Frequent Emergency Department Use Research Articles

Payment Innovation in Emergency Care: A Case for Global Clinician Budgets

The fee-for-service funding model for U.S. emergency department (ED) clinician groups is increasingly fragile. Traditional FFS payment systems offer no financial incentives to improve quality, address population health, or make value-based clinical decisions. FFS also does not support maintaining ED capacity to handle peak demand periods. In FFS, clinicians rely heavily on cross subsidization where high reimbursement from commercial payors offsets low reimbursement from government payors and the uninsured. While FFS survived decades of steady cuts in government reimbursement rates, it is increasingly strained due to visit volatility and the effects of the No Surprises Act, which is driving down commercial reimbursement. Financial pressures on ED clinician groups, combined with higher hospital boarding and clinical workloads are increasing workforce attrition. Here we propose an alternative model to address some of these fundamental issues: an all-payer-funded, voluntary global budget for ED clinician services. If designed and implemented effectively, the model could effectively support robust clinician staffing over the long-term, ensure stability in clinical workload, and potentially improve the equity in payments. The model could also be combined with population health programs (e.g., pre- and post-ED telehealth, frequent ED use programs, and other innovations) which offer significant payer returns and address both quality and value. A linked program could also change hospital incentives that contribute to boarding. Strategies exist to test and refine ED clinician global budgets through existing government programs in Maryland and potentially through state-level legislation, as a precursor to broader adoption.

Emergency Department Use Among Combat and Non-Combat Post-9/11 Military Veterans.

Most post-9/11 Veterans have completed at least 1 combat deployment-a known factor associated with adverse health outcomes. Such Veterans are known to have unmet health care needs, and the emergency department (ED) may serve as a safety net, yet little is known about whether combat status is associated with more frequent ED use. We sought to evaluate the relationship between combat status and frequency of ED use among post-9/11 Veterans and assess the most common reasons for ED visits. This retrospective cohort study consisted of post-9/11 Veterans who enrolled in U.S. Department of Veterans Affairs (VA) care between fiscal years (FYs) 2005 and 2015. Data were obtained from the VA Corporate Data Warehouse. Incidence rates for ED visits for combat and non-combat Veterans were compared from FY 2010 to 2019 using zero-inflated negative binomial regression. The most frequent reasons for ED visits were determined using International Classification of Diseases codes. This study was approved by the Stanford Institutional Review Board. Among 1.3 million Veterans included in analyses, 70.4% had deployed to a combat zone. The mean (SD) age of our cohort was 32.6 (5.0) years and 83.5% of Veterans were male. After controlling for other factors, combat Veterans had 1.84 times the rate of ED visits compared to non-combat Veterans (95% CI, 1.83-1.85). Only combat Veterans had a mental health-related ED visit (suicidal ideations) among the top 3 reasons for ED presentation. Those who deployed to a combat zone had a significantly higher rate of ED use compared to those who did not. Further, mental health-related ED diagnoses appeared to be more prevalent in combat Veterans. These findings highlight the unique health care needs faced by combat Veterans and emphasize the importance of tailored interventions and support services for this specific population.

A mapping review of interventions to address patients who frequently seek care in the emergency department

BackgroundThe high utilization of acute care services, particularly emergency departments (ED), continues to be a significant concern for healthcare providers. Numerous approaches have been studied to meet the care needs of patients who frequently seek care in the ED; however, there is no comprehensive review of the current literature base. As such, a current understanding of the interventions initiated within the ED to address the needs of frequent users is required. This mapping review had three objectives: identify the characteristics associated with the need to frequently seek care in the ED; identify interventions implemented to address the needs of this population; and identify gaps in the current evidence base.MethodsA knowledge map was created by scoping the literature to identify characteristics associated with frequent ED use and interventions implemented to address frequent use. Then, a literature search was conducted to determine what has been implemented by EDs to reduce frequent ED use. The literature was searched from 2013 to January 2023. MeSH terms and keywords were used to identify relevant studies. Studies implementing an intervention for those with characteristics associated with frequent ED use and reporting on ED use were included.ResultsTwenty-three (23) controlled trials and 35 observational studies were included. The most common populations were older adults, those with chronic conditions, and generic “frequent users”. No studies assessed Indigenous Peoples or racial minorities, and few assessed patients with a disability or patients experiencing homelessness. The most common interventions were referrals, care plans, case management, care coordination, and follow-up phone calls. Most studies reported ED revisits, hospitalization, costs, length-of-stay, or outpatient utilization. Few assessed patient or staff perspectives. About one-third of studies (n = 24) reported significant reductions in ED revisits.ConclusionsSimilar interventions, mainly focused on care coordination and planning, have been implemented to address frequent use of the ED. There are still significant gaps in the populations that have been studied. Efforts now must be undertaken to study more diverse populations whose care needs are not being met elsewhere and thus frequent the ED often.

