Excess Emergency Department Research Articles

Trends in Substance Use Disorder-Related Emergency Department Visits in California: An Analysis of 46 Million Visits From 2006 to 2011.

To better understand the development of the growing opioid crisis in the early 21st century, the authors studied trends in substance use disorder among 46,132,211 emergency department (ED) visit discharges in California between 2006 and 2011. Utilizing the California State Emergency Department Database, the authors identified substance use based on International Classification of Diseases, Ninth Revision codes. Tabular and multivariable analysis methods were applied. ED visits were considered clustered at the level of patient. The authors observed a notable increase in substance use prevalence from 7.32 ± 6.07 to 12.21 ± 9.35 per 1000 ED visits. Nonopioid substance use was more prevalent among individuals aged ≤ 50 years old. Opioid use disorder (OUD) was associated with a higher mortality rate in the ED. In 2011, OUD was significantly higher among American Indians visiting the ED. A multivariable analysis revealed that OUD was an independent predictor for increased ED visits after controlling for demographic factors. Despite an overall decrease in mortality rate, opioid-related ED visits showed a higher mortality rate, underscoring the grave consequences of OUD. Nonopioid substance use was prevalent among younger age groups, suggesting a need for age-specific interventions. A major finding was the elevated OUD among American Indians, indicating persistent health disparities impacting this demographic. OUD was an independent risk factor for excess ED visits, which could strain health care systems. The authors suggest strategies like nonopioid pain management, community-level programs, and bridging ED with outpatient treatment facilities to mitigate the opioid crisis and ED overutilization. These findings advocate for tailored public health strategies, addressing the underlying disparities to combat the opioid epidemic effectively.

Impact of extreme weather events on healthcare utilization and mortality in the United States.

Climate change is intensifying extreme weather events. Yet a systematic analysis of post-disaster healthcare utilization and outcomes for severe weather and climate disasters, as tracked by the US government, is lacking. Following exposure to 42 US billion-dollar weather disasters (severe storm, flood, flood/severe storm, tropical cyclone and winter storm) between 2011 and 2016, we used a difference-in-differences (DID) approach to quantify changes in the rates of emergency department (ED) visits, nonelective hospitalizations and mortality between fee-for-service Medicare beneficiaries in affected compared to matched control counties in post-disaster weeks 1, 1-2 and 3-6. Overall, disasters were associated with higher rates of ED utilization in affected counties in post-disaster week 1 (DID of 1.22% (95% CI, 0.20% to 2.25%; P < 0.020)) through week 2. Nonelective hospitalizations were unchanged. Mortality was higher in affected counties in week 1 (DID of 1.40% (95% CI, 0.08% to 2.74%; P = 0.037)) and persisted for 6 weeks. Counties with the greatest loss and damage experienced greater increases in ED and mortality rates compared to all affected counties. Thus, billion-dollar weather disasters are associated with excess ED visits and mortality in Medicare beneficiaries. Tracking these outcomes is important for adaptation that protects patients and communities, health system resilience and policy.

Short term exposure to low level ambient fine particulate matter and natural cause, cardiovascular, and respiratory morbidity among US adults with health insurance: case time series study

ObjectiveTo estimate the excess relative and absolute risks of hospital admissions and emergency department visits for natural causes, cardiovascular disease, and respiratory disease associated with daily exposure to fine particulate...

Effects of socioeconomic status and greenspace on respiratory emergency department visits under short-term temperature variations: An age-stratified case time-series study

