgery

Background: Canadian Emergency Departments (EDs) are overburdened. Understanding the drivers for postoperative patients to attend the ED allows for targeted interventions thereby reducing demand. We sought to identify “bounce back” patterns for subsequent QI initiatives. Methods: From April 1, 2016 to March 31, 2022, all provincial ED datasets (EDIS, STAR, Meditech) identified patients presenting within 90 days post-spine surgery. Using Canadian Classification of Health Interventions codes, laminectomies (1SC80) and discectomies (1SE87) demonstrated the highest ED visit rates. Comprehensive chart reviews were conducted identifying surgical and medical reasons for presentation within this timeframe. Results: Reviewing a cohort of 2165 post-decompression patients, 42.1% presented to the ED (n=912) with 62.8% of these directly related to surgery. Primary reasons included wound care (31.6%), pain management (31.6%), and bladder issues (retention or UTI, 11.0%). Simple wound evaluation constituted 49.7% of wound-related visits, with surgical site infection 37.6% and dehiscence 6.6% accounting for the remainder. Pain-related presentations resulted in 72.3% discharge with additional medications, and 27.7% necessitating hospital admission. New or worsening neurologic deficits were reported in 8.9% of ED visits. Conclusions: These findings illuminate crucial aspects of postoperative care and ED utilization patterns. Prioritizing patient education, pain management, and wound care could help alleviate the national ED crisis.

#365 Dialysis centers performance: socioeconomic and environmental determinants

Abstract Background and Aims Healthcare outcomes in hemodialysis centers are intricately shaped by a myriad of factors extending beyond clinical realms. This study explores the interplay of socioeconomic and environmental determinants on the performance of 7638 hemodialysis centers in the United States during 2022. Leveraging data from the Centers for Medicare &amp; Medicaid Services, the United States Census Bureau, and the National Center for Environmental Information, our analysis encompasses outcomes like mortality, hospitalization, readmission rates, and emergency department visit rates. Method A dataset comprising information from 7638 US hemodialysis centers, spanning January to December 2022, was obtained through the Centers for Medicare &amp; Medicaid Services, US Census Bureau and environmental data, and from the National Center for Environmental Information. The study assessed mortality, hospitalization, readmission, and emergency department visits within one-month post-hospitalization. Independent variables included dialysis center characteristics, state-specific socioeconomic and environmental data, analysed through descriptive statistics and a linear regression model. Results Results reveal a significant correlation between racial composition and outcomes, with states having higher Latino populations exhibiting lower ED visit rates, contrasting with elevated mortality rates in states with higher African American populations. Socioeconomic factors, such as education and insurance status, influence ED visit rates. Environmental determinants, specifically average yearly state temperature, impact mortality and hospitalization rates. Operational characteristics matter: for-profit centres and those providing higher number of hemodialysis bed correlate with decreased mortality rates, while centres offering peritoneal dialysis or late-shift services demonstrate lower emergency department visit rates. Conclusion Our study unveils a nuanced interplay of factors influencing outcomes in hemodialysis centers. Disparities rooted in race and socioeconomic status underscore the need for targeted interventions. Environmental considerations further contribute to the complexity, while operational characteristics reveal intriguing trends, challenging conventional expectations. This analysis provides a foundation for tailored strategies to enhance the performance and equity of hemodialysis centers.

Primary Care Enhanced Access Services and the Association With Nonurgent Pediatric Emergency Department Utilization and Child Opportunity Index.