Abstract 3468: Emerging lessons from patient-reported hospital discharge experiences among hospitalized cancer patients with frequent emergency department use

Abstract Background: While teamwork is essential to providing high-quality patient-centered care, challenges in interprofessional collaboration and decision-making in the hospital settings are common, especially for cancer patients. The purpose of this study was to identify emerging themes related to hospital discharge experiences among patients hospitalized for cancer who became frequent emergency department (ED) users following their hospital discharge. Design & Methods: A cohort of cancer patients discharged from an academic health center in Montreal (Canada) between October 2014 and November 2016 was assembled. Frequent ED (FED) users were identified as patients who had a > 4 ED visits in the year following hospital discharge using health administrative claims from the provincial universal health care program. Qualitative analysis of telephone interviews conducted with patients 30 days’ post-discharge were used for in-depth exploratory analyses to characterize hospital discharge experiences and transition process from the hospital to the community. Results: A cohort of 1253 cancer patients was formed. The mean age was 70.9 (SD=11.8) and the most frequent cancers included 488 (38.9%) respiratory and 309 (24.6%) upper digestive cancer. Overall, 14.5% (n=182) of patients became FED users. Content analyses revealed the most common emerging themes from the FED patients interviews on hospital discharge experiences. These included:1. Early hospital discharge putting patients at high risk of being re-admitted and going back to the ER shortly after that. Some patients mentioned post-discharge complications and emerging of new health issues that could have been avoided if patient was kept in the hospital for longer.2. Lack of communication between different specialists at the hospital. Some patients mentioned the help of a nurse as crucial during inpatient stays in maintaining communication between doctors. 3. Lack of communication of medications prescribed. Some patients mentioned the lack of communication of what doses was modified, what medications were stopped and which ones were newly prescribed.4. The need to schedule follow-up appointments at the time of hospital discharge. This becomes especially important for vulnerable patients who have been on pain medication during the hospital stay, affecting their cognitive abilities and making post-discharge planning more difficult. Conclusions: This study using integrated data from administrative claims and patient interviews provided insights into the challenges related to hospital discharge experiences and transition into community among hospitalized cancer patients with frequent emergency department use. Application of our findings could assist in hospital discharge preparation and improvement in healthcare delivery and health outcomes. Citation Format: Siyana Kurteva, Robyn Tamblyn. Emerging lessons from patient-reported hospital discharge experiences among hospitalized cancer patients with frequent emergency department use [abstract]. In: Proceedings of the American Association for Cancer Research Annual Meeting 2024; Part 1 (Regular Abstracts); 2024 Apr 5-10; San Diego, CA. Philadelphia (PA): AACR; Cancer Res 2024;84(6_Suppl):Abstract nr 3468.

Characteristics for Low, High and Very High Emergency Department Use for Mental Health Diagnoses from Health Records and Structured Interviews.