IntroductionNeighborhood socioeconomic status (SES) and greenspace can affect respiratory health. However, it is unclear whether effects of neighborhood SES and greenspace on respiratory health still exist regardless of temperature variations. MethodsThis paper conducted a two-stage, age-stratified case time-series study. The first goal is to examine the associations between two temperature metrics (daily mean temperature [DMT] and diurnal temperature range [DTR]) and respiratory emergency department (ED) visits among four age groups in New York City. The second goal is to evaluate whether neighborhood SES and greenspace would be determinants of respiratory ED visits independent from temperature varying factors. A distributed lag nonlinear model was applied on ED data from 135 zip codes (October 2016 - February 2020). ResultsOur first-stage analysis indicated that older adults aged 65+ had higher risk of ED visits (RR=2.78, 95% eCI: 2.41, 3.22; with 7 days of lag) on days with low DMT (-10°C), followed by adults aged 18-64 (RR=2.48, 95% eCI: 2.32, 2.65), children and youth aged 5-17 (RR=1.38, 95% eCI: 1.24, 1.53), and young children aged 0-4 (RR=1.04, 95% eCI: 0.96, 1.13). However, no excess respiratory ED visits were observed on days with high DMT (30°C). Higher DTR was associated with higher risk, with children and youth more susceptible when DTR was high (DTR 20°C; RR=5.70, 95% eCI: 3.42, 9.49; with 7 days of lag). The second-stage analysis indicated neighborhood SES and greenspace had significant associations with respiratory ED visits regardless of temperature variations. Specifically, Higher income and greenspace exposure were negatively associated with ED visits among all age groups. ConclusionsNeighborhood SES and greenspace could affect respiratory morbidity regardless of weather conditions. Daily temperature variations accelerated the short-term risk among population subgroups under different weather conditions (e.g., higher risk of days with low DMT among older adults, higher risk of days with high DTR among children and youth aged 5-17), which could create co-effects with neighborhood SES and greenspace on respiratory health.

Quantifying fire-specific smoke exposure and health impacts.

Rapidly changing wildfire regimes across the Western United States have driven more frequent and severe wildfires, resulting in wide-ranging societal threats from wildfires and wildfire-generated smoke. However, common measures of fire severity focus on what is burned, disregarding the societal impacts of smoke generated from each fire. We combine satellite-derived fire scars, air parcel trajectories from individual fires, and predicted smoke PM2.5 to link source fires to resulting smoke PM2.5 and health impacts experienced by populations in the contiguous United States from April 2006 to 2020. We quantify fire-specific accumulated smoke exposure based on the cumulative population exposed to smoke PM2.5 over the duration of a fire and estimate excess asthma-related emergency department (ED) visits as a result of this exposure. We find that excess asthma visits attributable to each fire are only moderately correlated with common measures of wildfire severity, including burned area, structures destroyed, and suppression cost. Additionally, while recent California fires contributed nearly half of the country's smoke-related excess asthma ED visits during our study period, the most severe individual fire was the 2007 Bugaboo fire in the Southeast. We estimate that a majority of smoke PM2.5 comes from sources outside the local jurisdictions where the smoke is experienced, with 87% coming from fires in other counties and 60% from fires in other states. Our approach could enable broad-scale assessment of whether specific fire characteristics affect smoke toxicity or impact, inform cost-effectiveness assessments for allocation of suppression resources, and help clarify the growing transboundary nature of local air quality.

Towards an Implicit Measure of Patient Engagement in Sickle Cell Disease: Relationships between Implicit Measures of Engagement and Previous Childhood Trauma Among Adolescents and Young Adults

Background: Historically, patient engagement among adolescents and young adults (AYAs, age 18-25) decreases, parallel with the shift from parental to patient responsibility for engagement, and the transition from pediatric to adult care. Simultaneously, among AYAs with sickle cell disease (SCD), increases in organ failure, visits for VOCs, and mortality occur during this period. One previously shown predictor of excess hospital and ED utilization is prior childhood trauma, including medical trauma from treatment, parental abuse, or neglect. We found no implicit and few explicit measures of SCD AYA engagement in self-care or cooperation with professional care. We did find that Adverse Childhood Experiences (ACEs) are linked to increased morbidity. Particularly Emergency Department (ED) visits for pain, among children and adolescents with SCD. So, as part of validating an empirically derived implicit measure of SCD AYA engagement, we tested the relationship of the new measure to a validated measure of previous childhood trauma. Method: We studied selected AYA patients (N=20) enrolled in an Adult Sickle Cell Medical Home. Childhood trauma was assessed using the Center for Disease Control's 13-item, Behavioral Risk Factor Surveillance System Adverse Childhood Experience (ACE) module, measuring self-reported exposure to 9 types of childhood adversities: emotional abuse, physical abuse, sexual abuse, household member mental illness, household member substance abuse, witnessing domestic violence, parental separation or divorce, and incarcerated family members. The implicit measure of patient engagement was the draft 4-item Tiers of Engagement (TOE) tool. The original TOE was developed for pediatric patients and assessed parental as well as patient engagement. The adult TOE assesses only AYA engagement. The TOE tool asks professionals of all disciplines caring for SCD patients to confer as a group during interprofessional meetings to subjectively assign ratings of one (ideal engagement) to three (poor engagement) to four different domains: medical, educational, mental, and social. The analysis of variance (ANOVA) test was used to analyze the relationship between the ACE score and each of the engagement sectors (medical, educational, mental, and social). Results: The graphs below show ANOVA results for the relationship of the ACE score to each TOE domain score. We found no significant relationships between ACE scores and TOE domain scores. Conclusion: We observed no significant relationships between childhood trauma and implicitly measured patient engagement among AYAs with SCD. Future research should measure the TOE in larger samples and identify whether the TOE score is related to explicit measures of SCD AYA engagement, or hypothesized predictors of SCD AYA engagement and healthcare utilization. Future research should also utilize the ACE measures to implement trauma-informed care in AYAs with SCD.