This study aims to examine the association between primary care practice characteristics (enhanced access services) and practice-level rates of nonurgent emergency department (ED) visits using ED and practice-level data. Survey data suggest that enhanced access services within a child's primary care practice may be associated with reduced nonurgent ED visits. We performed a cross-sectional analysis of nonurgent ED visits to a tertiary pediatric hospital in Western Pennsylvania with nearly 85,000 annual ED visits. We obtained patient encounter data of all nonurgent pediatric ED (PED) visits between January 2018 and December 2019. We identified the primary care provider at the time of the study period. For each of the 42 included offices, we determined the number of unique children in the office with a nonurgent PED visit, allowing us to determine the percentage of children in the practice with such a visit during the study period. We then stratified the 42 offices into low, intermediate, and high tertiles of nonurgent PED use. Using Kruskal-Wallis tests, logistic regression, and Pearson χ2 tests, we compared practice characteristics, enhanced access services, practice location Child Opportunity Index 2.0, and PED visit diagnoses across tertiles. We examined 52,459 nonurgent PED encounters by 33,209 unique patients across 42 outpatient offices. Primary care practices in the lowest ED visit tertile were more likely to have 4 or more evenings with office hours (36% vs 14%, P = 0.04), 4 or more evenings of weekday extended hours (43% vs 14%, P = 0.05), and at least 1 day of any weekend hours (86% vs 29%, P = 0.01), compared with practices in other tertiles. High PED use tertile offices were also associated with lower Child Opportunity Index scores. Primary care offices with higher nonurgent PED utilization had fewer enhanced access services and were located in neighborhood with fewer child-focused resources.

The effect of Certificate‐of‐Need laws on substance use disorder care for vulnerable populations

AbstractSubstance use disorders are a prevalent and growing problem across the United States, especially for households that rely on publicly funded healthcare insurance plans. State Certificate‐of‐Need (CON) laws for substance use disorder (SUD) treatment facilities can worsen outcomes for these patients by restricting the supply of facilities and beds, leading to spillovers into the general hospital system. We present a choice theory for treatment facility patient admission and model the outcome as a function of the patient's insurance type. We then combine two datasets on state CON laws for SUD treatment facilities with Medicaid patient data from 2017 to 2020 to test the model using a three‐stage least squares design and provide some of the first evidence on Medicaid patient outcomes under CON laws for SUD treatment facilities. We find significant evidence that state CON laws for SUD treatment facilities are associated with higher rates of hospital bed utilization, increases in the number of infants born with Neonatal Abstinence Syndrome, and higher rates of emergency department visits. Our findings are robust to several specification tests, including a model of conditional mixed method endogeneity and incorporating timing of the Affordable Care Act.

Abstract PO1-10-03: Prevalence of and Factors Associated with Food Insecurity and Other Adverse Social Determinants of Health Among Breast Oncology Patients