Patients with mental health diagnoses (MHD) are among the most frequent emergency department (ED) users, suggesting the importance of identifying additional factors associated with their ED use frequency. In this study we assessed various patient sociodemographic and clinical characteristics, and service use associated with low ED users (1-3 visits/year), compared to high (4-7) and very high (8+) ED users with MHD. Our study was conducted in four large Quebec (Canada) ED networks. A total of 299 patients with MHD were randomly recruited from these ED in 2021-2022. Structured interviews complemented data from network health records, providing extensive data on participant profiles and their quality of care. We used multivariable multinomial logistic regression to compare low ED use to high and very high ED use. Over a 12-month period, 39% of patients were low ED users, 37% high, and 24% very high ED users. Compared with low ED users, those at greater probability for high or very high ED use exhibited more violent/disturbed behaviors or social problems, chronic physical illnesses, and barriers to unmet needs. Patients previously hospitalized 1-2 times had lower risk of high or very high ED use than those not previously hospitalized. Compared with low ED users, high and very high ED users showed higher prevalence of personality disorders and suicidal behaviors, respectively. Women had greater probability of high ED use than men. Patients living in rental housing had greater probability of being very high ED users than those living in private housing. Using at least 5+ primary care services and being recurrent ED users two years prior to the last year of ED use had increased probability of very high ED use. Frequency of ED use was associated with complex issues and higher perceived barriers to unmet needs among patients. Very high ED users had more severe recurrent conditions, such as isolation and suicidal behaviors, despite using more primary care services. Results suggested substantial reduction of barriers to care and improvement on both access and continuity of care for these vulnerable patients, integrating crisis resolution and supported housing services. Limited hospitalizations may sometimes be indicated, protecting against ED use.

EVALUATION OF THE FREQUENT APPLICATIONS TO AN UNIVERSITY HOSPITAL EMERGENCY DEPARTMENT: A 1-YEAR REVIEW

Objective: Frequent use of emergency departments is an important problem that leads to decreased service quality and increased health costs in these departments. In the present study, the purpose was to analyze the demographic and clinical characteristics of “frequent users’ in applications to emergency departments. 
 Material and Methods: In the study, the records of patients, who were aged 18 years and older and who applied to the emergency department of a university hospital in 2016, were analyzed retrospectively. Those who applied to the emergency department between 4 and 9 times were defined as “Low ED Users’, and those who applied for 10 or more were defined as “High ED Users’. 
 Results: In 1 year, a total of 86.287 applications were made to the emergency department by 54.258 patients, during which 5.26% (n=2859) of those who applied to the emergency department applied 4-9 times (Low ED Users) and 0.29% (n=162) applied 10 or more times (High ED Users). Applications made by frequent users (n=16.277) constituted 18.8% of all applications in a year. The most common reason for frequent users’ admission was upper respiratory tract infections and 44.3% of the frequent user referrals were young patients who were under the age of 30. It was found that the patients in the High ED Users group underwent more examination and treatment than the Low ED Users group, and the hospitalization rates were higher in the High ED Users group (p

Self-help measures as determinants of emergency department utilization among people with and without a migration history in Germany

We analyzed whether there were differences between people with and without migration history in their implementation of self-help measures before they accessed the services of an emergency department and if there was an association between self-help measures and an appropriate utilization of emergency departments. The data basis of this secondary analysis is the EUMaR study, which was conducted from July 2018 to July 2019 and aimed to identify causes contributing to inappropriate and frequent use of emergency departments by migrants. Our study aimed to analyze the differences in self-help measures carried out by the population groups using several multiple logistic regressions. The association between self-help measures implemented and appropriate emergency department utilization was quantified using a multiple logistic regression as well as interactions. The odds of first-generation migrants visiting an emergency department on their own initiative (OR=1.28; 95% CI, 1.01-1.61) was high compared to people without migrant history. Furthermore, the odds of their doing something by themselves against their complaints (OR=0.70; 95% CI, 0.56-0.86) were low. The odds of appropriate utilization of emergency services by respondents who self-initiated a visit to an emergency department were lower (OR=0.41; 95% CI, 0.34-0.50). The odds of appropriate utilization of emergency department services by respondents who had previously measured vital signs (e. g., blood pressure) were higher (OR=1.28; 95% CI, 1.02-1.59). Barriers to the health care system as well as to general practitioners, medicines or medical aids among first-generation migrants could explain the increased odds of their visiting an emergency department on their own and the lower odds of their doing something by themselves about their complaints. A hypothesis of our study is that measuring vital signs may help to better assess individual health status.