Evaluation of a transitions clinic to bridge emergency department and primary care.

Suboptimal transitions from the emergency department (ED) to ambulatory settings contribute to poor clinical outcomes and unnecessary nonurgent ED utilization. Care transition clinics (CTCs) are a potential solution by providing ED follow-up and facilitating the bridge to longer-term primary care. The objective was to evaluate the implementation of an ED transitions clinic on 30-day ED revisits and hospital readmissions. Retrospective cross-sectional study. This study included adults 18 years and older discharged from the ED and reeferred to the CTC. Appointment attendance, follow-up time, and frequencies of care type provided were computed to assess clinic utilization. Rates of 30-day ED revisit and hospital admission were compared between completed and missed appointments using logistic regression. Between March 2021 and March 2022, 373 patients were referred to the CTC totaling 405 appointments. Half (53%) of appointments were completed with a median follow-up time of 4 days (IQR = [2, 7]). The most common care types provided were wound care (44%) and clinical problem management (33%), with wound care appointments more likely to be completed compared with clinical appointments (OR = 1.7, CI = [1.1, 2.8], p = .03). Patients who completed their CTC appointment were 50% less likely to return to the ED in 30 days compared with those who did not complete their appointment (OR = 0.51, CI = [0.27, 0.98], p < .05). No effect was seen for CTC appointment completion on hospital readmission. Transition clinics are a viable method to provide timely access to follow-up for patients discharged from the ED and may help reduce excess ED use for ambulatory care needs.

State Mandatory Paid Sick Leave Associated With A Decline In Emergency Department Use In The US, 2011-19.

Paid sick leave provides workers with job-protected paid time off to address short-term illnesses or seek preventive care for themselves and their family members. We studied the impact of mandatory paid sick leave at the state level on emergency department (ED) visit rates, using all-payer, longitudinal ED data from the Healthcare Cost and Utilization Project for the period 2011-19. We found that state implementation of paid sick leave mandates was associated with a 5.6percent reduction in the total ED visit rate relative to the baseline, equivalent to 23 fewer visits per 1,000 population per year. The reduction was concentrated in Medicaid patients. Some of the largest reductions were ED visits related to adult dental conditions, adult mental health or substance use disorders, and pediatric asthma. Mandatory paid sick leave may be an effective policy lever to reduce excess ED use and costs.

The Role of Cooling Centers in Protecting Vulnerable Individuals from Extreme Heat.

The Role of Cooling Centers in Protecting Vulnerable Individuals from Extreme Heat.

Excess emergency department visits for cardiovascular and respiratory diseases during the 2019–20 bushfire period in Australia: A two-stage interrupted time-series analysis

The health effects of the unprecedented bushfires in Australia in 2019–20 have not been fully examined. We aimed to examine the excess emergency department (ED) visits related to the 2019–20 bushfires in New South Wales (NSW). We obtained weekly data of ED visits for cardiovascular and respiratory diseases in all the 28 Statistical Area Level 4 (SA4) regions in NSW during the bushfire seasons from 2017 to 2020. A two-stage interrupted time-series analysis was applied to quantify the excess risk for ED visits in 2019–20. The total number of excess ED visits, excess percentages, and their empirical confidence intervals (eCIs) were calculated to estimate the impacts of the bushfire season. A total of 416,057 records of cardiorespiratory ED visits were included in our analysis. The bushfire season in 2019–20 was significantly associated with a 6.0% increase (95% eCI: 1.9, 10.3) in ED visits for respiratory diseases and a 10.0% increase (95% eCI: 5.0, 15.2) for cardiovascular diseases, corresponding to 6177 (95% eCI: 1989, 10,166) and 3120 (95% eCI: 1628, 4544) excess ED visits, respectively. The percentage of excess ED visits was higher in regions with lower SES and high fire density. In the context of climate change, more targeted strategies should be developed to prevent adverse bushfire effects and recover from such extreme environmental events.