Abstract Background: Social determinants of health (SDOH), the non-medical factors that influence health status, have a profound impact on breast cancer (BC) outcomes and contribute to survival disparities. Food insecurity (FI), defined as a lack of consistent access to adequate food resources, is a modifiable SDOH associated with treatment disruptions, medication nonadherence, and decreased quality of life. To identify at-risk patients and inform future interventions, we implemented SDOH screening of patients seen in breast oncology clinic at our urban academic medical center. Methods: Screening was conducted through an 8-item questionnaire on the electronic patient portal. The questions covered FI, housing and transportation challenges, and emergency department (ED) visits. We conducted a retrospective analysis of SDOH data collected among patients scheduled for a breast oncology appointment between 11/1/22 and 5/25/23. Any level of food hardship or concern constituted a positive FI screen. Descriptive statistics were used to determine the prevalence of FI and other SDOH, to assess differences in FI rates by age, race/ethnicity, and clinical stage, and to compare characteristics of food-insecure vs food-secure patients. We also conducted a multivariable logistic regression analysis to estimate the odds ratio (OR) and 95% confidence interval (CI) associated with sociodemographic/clinical factors and FI. Results: A total of 2,585 patients were seen in our breast oncology practice, of which 1,189 (46.0%) were screened for SDOH, including 41.2% non-Hispanic White (NHW), 9.6% non-Hispanic Black (NHB) and 21.0% Hispanic patients. Among patients who responded to each SDOH question, 15.5% (146/940) reported some level of FI; 8.7% (84/962) were unable to pay their rent or mortgage on time; for 5.8% (57/989), lack of transportation interfered with their treatment. The FI rate differed significantly by race and ethnicity: 4.5% of NHW, 15.2% of NHB, and 41.8% of Hispanic patients reported FI (p&amp;lt; 0.001). In multivariable analysis, NHB and Hispanic patients also had significantly higher odds of FI compared to NHW patients (OR=3.68, 95% CI=1.7-7.7, p&amp;lt; 0.001 for NHB and OR=15.0, 95% CI=8.8-27.1, p&amp;lt; 0.001 for Hispanic patients). Patients with metastatic disease had higher rates of FI compared to other breast oncology patients (23.6% vs 14.8%, p=0.048), and a metastatic BC diagnosis was associated with over twice the odds of FI (OR=2.18, 95% CI=1.1-4.2, p=0.02). Among food-insecure patients, 41.1% were unable to pay their rent or mortgage on time and 22.6% reported transportation difficulties interfering with treatment (vs 2.6% and 2.4%, respectively, for food-secure patients (p&amp;lt; 0.001)). Compared to food-secure patients, those who were food-insecure had significantly higher rates of self-reported ED visits in the past 12 months: 18.8% vs. 33.6% reported at least 1 ED visit, respectively, and 5.2% vs. 16.4% reported multiple ED visits, respectively (p&amp;lt; 0.001). Conclusions: In this analysis of SDOH data among patients seen in breast oncology clinic, FI was the most common social health risk reported, with nearly a quarter of patients with metastatic BC reporting FI. Racial/ethnic minorities were also at considerably higher risk for FI. ED utilization was significantly higher among food-insecure patients. Targeted interventions to reduce FI in at-risk populations are warranted to improve clinical and healthcare utilization outcomes. Sociodemographic and Clinical Characteristics and Other Reported Social Determinants of Health Among Food-Secure vs Food-Insecure Patients Citation Format: Claire Sathe, David DeStephano, Anita Gul, Melissa Beauchemin, Justine Kahn, Melissa Accordino, Katherine Crew, Ngozika Emezienna, Dawn Hershman. Prevalence of and Factors Associated with Food Insecurity and Other Adverse Social Determinants of Health Among Breast Oncology Patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-10-03.

Revision Total Knee Arthroplasty in an Outpatient Setting: A Growing Alternative

IntroductionRecent studies have focused on the safety and efficacy of performing primary total knee arthroplasty (TKA) in an outpatient setting. Despite being associated with greater costs, much less is known about the accompanying impact on revision TKA (rTKA). The purpose of this study was to describe the trends in costs and outcomes of patients undergoing inpatient and outpatient rTKA. MethodsAn observational cohort study was conducted using commercial claims databases. Patients who underwent one- and two-component rTKA in an inpatient setting, hospital-based outpatient department (HOPD), or ambulatory surgery center (ASC) from 2018 to 2020 were included. The primary outcome was the 30-day episode of care costs following rTKA. Secondary outcomes included surgical cost, 90-day readmission rate, and emergency department (ED) visit rate. Covariates for analyses included patient demographics, surgery type, and indication for revision. ResultsThere were 6,515 patients who were identified, with 17.0% of rTKAs taking place in an outpatient setting. On adjusted analysis, patients in the highest quartile of 30-day postoperative costs were more likely to be those whose rTKA was performed in an inpatient setting. One-component revisions were more common in an outpatient setting (HOPD, 50.7%; ASC, 62.0%) compared to an inpatient setting (39.6%). The 90-day readmission rates were higher (P = 0.003) for rTKAs performed in inpatient (+9.2%) and HOPD (+8.6%) settings compared to those in an ASC. ConclusionThe ASC may be a suitable setting for simpler revisions performed for less severe indications and is associated with lower costs and 90-day readmission and ED visit rates.