Determinants of Persistent, Multi-Year, Frequent Emergency Department Use Among Children and Young Adults in Three US States

ObjectiveThis study examines the factors associated with persistent, multi-year, and frequent emergency department (ED) use among children and young adults. MethodsWe conducted a retrospective secondary analysis using the 2012–2017 Healthcare Cost and Utilization Project State Emergency Department Databases for children and young adults aged 0–19 who visited any ED in Florida, Massachusetts, and New York. We estimated the association between persistent frequent ED use and individuals’ characteristics using multivariable logistic regression models. ResultsAmong 1.3 million patients with 1.8 million ED visits in 2012, 2.9% (37,558) exhibited frequent ED use (≥4 visits in 2012) and accounted for 10.2% (181,138) of all ED visits. Longitudinal follow-up of frequent ED users indicated that 15.4% (5770) remained frequent users periodically over the next 1 or 2 years, while 2.2% (831) exhibited persistent frequent use over the next 3–5 years. Over the 6-year study period, persistent frequent users had 31,551 ED visits at an average of 38.0 (standard deviation = 16.2) visits. Persistent frequent ED use was associated with higher intensity of ED use in 2012, public health insurance coverage, inconsistent health insurance coverage over time, residence in non-metropolitan and lower-income areas, multimorbidity, and more ED visits for less medically urgent conditions. ConclusionsClinicians and policymakers should consider the diverse characteristics and needs of pediatric persistent frequent ED users compared to broader definitions of frequent users when designing and implementing interventions to improve health outcomes and contain ED visit costs.

Factors related to the frequent use of emergency department services in Korea

BackgroundFrequent Emergency Department (ED) visitors are identified by the policymakers to reduce avoidable ED visits and lessen the financial and operational burden. This study aimed to identify the factors related to the frequent use of ED services.MethodsThis nationwide, cross-sectional observational study was conducted using information obtained from the 2019 National Emergency Department Information System (NEDIS) database. Frequent ED users were defined as patients with four or more ED visits a year. We performed multiple logistic regression analyses to verify the relationship among sociodemographic characteristics, residential characteristics, clinical characteristics, and frequency of ED visits.ResultsAmong 4,063,640 selected patients, 137,608 patients visited the ED four or more times a year (total number of visits = 735,502 times), which accounted for 3.4% and 12.8% of the total number of ED users and ED visits, respectively. A high ED visit frequency was associated with male sex, age < 9 or ≥ 70 years, Medical Aid (based on the insurance type), lower number of medical institutions and beds compared with that of the national average, and conditions, such as cancer, diabetes, renal failure, and mental illness. A low ED-visit frequency was associated with residence in regions vulnerable to emergency medical care and regions with high income. The possibility of frequent ED visits was high for patients with level 5 severity (non-emergent) and those with an increased need for medical treatment, including older patients and patients with cancer or mental illness. The possibility of frequent ED visits was low for patients aged > 19 years with level 1 severity (resuscitation).ConclusionsHealth service accessibility factors, including low income and medical resource imbalance, were associated with frequent ED visits. Future large-scale prospective cohort studies are warranted to establish an efficient emergency medical system.

Reliance on Community Emergency Departments by People Ever Detained in Jail: Retrospective Cross-Sectional Study.

Millions are confined in U.S. jails each year, often with unmet health and social needs. After release, many will visit the emergency department (ED). To illuminate their patterns of ED use, this study linked records from all individuals detained at a Southern urban jail over a 5-year period with health records from a large health care system with three EDs. Over half used the ED at least once, and of those who received care at the health system, 83% visited the ED. Jail-involved people made up 4.1% of the health care system's ED users but 21.3% of its chronic frequent ED users. Frequent ED use was associated with more frequent jail bookings and with co-occurring serious mental illness and substance use disorder. Health systems and jails have a common interest in addressing the needs of this population. Individuals with co-occurring disorders should be prioritized for intervention.

OP4 Prioritization of ADT Notifications Improves Efficiency of New Blue Cross and Blue Shield of Louisiana Care Management Referral Process

Blue Cross and Blue Shield of Louisiana in 2018 began receiving daily admission-discharge-transfer (ADT) notifications to develop a clinical intervention program. To improve management of resources and increase the efficacy of outreach efforts, Blue Cross developed a daily selection algorithm to prioritize members with the highest risk, highest cost, or frequent use of emergency departments, and who are most likely to respond positively to clinical intervention. Prioritized outreach began December 2021 and is ongoing.