Social and spatial variation in heatwave-related emergency department visits in Australia

BACKGROUND AND AIM: Heatwaves are extreme weather events that cause more urgent medical care than any other hazard in Australia. Heatwave impacts vary between populations and locations and empirical evidence concerning vulnerable places and people at a local level is critical for effective policy, planning, and interventions, especially in a warming climate. This study aimed to examine heatwave-related morbidity in Australia (using emergency department (ED) presentations) at a small-area level and identify susceptibility by neighbourhood characteristics. METHODS: ED presentations data for eight Australian cities from 2013-2018 during the warm-season (October- March) were extracted from a national database. In each city, we examined the association of heatwave severity (defined using Excess Heat Factor) with ED visits at the Statistical Areas 2 geographical unit using a time-stratified case-crossover approach. Effect modification by neighbourhood characteristics were examined and city-level estimates were pooled using random-effects meta-analyses. RESULTS:A total of 23,233,374 all-cause ED presentations were included in the analysis. Pooled ED relative risk estimates indicate that ED visits increased by 2.9% (95%CI: 1.5-4.2%) and 3.4% (95%CI: 1.2-5.5%) during low-intensity and severe/extreme heatwaves, respectively. There were 67,974 excess ED presentations during heatwaves with 82% of these occurring during low-intensity events which are more frequent than severe/extreme heatwaves. The effects varied substantially by city with the highest number of excess ED presentations observed in Adelaide (28,198) and Sydney (19,899). Heat-related conditions such as dehydration and heat exhaustion/stroke were significantly greater during heatwaves and the effect increased from low-intensity to severe/extreme heatwaves. Analysis of neighbourhood characteristics on heatwave-related ED presentations revealed greater health impacts for areas with high social vulnerability e.g., household composition, language and culture, and housing quality. CONCLUSIONS:Overall, ED presentations are sensitive to heatwaves across all severity classes and the effects are stronger for individuals with certain health conditions and neighbourhood contexts. KEYWORDS: Heatwaves, integrated data, vulnerability, excess heat factor

Emergency department provider in triage: assessing site-specific rationale, operational feasibility, and financial impact.

Emergency department (ED) crowding is recognized as a critical threat to patient safety, while sub‐optimal ED patient flow also contributes to reduced patient satisfaction and efficiency of care. Provider in triage (PIT) programs—which typically involve, at a minimum, a physician or advanced practice provider conducting an initial screening exam and potentially initiating treatment and diagnostic testing at the time of triage—are frequently endorsed as a mechanism to reduce ED length of stay (LOS) and therefore mitigate crowding, improve patient satisfaction, and improve ED operational and financial performance. However, the peer‐reviewed evidence regarding the impact of PIT programs on measures including ED LOS, wait times, and costs (as variously defined) is mixed. Mechanistically, PIT programs exert their effects by initiating diagnostic work‐ups earlier and, sometimes, by equipping triage providers to directly disposition patients. However, depending on local contextual factors—including the co‐existence of other front‐end interventions and delays in ED throughput not addressed by PIT—we demonstrate how these features may or may not ultimately translate into reduced ED LOS in different settings. Consequently, site‐specific analysis of the root causes of excessive ED LOS, along with mechanistic assessment of potential countermeasures, is essential for appropriate deployment and successful design of PIT programs at individual EDs. Additional motivations for implementing PIT programs may include their potential to enhance patient safety, patient satisfaction, and team dynamics. In this conceptual article, we address a gap in the literature by demonstrating the mechanisms underlying PIT program results and providing a framework for ED decision‐makers to assess the local rationale for, operational feasibility of, and financial impact of PIT programs.

Ambulatory Care Fragmentation and Incident Stroke.