Impact of the COVID-19 pandemic on regular emergency department users.

Regular users of the emergency department (ED) include both patients who could be better served in lower-acuity settings and those with high-severity conditions. ED use decreased during the COVID-19 pandemic, but patterns among regular ED users are unknown. To determine the impact of the COVID-19 pandemic on this population, we examined quarterly postpandemic ED utilization among prepandemic regular ED users. Key subgroups included prepandemic ED users with regular visits for (1) low-severity conditions and (2)high-severityconditions. An event study design with COVID-19 and historic controls cohorts. We identified 4710 regular ED users at baseline and followed their ED utilization for 7 quarters. We used a generalized estimating equations model to compare the relative quarterly percent difference in ED visit rates between the COVID-19 and historic controls cohorts. The first postpandemic quarter was associated with the largest decline in ED visits, at -36.0% (95% CI, -42.0% to -29.3%) per regular ED user overall, -52.2% (95% CI, -69.4% to -25.3%) among high-severity users, and -29.6% (95% CI, -39.8% to -17.8%) among low-severity users. However, use did not statistically differ from expected levels after 5 quarters among all regular ED users, 1 quarter among high-severity users, and 3 quarters among regular low-severity users. Initial reductions among regular high-severity ED users raise concern for harm from delayed or missed care but did not result in increased high-severity visits later. Nonsustained declines among regular low-severity ED users suggest barriers to and opportunities for redirecting nonurgent ED use to lower-acuity settings.

The Impact of Primary Care Clinic and Family Physician Continuity on Patient Health Outcomes: A Retrospective Analysis From Alberta, Canada.

Continuity of care is broadly associated with better patient health outcomes. The relative contributions of continuity with an individual physician and with a practice, however, have not generally been distinguished. This retrospective observational study examined the impact of continuity of care for patients seen at their main clinic but by different family physicians. We analyzed linked health administrative data from 2015-2018 from Alberta, Canada to explore the association of physician and clinic continuity with rates of emergency department (ED) visits and hospitalizations across varying levels of patient complexity. Physician continuity was calculated using the known provider of care index and clinic continuity with an analogous measure. We developed zero-inflated negative binomial models to assess the association of each with all-cause ED visits and hospitalizations. High physician continuity was associated with lower ED use across all levels of patient complexity and with fewer hospitalizations for highly complex patients. Broadly, no (0%) clinic continuity was associated with increased use and complete (100%) clinic continuity with decreased use, with the largest effect seen for the most complex patients. Levels of clinic continuity between 1% and 50% were generally associated with slightly higher use, and levels of 51% to 99% with slightly lower use. The best health care outcomes (measured by ED visits and hospitalizations) are associated with consistently seeing one's own primary family physician or seeing a clinic partner when that physician is unavailable. The effect of partial clinic continuity appears complex and requires additional research. These results provide some reassurance for part-time and shared practices, and guidance for primary care workforce policy makers.

Sociodemographic Factors and Trends in Bronchiolitis-Related Emergency Department Visit and Hospitalization Rates