Use of high cost care among Veterans with comorbid mental illness and Alzheimer's Disease and related dementias.

Alzheimer's Disease and Other Related Dementias (AD/ADRD) leads to frequent emergency department (ED) and inpatient use. Mental health symptoms among persons with AD/ADRD increases cognitive and functional disabilities and could contribute to these high rates of intensive health care use. The objective of this paper is to assess the relationship of mental illness on 12-month patterns in hospitalization and ED use among Veterans aged 65 and over with a new AD/ADRD diagnosis. We used an existing dataset of administrative electronic health record data of Veterans with AD/ADRD from the US Veterans Health Administration linked with Medicare claims data from 2011-2015. We use multivariable logistic regression to examine the association between no pre-existing mental illness, pre-existing mental illness (e.g., major depressive disorder, generalized anxiety disorder, or post-traumatic stress disorder), and pre-existing severe mental illness-or SMI-(e.g., bipolar disorder, major depressive disorder with psychosis, or schizophrenia) and 12- month ED and hospitalization use and readmissions among Veterans who had an initial hospitalization visit. We estimated predicted probabilities, differential effect, and associated 95% confidence intervals. In our sample, 1.4% had SMI and 11% had non-SMI mental illness. The unadjusted percentage with inpatient and ED use was higher among Veterans with SMI (34% and 26%, respectively) and Veterans with non-SMI mental illness (20%, 16%) compared with Veterans without pre-existing mental illness (12%, 9%). Compared to individuals with no pre-existing mental illness, having a pre-existing mental illness (1.27 percentage points, 95% CI: 0.76, 1.78) and a pre-existing SMI (7.17 percentage points, 95% CI: 5.66, 8.69) were both associated with an increased likelihood of ED use. The same pattern was observed for any inpatient use (mental illness 2.18, 95% CI: 1.59, 2.77; SMI 9.91, 95% CI: 8.21, 11.61). Only pre-existing SMI was associated higher hospitalization readmission. Pre-existing mental illness increases use of high cost, intensive health care and this association is higher of more severe mental health conditions. We also show that pre-existing mental illness exerts a unique influence, above and beyond other comorbidities, such as diabetes, on ED and inpatient visits. More needs to be done to increase recognition of the unique risks of this combination of health conditions and encourage strategies to address them. Developing, testing, and implementing comprehensive strategies that address the intersection of ADRD and mental illness is promising approach that requires more focused attention.

Factors associated with persistent multiyear frequent emergency department use

BackgroundAlthough frequent emergency department (ED) users have been widely studied in cross-sectional settings, there is some evidence suggesting that most frequent ED users do not remain frequent users over multiple...

Predictors of dropout from treatment among patients using specialized addiction treatment centers

ObjectivesThis study investigated the use of outpatient care, and sociodemographic and clinical characteristics of patients with substance-related disorders (SRD) to predict treatment dropout from specialized addiction treatment centers. The study also explored risks of adverse outcomes, frequent emergency department (ED) use (3+ visits/year), and death, associated with treatment dropout within the subsequent 12 months. MethodsThe study examined a cohort of 16,179 patients who completed their last treatment episode for SRD between 2012–13 and 2014–15 (financial years: April 1 to March 31) in 14 specialized addiction treatment centers using Quebec (Canada) health administrative databases. We used multivariable logistic regressions to measure risk of treatment dropout (1996–96 to 2014–15), while we used survival analysis controlling for sex and age to assess the odds of frequent ED use and death in 2015–16. ResultsOf the 55 % of patients reporting dropout from SRD treatment over the 3-year period, 17 % were frequent ED users, and 1 % died in the subsequent 12 months. Patients residing in the most socially deprived areas, having polysubstance-related disorders or personality disorders, and having previously dropped out from specialized addiction treatment centers had increased odds of current treatment dropout. Older patients, those with a history of homelessness, past SRD treatment, or more concurrent outpatient care outside specialized addiction treatment centers had decreased odds of treatment dropout. Patients who dropped out were subsequently at higher risk of frequent ED use and death. ConclusionsThis study highlighted that patients with more severe problems and previous dropout may need more sustained and adequate help to prevent subsequent treatment dropout. Specialized addiction treatment centers may consider enhancing their follow-up care of patients over a longer duration and better integrating their treatment with other outpatient care resources to meet the multiple needs of the more vulnerable patients using their services.