BackgroundMore fragmented ambulatory care (ie, care spread across many providers without a dominant provider) has been associated with excess emergency department and inpatient care. We sought to determine whether more fragmented ambulatory care is associated with an increase in the hazard of incident stroke, overall and stratified by health status and by race.Methods and ResultsWe conducted a secondary analysis of data from the REGARDS (Reasons for Geographic and Racial Differences in Stroke) study (2003–2016), including participants aged ≥65 years who had linked Medicare fee‐for‐service claims and no history of stroke (N=12 510). We measured fragmentation of care with the reversed Bice‐Boxerman index. We used Poisson models to determine the association between fragmentation and adjudicated incident stroke. The average age of participants was 70.5 years; 53% were women, 32% were Black participants, and 16% were participants with fair or poor health. Overall, the adjusted rate of incident stroke was similar for high versus low fragmentation (8.2 versus 8.1 per 1000 person‐years, respectively; P=0.89). Among participants with fair or poor self‐rated health, having high versus low fragmentation was associated with a trend toward a higher adjusted rate of incident strokes (14.8 versus 10.4 per 1000 person‐years, respectively; P=0.067). Among Black participants with fair or poor self‐rated health, having high versus low fragmentation was associated with a higher adjusted rate of strokes (19.3 versus 10.3 per 1000 person‐years, respectively; P=0.02).ConclusionsHighly fragmented ambulatory care is independently associated with incident stroke among Black individuals with fair or poor health.

Projecting Health Impacts of Future Temperature: A Comparison of Quantile-Mapping Bias-Correction Methods.

Health impact assessments of future environmental exposures are routinely conducted to quantify population burdens associated with the changing climate. It is well-recognized that simulations from climate models need to be bias-corrected against observations to estimate future exposures. Quantile mapping (QM) is a technique that has gained popularity in climate science because of its focus on bias-correcting the entire exposure distribution. Even though improved bias-correction at the extreme tails of exposure may be particularly important for estimating health burdens, the application of QM in health impact projection has been limited. In this paper we describe and apply five QM methods to estimate excess emergency department (ED) visits due to projected changes in warm-season minimum temperature in Atlanta, USA. We utilized temperature projections from an ensemble of regional climate models in the North American-Coordinated Regional Climate Downscaling Experiment (NA-CORDEX). Across QM methods, we estimated consistent increase in ED visits across climate model ensemble under RCP 8.5 during the period 2050 to 2099. We found that QM methods can significantly reduce between-model variation in health impact projections (50–70% decreases in between-model standard deviation). Particularly, the quantile delta mapping approach had the largest reduction and is recommended also because of its ability to preserve model-projected absolute temporal changes in quantiles.

Heat, Medical Fragility, and Child Morbidity in a U.S. Urban Setting

Background: The majority of research on ambient heat and health has highlighted vulnerability of older populations. Studies of ambient heat and children’s health is an emerging focus area. We aim to explore the risk of high ambient temperatures to children aged 0-18 in New York City, examining inpatient and emergency department (ED) admissions from 2005- 2011 during the warm season months (May -September). We also explore an initial definition of medically fragile children to further characterize heat vulnerability. Methods: We apply a time-stratified, case-crossover design, using conditional logistic regression to estimate percent excess ED (n=2,252,550) and inpatient (n=228,006) admission risks for same-day exposure, controlling for relative humidity. We also conduct subgroup analysis stratifying by age (0-4, 5-12, and 13-18 years old) and by medical fragility, as defined by the Feudtner Pediatric Complex Chronic Conditions (CCC) classification system. We report relative risk and its 95% confidence interval (RR (95%CI)) per 13°F increase in ambient temperature. Results: Same-day heat exposure is significantly associated with a greater percent excess risk (RR) of ED admission for children across all age groups [RR = 2.0 (1.8 - 2.3)], and within each age group. A statistically-significant increased risk of inpatient admission was observed only among children aged 13-18 [RR= 1.9 (0.4 - 3.4)]. Children without medical fragility showed a significantly increased percent risk of ED visit [RR= 0.5 (-2.3 - 3.4)], but not of inpatient admission [RR = 1.5 (-0.4 - 3.4)]. The associations for ED [RR= 0.5 (-2.3-3.4)] or inpatient admissions [RR= 1.5 (-0.4 - 3.4)] were not significant among children with medical fragility. Conclusions: Additional work will better characterize childhood vulnerability and redefine the concept of medically-fragile children as it pertains to heat exposure.