Bronchiolitis is the most common and most cumulatively expensive condition in pediatric hospital care. Few population-based studies have examined health inequalities in bronchiolitis outcomes over time. To examine trends in bronchiolitis-related emergency department (ED) visit and hospitalization rates by sociodemographic factors in a universally funded health care system. This repeated cross-sectional cohort study was performed from April 1, 2004, to March 31, 2022, using population-based health administrative data from children younger than 2 years in Ontario, Canada. Bronchiolitis ED visit and hospitalization rates per 1000 person-years reported for the equity stratifiers of sex, residence location (rural vs urban), and material resources quintile. Trends in annual rates by equity stratifiers were analyzed using joinpoint regression and estimating the average annual percentage change (AAPC) with 95% CI and the absolute difference in AAPC with 95% CI from April 1, 2004, to March 31, 2020. Of 2 921 573 children included in the study, 1 422 088 (48.7%) were female and 2 619 139 (89.6%) lived in an urban location. Emergency department visit and hospitalization rates were highest for boys, those with rural residence, and those with least material resources. There were no significant between-group absolute differences in the AAPC in ED visits per 1000 person-years by sex (female vs male; 0.22; 95% CI, -0.92 to 1.35; P = .71), residence (rural vs urban; -0.31; 95% CI -1.70 to 1.09; P = .67), or material resources (quintile 5 vs 1; -1.17; 95% CI, -2.57 to 0.22; P = .10). Similarly, there were no significant between-group absolute differences in the AAPC in hospitalizations per 1000 person-years by sex (female vs male; 0.53; 95% CI, -1.11 to 2.17; P = .53), residence (rural vs urban; -0.62; 95% CI, -2.63 to 1.40; P = .55), or material resources (quintile 5 vs 1; -0.93; 95% CI -3.80 to 1.93; P = .52). In this population-based cohort study of children in a universally funded health care system, inequalities in bronchiolitis ED visit and hospitalization rates did not improve over time.

Burden of gallstone disease in the United States population: Prepandemic rates and trends.

Gallstone disease is one of the most common digestive disorders in the United States and leads to significant morbidity, mortality, and health care utilization. To expand on earlier findings and investigate prepandemic rates and trends in the gallstone disease burden in the United States using national survey and claims databases. The National Ambulatory Medical Care Survey, National Inpatient Sample, Nationwide Emergency Department Sample, Nationwide Ambulatory Surgery Sample, Vital Statistics of the United States, Optum Clinformatics® Data Mart, and Centers for Medicare and Medicaid Services Medicare 5% Sample and Medicaid files were used to estimate claims-based prevalence, medical care including cholecystectomy, and mortality with a primary or other gallstone diagnosis. Rates were age-adjusted (for national databases) and shown per 100000 population. Gallstone disease prevalence (claims-based, 2019) was 0.70% among commercial insurance enrollees, 1.03% among Medicaid beneficiaries, and 2.09% among Medicare beneficiaries and rose over the previous decade. Recently, in the United States population, gallstone disease contributed to approximately 2.2 million ambulatory care visits, 1.2 million emergency department visits, 625000 hospital discharges, and 2000 deaths annually. Women had higher medical care rates with a gallstone disease diagnosis, but mortality rates were higher among men. Hispanics had higher ambulatory care visit and hospital discharge rates compared with Whites, but not mortality rates. Blacks had lower ambulatory care visit and mortality rates, but similar hospital discharge rates compared with whites. During the study period, ambulatory care and emergency department visit rates with a gallstone disease diagnosis rose, while hospital discharge and mortality rates declined. Among commercial insurance enrollees, rates were higher compared with national data for ambulatory care visits and hospitalizations, but lower for emergency department visits. Cholecystectomies performed in the United States included 605000 ambulatory laparoscopic, 280000 inpatient laparoscopic, and 49000 inpatient open procedures annually. Among commercial insurance enrollees, rates were higher compared with national data for laparoscopic procedures. The gallstone disease burden in the United States is substantial and increasing, particularly among women, Hispanics, and older adults with laparoscopic cholecystectomy as the mainstay treatment. Current practice patterns should be monitored for better health care access.

Suicide prevention-related Google searches and subsequent emergency department visits in California and Arizona, 2007–2015