Appropriateness of frequent use of emergency departments: A retrospective analysis in Rome, Italy.

Frequent users (FUs) are patients who repeatedly and inappropriately visit the emergency department (ED) for low-grade symptoms that could be treated outside the hospital setting. This study aimed to investigate the phenomenon of the FU in Rome by profiling such users and analyzing ED attendance by FUs. The analysis was carried out for attendance in 2021 at 15 EDs in the Local Health Authority Roma 1 geographical area. A digital app collected data, including information on the following variables: number of attendance, demographic characteristics, emergency medical service (EMS) usage, triage code, and appropriateness of attendance. COVID-19 diagnosis was also studied to analyze any possible influence on ED attendance. Differences between FUs and non-FUs were investigated statistically by t-test and chi-square test. Univariate analysis and multivariable logistic regression were performed to analyze the associated factors. A total of 122,762 ED attendance and 89,036 users were registered. The FU category represented 2.9% of all users, comprising 11.9% of total ED attendance. There was a three times higher frequency of non-urgent codes in attendance of FU patients (FU: 9.7%; non-FU: 3.2%). FUs were slightly more likely to have used the EMS (13.6% vs. 11.4%) and had a lower frequency of appropriate ED attendance (23.8% vs. 27.0%). Multivariate logistic analysis confirmed a significant effect of triage code, gender, age, EMS usage, and COVID-19 diagnosis for the appropriateness of attendance. The results were statistically significant (p < 0.001). The FU profile describes mostly non-urgent and inappropriate attendance at the ED, including during the COVID-19 pandemic. This study represents an important tool for strengthening preventive policies outside the hospital setting. The Italian National Recovery and Resilience Plan represents an excellent opportunity for the development of new strategies to mitigate the phenomenon of FUs.

Machine learning to improve frequent emergency department use prediction: a retrospective cohort study

Frequent emergency department use is associated with many adverse events, such as increased risk for hospitalization and mortality. Frequent users have complex needs and associated factors are commonly evaluated using logistic regression. However, other machine learning models, especially those exploiting the potential of large databases, have been less explored. This study aims at comparing the performance of logistic regression to four machine learning models for predicting frequent emergency department use in an adult population with chronic diseases, in the province of Quebec (Canada). This is a retrospective population-based study using medical and administrative databases from the Régie de l’assurance maladie du Québec. Two definitions were used for frequent emergency department use (outcome to predict): having at least three and five visits during a year period. Independent variables included sociodemographic characteristics, healthcare service use, and chronic diseases. We compared the performance of logistic regression with gradient boosting machine, naïve Bayes, neural networks, and random forests (binary and continuous outcome) using Area under the ROC curve, sensibility, specificity, positive predictive value, and negative predictive value. Out of 451,775 ED users, 43,151 (9.5%) and 13,676 (3.0%) were frequent users with at least three and five visits per year, respectively. Random forests with a binary outcome had the lowest performances (ROC curve: 53.8 [95% confidence interval 53.5–54.0] and 51.4 [95% confidence interval 51.1–51.8] for frequent users 3 and 5, respectively) while the other models had superior and overall similar performance. The most important variable in prediction was the number of emergency department visits in the previous year. No model outperformed the others. Innovations in algorithms may slightly refine current predictions, but access to other variables may be more helpful in the case of frequent emergency department use prediction.