Constructing Causal Networks Through Regressions: A Tutorial.

Significant progress has been made in the practice of conducting causal analysis using network models. Despite this progress, there is limited evidence that hospital risk managers are using these analytical models. This article introduces the causal network, its related concepts, and methods of analysis. The article demonstrates how hospital risk managers can use existing regression software to construct a causal network and identify root causes of an adverse event. Causal networks depict cause and effect in a set of variables. In this context, causes are strong correlations that meet 3 additional criteria: (1) causes occur prior to effects, (2) there is an articulated mechanism for how causes lead to effects, and (3) the association between cause and effect is not spurious, meaning the association persists even after other variables are statistically controlled for (a method of analysis called counterfactual). A causal network can be constructed through repeated use of least absolute shrinkage and selection operator (LASSO) regression. In the proposed regressions, the response variable is any variable in the data. The independent variables are variables that occur prior to the response variable. By design, the statistically significant coefficients in the time-constrained LASSO regressions identify "direct" causes of the response variables. When direct causes of all variables are identified, then the entire network model, including root causes, has been specified. In the final step, the parameters of the network model (ie, strength of causal associations) are estimated by fitting the network structure to the available data. We demonstrate these concepts through fitting a network model to simulated data for causes of excessive boarding in emergency departments. The network (involving 12 causes, over 4 periods, and 1 sentinel event) was accurately recovered from the simulated case reports. The recovered network did not differ from the original network used to simulate the data in any of the 156 possible links. The recovered network allowed the identification of root and direct causes. It showed that hospital occupancy rate, and not emergency department efficiency, was root cause of excessive emergency department boarding. Causal networks can provide insights into root, and direct, causes of an adverse event. These models provide empirical tests of causes of adverse events. We encourage the use of these methods by hospital risk managers.

Health Literacy and Emergency Department Utilization Among Community Adults With Mental and Chronic Health Conditions

Reducing unnecessary emergency department (ED) utilization is a national health care priority. Low health literacy is a little explored but suggested cause of excess ED utilization. This study investigated the association between health literacy and ED utilization among a community sample of adults with common mental and chronic health conditions. Cross-sectional health interview survey data from Schenectady, New York, were used. Adults (aged ≥18 years) who were diagnosed with anxiety/emotional disorders, depression, asthma, or diabetes were included in the study. Health literacy was assessed using the three-question screener developed and validated by L. D. Chew et al. (2004). ED visits in the previous 12 months specific to these health conditions were analyzed. Multivariable regression models were fitted for each condition with incremental covariate adjustments of demographics, health care access, and number of comorbidities. Odds ratio (OR) and 95% confidence intervals (CI) were reported. Sample sizes were 404, 509, 409, and 237 for anxiety/emotional disorders, depression, asthma, and diabetes, respectively. Inadequate health literacy was significantly higher among individuals who had depression and visited an ED compared with individuals with depression without an ED visit (28.1% vs. 16.9%, p = 0.029). Significant and independent associations between inadequate health literacy and ED utilization was found among adults with anxiety/emotional disorder (fully-adjusted OR 2.22 [CI: 1.03, 4.76]) and among adults with depression (fully-adjusted OR 2.29 [CI: 1.18, 4.44]). No significant association was found among adults with asthma or diabetes. This study presented evidence that inadequate health literacy is common and independently associated with ED utilization among adults with mental health conditions. It supports an initiative to prioritize individuals with mental health conditions, and systematically screen, identify, and provide assistance to those with inadequate health literacy to reduce excess ED utilization. Several existing health literacy screening tools suitable for an emergency care setting are suggested.