IntroductionUnited States emergency departments (ED) visit rates for nonfatal self-harm increased by 42% from 2001 to 2016. Previous suicide mortality research has provided conflicting evidence on the use of suicide-related Internet searches as a surveillance tool for self-harm and suicidal ideation. However, few have used rigorous approaches to account for autocorrelation at the aggregate level, and none have focused on Internet searches related to suicide prevention. Methods and resultsOver a 9-year study period (2007–2015), suicidality-related search data were extracted using the Google Health Application Programming Interface (API) for Arizona and California – states, chosen for their differing age distributions and rigorous ED injury coding policies. We examined several combined suicide prevention-related search queries. Using autoregressive integration moving average (ARIMA) models and a Box-Jenkins approach, we assessed whether increased prevention-related Internet searches related to suicidality are predictive of lower subsequent ED visits related to suicidal ideation with or without self-harm injury. In both states, greater prevention-related queries were associated with lower ED visits approximately four to six weeks later. ConclusionsOur results indicate that Internet-based search volumes related to suicide prevention may have the potential to monitor suicidality and online suicide prevention resources offer meaningful opportunities for mental health support.

Immune-related adverse effects: Recognition and initiation of appropriate treatment in cancer patients on immunotherapy.

Delayed or improper identification of immune-related adverse events (IRAEs) during cancer treatment can impact time to receive proper treatment. This study describes rates of IRAE recognition and appropriate treatment in adult patients with cancer at a community teaching hospital. This single-center, retrospective, cohort study evaluated rates of proper IRAE treatment in conjunction with National Comprehensive Cancer Network (NCCN) guidelines. Secondary outcomes included time from presentation to IRAE diagnosis and hospital readmissions/repeat emergency department (ED) visits following initial admission for IRAE. Retrospective chart review assessed IRAE presentation including common terminology criteria for adverse event (CTCAE) grading and treatment choices. Fifteen subjects included in this study contributed to 21 encounters with noted IRAE. Over half (52.4%) of the encounters received proper IRAE treatment (e.g. correct drug, dose, route, frequency, or therapy duration). Nearly 22% of total actionable components were improper, occurring more often in patients with colitis, pneumonitis, and hepatitis. Median time to IRAE diagnosis was approximately 3.5 days, with the longest being 24 days. There were eight all-cause rehospitalizations one year after initial IRAE presentation, with four directly IRAE-related. Most (75%) IRAE-related rehospitalizations occurred with colitis. Seven ED return visits were also noted. Many IRAEs were misdiagnosed and/or received improper treatment resulting in increased rehospitalization/return ED visit rates. The importance of medical oncology involvement (e.g. medical oncology consult at time of admission and/or notification of primary oncologist) in IRAE management in the hospital or ED was also stressed. Organizations may benefit from systematic improvements and staff education to improve patient outcomes and prevent readmissions.

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.

Clinical Impact of Routine Assessment of Patient-Reported Health Status in Heart Failure Clinic: The PRO-HF Trial.

The impact of routine clinic use of patient-reported outcome (PRO) measures on clinical outcomes in patients with heart failure (HF) has not been well-characterized. We tested if clinic-based use of a disease-specific PRO improves patient-reported quality of life at 1 year. The PRO-HF trial (Patient-Reported Outcome Measurement in Heart Failure Clinic) was an open-label, parallel, patient-level randomized clinical trial of routine PRO assessment or usual care at an academic HF clinic between August 30, 2021, and June 30, 2022, with 1 year of follow-up. In the PRO assessment arm, participants completed the Kansas City Cardiomyopathy Questionnaire-12 (KCCQ-12) at each HF clinic visit, and results were shared with their treating clinician. The usual care arm completed the KCCQ-12 at randomization and 1 year later, which was not shared with the treating clinician. The primary outcome was the KCCQ-12 overall summary score (OSS) between 12 and 15 months after randomization. Secondary outcomes included domains of the KCCQ-12, hospitalization and emergency department visit rates, HF medication therapy, clinic visit frequency, and testing rates. Across 17 clinicians, 1248 participants were enrolled and randomized to PRO assessment (n=624) or usual care (n=624). The median age was 63.9 years (interquartile range [IQR], 51.8-72.8), 38.9% were women, and the median baseline KCCQ-12 OSS was 82.3 (IQR, 58.3-94.8). Final KCCQ-12 (available in 87.9% of the PRO arm and 85.1% in usual care; P=0.16) median OSS were 87.5 (IQR, 68.8-96.9) in the PRO arm and 87.6 (IQR, 69.7-96.9) in the usual care arm with a baseline-adjusted mean difference of 0.2 ([95% CI, -1.7 to 2.0]; P=0.85). The results were consistent across prespecified subgroups. A post hoc analysis demonstrated a significant interaction with greater benefit among participants with a baseline KCCQ-12 OSS of 60 to 80 but not in less or more symptomatic participants. No significant differences were found in 1-year mortality, hospitalizations, emergency department visits, medication therapy, clinic follow-up, or testing rates between arms. Routine PRO assessment in HF clinic visits did not impact patient-reported quality of life or other clinical outcomes. Alternate strategies and settings for embedding PROs into routine clinical care should be tested. URL: https://www.clinicaltrials.gov; Unique identifier: NCT04164004.