P1546UK ANNUAL THERAPY COST OF DIALYSIS WITH THE QUANTA SC+ PERSONAL HAEMODIALYSIS SYSTEM

Abstract Background and Aims The number of patients receiving dialysis is increasing in the United Kingdom, costing the National Health Service (NHS) over 500 million GBP annually. New personal haemodialysis systems are being developed, such as the Quanta SC+, that are smaller and simpler to use by patients while providing the clearances of conventional systems. Increasing uptake of lower intensity assistance and full self-care dialysis may provide economic benefits to the public health payer. In addition, promotion of every other day dialysis (3.5x weekly) may improve costs to the health system by helping to close the “post-weekend effect” with increased emergency department use and hospitalisations following the long interdialytic gap. As such, we aimed to describe the annual therapy costs of using SC+ in the UK for 3x weekly and 3.5x weekly dialysis regimens, both for self-care haemodialysis provided in-centre and at home in comparison to dialysis provided with conventional machines from the perspective of the health care system. Method Cost minimisation approach. Costs for human resources, equipment, and consumables were sourced from the dialysis machine developer (Quanta Dialysis Technologies). Other costs, such as facility expenses, dialysis-related drugs, avoided emergency department and hospitalisation events, and utilities were taken from a review of the literature. Costs are provided in 2018 GBP. Results Therapy provided as self-care in-centre or full self-care at home were found to have similar costs (£33,721 in-centre versus £33,836 at home for the 3x weekly regimen). Costs increased to £37,238 for self-care in-centre and £35,557 at home for the 3.5x weekly regimen. A comparator cost of £39,416 was established for dialysis provided with conventional machines in-hospital 3x weekly. For each dialysis patient, the health care system is anticipated to save £3,666 in costs associated with excess hospital stays and £2,176 in costs associated with excess emergency department visits. Conclusion In the UK, SC+ offers cost savings when used both for self-care in-centre and full self-care at home in comparison to dialysis provided in the clinic using conventional machines.

Diagnostic Performance of Emergency Physician Gestalt for Predicting Acute Appendicitis in Patients Age 5 to 20Years.

Pediatric appendicitis remains a challenging diagnosis in the emergency department (ED). Available risk prediction algorithms may contribute to excessive ED imaging studies. Incorporation of physician gestalt assessment could help refine predictive tools and improve diagnostic imaging decisions. This study was a subanalysis of a parent study that prospectively enrolled patients ages 5 to 20.9years with a chief complaint of abdominal pain presenting to 11 community EDs within an integrated delivery system between October 1, 2016, and September 30, 2018. Prior to diagnostic imaging, attending emergency physicians enrolled patients with ≤5days of right-sided or diffuse abdominal pain using a Web-based application embedded in the electronic health record. Predicted risk (gestalt) of acute appendicitis was prospectively entered using a sliding scale from 1% to 100%. As a planned secondary analysis, we assessed the performance of gestalt via c-statistics of receiver operating characteristic (ROC) curves; tested associations between gestalt performance and patient, physician, and facility characteristics; and examined clinical characteristics affecting gestalt estimates. Of 3,426 patients, 334 (9.8%) had confirmed appendicitis. Physician gestalt had excellent ROC curve characteristics (c-statistic=0.83, 95% confidence interval=0.81 to 0.85), performing particularly well in the low-risk strata (appendicitis rate=1.1% in gestalt 1%-10% range, negative predictive value of 98.9% for appendicitis diagnosis). Physicians with ≥5years since medical school graduation demonstrated improved gestalt performance over those with less experience (p=0.007). All clinical characteristics tested, except pain <24hours, were significantly associated with physician gestalt value (p<0.05). Physician gestalt for acute appendicitis diagnosis performed well, especially in low-risk patients and when employed by experienced physicians.

Better Health Service Use for Families of Children With Special Health Care Needs.

* Abbreviations: CSHCN — : children with special health care needs ED — : emergency department The article by Fuller et al,1 which examines relationships between family material hardships, resilience, and suboptimal health care use, is a refreshing and constructive step forward in unpacking the relationship between family difficulties, ability to cope with those difficulties, and health care needs that both go unmet and are met through the less-desirable route of the emergency department (ED). Including children both with and without special health care needs, this article paves the way toward potential practical interventions to enhance family resilience and mitigate material hardships that could address the difficult problem of excessive ED use and, instead, point families toward care that meets their child’s needs in a more durable way. In previous work,2 the authors added to the growing body of evidence3,4 linking material hardships with unmet health care needs and increased ED … Address correspondence to Christopher J. Stille, MD, MPH, Section of General Academic Pediatrics, University of Colorado School of Medicine and Children’s Hospital Colorado, 13123 E 16th Ave, Mailstop B032, Aurora, CO 80045. E-mail: christopher.stille{at}childrenscolorado.org