Impact of surgeon volume, experience, and training on outcomes after arthroscopic rotator cuff repair: a nationwide analysis of 1489 surgeons

BackgroundGiven the complexity of arthroscopic rotator cuff repair (ARCR) and increasing prevalence, there is a need for comprehensive, large-scale studies that investigate potential correlations between surgeon-specific factors and postoperative outcomes after ARCR. This study examines how surgeon-specific factors including case volume, career length, fellowship training, practice setting, and regional practice impact two-year reoperation rates, conversion to total shoulder arthroplasty (anatomic or reverse) (TSA), and 90-day post-ARCR hospitalization. MethodsThe PearlDiver Mariner Database was used to collect surgeon-specific variables and query patients who underwent ARCR from 2015 to 2018. Patient outcomes were tracked for two years, including reoperations, hospitalizations, and ICD-10 codes for revision rotator cuff repair (RCR) laterality. Hospitalizations were defined as any emergency department (ED) visit or hospital readmission within 90 days after primary ARCR. Surgeon-specific factors including surgeon case volume, career length, fellowship training, practice setting, and regional practice were analyzed in relation to postoperative outcomes using both univariate and multivariate logistic regression. Results94,150 patients underwent ARCR by 1,489 surgeons. On multivariate analysis, high volume surgeons demonstrated a higher risk for two-year total reoperation (OR = 1.06, 95% CI: 1.01-1.12, P = 0.03) and revision RCR (OR = 1.06, 95% CI: 1.01-1.12, P = 0.02) compared to low volume surgeons. Early-career surgeons showed higher rates of 90-day ED visits (mid-career surgeons: OR = 0.78, 95% CI: 0.73-0.83, P < 0.001; late-career surgeons: OR = 0.73, 95% CI: 0.68-0.78, P < 0.001) and hospital readmission (mid-career surgeons: OR = 0.74, 95% CI: 0.63-0.87, P < 0.001; late-career surgeons: OR = 0.73, 95% CI: 0.61-0.88, P = 0.006) compared to mid- and late-career surgeons. Sports Medicine and/or Shoulder and Elbow fellowship-trained surgeons demonstrated lower two-year reoperation risk (OR = 0.95, CI: 0.91-0.99, P = 0.04) and fewer 90-day ED visits (OR = 0.93, 95% CI = 0.88-0.98, P = 0.002). Academic surgeons experienced higher readmission rates compared to community surgeons (OR = 1.16, 95% CI = 1.01-1.34, P = 0.03). Surgeons practicing in the Northeast demonstrated lower two-year reoperation (OR = 0.88, 95% CI: 0.83-0.93, P < 0.001) and revision (OR = 0.88, 95% CI: 0.83-0.94, P < 0.001) rotator cuff repair risk, compared to surgeons in the Southern United States. ConclusionsHigh-volume surgeons exhibit higher two-year reoperation rates after ARCR compared to low-volume surgeons. Early-career surgeons demonstrate increased hospitalizations. Sports Medicine or Shoulder and Elbow Surgery fellowships correlate with reduced two-year reoperation rates and 90-day ED visits.

Socioeconomic Disparities in Online Patient Portal Utilization Among Total Knee Arthroplasty Recipients

BackgroundSince 2021, the Centers for Medicare and Medicaid Services have mandated that patients have open access to their medical records. Many institutions use online portals, which allow patients to access their health information and communicate with care teams. Our research aimed to evaluate demographic patterns for online patient portal utilization in patients undergoing total knee arthroplasty (TKA). Further, we assessed if and how portal engagement contributes to perioperative outcomes. MethodsThis study retrospectively reviewed primary and elective TKA from 2017 to 2022 at a single academic institution. Patients were stratified into two groups based on their online portal status: activated (A) or not-activated (NA). Baseline characteristics and postoperative outcomes were collected from the electronic medical record and compared. ResultsIn total, 10,995 patients were included: 8,330 (75.8%) were A and 2,625 (24.2%) were NA. The NA group was significantly older (P < 0.001); more likely to be Black (P < 0.001), women (P < 0.001), single/divorced/widowed (P < 0.001), non-English speaking (P < 0.001), and Medicare or Medicaid insured (P < 0.001); from zip codes with median incomes below $50,000 (P < 0.001), and more likely to be American Society of Anesthesiologists (ASA) class III or IV (P < 0.001). Patient-reported outcome measure (PROM) completion rates were significantly lower in the NA group (15.3 versus 47.7%, P < 0.001). Lengths of stay (LOS) were significantly higher in the NA group (2.7 versus 2.1 days, P < 0.001). The NA group was significantly more likely to be discharged to skilled nursing facilities (P < 0.001). Comparable rates of 90-day emergency department visits, readmissions, as well as 90-day and two-year revisions, were observed across groups. ConclusionThere are significant disparities in online portal activation status based on patient demographics. Patients who have activated portals had significantly higher PROM completion rates, shorter LOS, and higher rates of home discharge. Further research should determine which other factors may affect patient portal utilization and inform interventions to improve portal utilization among minority populations.

Emergency department visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019

BackgroundVisits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits.MethodsA retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits.ResultsIn 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51–1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08–2.31).ConclusionsOur study indicates that more than half of NH residents’ ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely.

Readmission following methotrexate treatment for tubal pregnancy.

To identify risk factors for readmission following methotrexate treatment for tubal pregnancy. A retrospective study undertaken in two tertiary medical centers, including all individuals with medically treated tubal pregnancy (N = 511), between December 2009 and June 2021. Individuals with and without readmission following methotrexate treatment were compared. The primary outcome was the readmission rate. Secondary outcomes included the rate of post-discharge gynecological emergency department visits, tubal rupture rate, and the eventual need for surgical treatment. Readmission following methotrexate treatment occurred in 224/511 patients (43.8%). Most readmissions were due to abdominal pain or suspicion of treatment failure. Readmitted individuals were more likely to have a history of pelvic inflammatory disease and pretreatment serum human chorionic gonadotropin (hCG) >2000 mIU/mL. Both factors remained significantly associated with higher readmission rates in a logistic regression analysis (adjusted odds ratio [OR] 6.28, 95% confidence interval [CI] 1.30-30.45, and adjusted OR 2.73, 95% CI 1.83-4.07, respectively) after adjustment for age, endometriosis, tubal pathology, abdominal pain, and presence of yolk sac or embryo at diagnosis. A dose-dependent association was observed between pretreatment serum hCG levels and readmission rate (P < 0.001). Pretreatment hCG levels were also associated with tubal rupture and the eventual need for surgical treatment (P < 0.001 for both). A prediction model using hCG was not sufficiently accurate to predict readmission risk. Readmission following methotrexate treatment for tubal pregnancy was independently associated with previous pelvic inflammatory disease and pretreatment serum hCG levels. The latter was also associated with surgical intervention rate.