Profiles of quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes among patients with substance-related disorders

BackgroundThis study identified patient profiles in terms of their quality of outpatient care use, associated sociodemographic and clinical characteristics, and adverse outcomes based on frequent emergency department (ED) use, hospitalization, and death from medical causes.MethodsA cohort of 18,215 patients with substance-related disorders (SRD) recruited in addiction treatment centers was investigated using Quebec (Canada) health administrative databases. A latent class analysis was produced, identifying three profiles of quality of outpatient care use, while multinomial and logistic regressions tested associations with patient characteristics and adverse outcomes, respectively.ResultsProfile 1 patients (47% of the sample), labeled “Low outpatient service users”, received low quality of care. They were mainly younger, materially and socially deprived men, some with a criminal history. They had more recent SRD, mainly polysubstance, and less mental disorders (MD) and chronic physical illnesses than other Profiles. Profile 2 patients (36%), labeled “Moderate outpatient service users”, received high continuity and intensity of care by general practitioners (GP), while the diversity and regularity in their overall quality of outpatient service was moderate. Compared with Profile 1, they were older, less likely to be unemployed or to live in semi-urban areas, and most had common MD and chronic physical illnesses. Profile 3 patients (17%), labeled “High outpatient service users”, received more intensive psychiatric care and higher quality of outpatient care than other Profiles. Most Profile 3 patients lived alone or were single parents, and fewer lived in rural areas or had a history of homelessness, versus Profile 1 patients. They were strongly affected by MD, mostly serious MD and personality disorders. Compared with Profile 1, Profile 3 had more frequent ED use and hospitalizations, followed by Profile 2. No differences in death rates emerged among the profiles.ConclusionsFrequent ED use and hospitalization were strongly related to patient clinical and sociodemographic profiles, and the quality of outpatient services received to the severity of their conditions. Outreach strategies more responsive to patient needs may include motivational interventions and prevention of risky behaviors for Profile 1 patients, collaborative GP-psychiatrist care for Profile 2 patients, and GP care and intensive specialized treatment for Profile 3 patients.

Effect of the COVID-19 pandemic on the frequency of emergency department visits in Portugal: An interrupted time series analysis until July 2021.

This study aims to evaluate the effect of the COVID-19 pandemic on the frequency of emergency department (ED) visits in Portugal between March 2020 and July 2021. We used data on the monthly number of visits for all public hospitals' EDs from mainland Portugal between January 2017 and July 2021. We studied the impact of the pandemic overall, by type of ED (general, pediatric, and obstetric) and by Manchester Triage System color (red, orange, yellow, green, and blue) using an interrupted time series analysis. The prepandemic period corresponded to the months from January 2017 to February 2020 and the pandemic period to the months from March 2020 to July 2021. We observed over 26 million ED visits, the majority in general EDs (74.0%) and triaged yellow (48.4%) or green (38.4%). During the pandemic period, ED visits decreased 45.7% (95% confidence interval [CI]: -39.8% to -51.2%) and pediatric ED visits decreased by 72.4% (95% CI: -64.6% to -78.6%). A decrease was observed for all colors but tended to be progressively smaller as the priority increased. There was an increase in ED visits during the pandemic period (2.3%; 95% CI: 1.4% to 3.2%), eventually returning to prepandemic values. Our data indicate a considerable and long-lasting effect of the COVID-19 pandemic affecting mainly pediatric and milder cases, which were returning toward prepandemic values as the pandemic progressed. In a country with frequent use of EDs, the health system may need to be prepared to respond to prepandemic baseline ED demand, together with additional demand because of long-term sequels of COVID-19 cases and delayed care for chronic and acute conditions.

COMPANION CARE ASSOCIATED WITH REDUCTION IN ADMISSIONS AND EMERGENCY DEPARTMENT USE AMONG OLDER ADULTS

Abstract Older adults with unmet social needs, including social isolation and loneliness, have higher rates of hospital readmission and emergency department (ED) use. Our objective was to determine if Papa Inc., a nationwide service that pairs older adults with “Papa Pals” for companionship and assistance, was associated with reductions in readmissions and ED visits. SummaCare, a Medicare Advantage Organization in Ohio, partnered with Papa to offer free companion care to their members. We explored changes in inpatient admission rates and ED high-utilizers (defined as members with 4+ ED visits in a calendar year) from 2018 through 2021 using a claims-based analysis. Analysis included members who used 30+ minutes of Papa services in 2021 and had historical claims data from 2019 (n=1,420), matched 1:1 to a non-Papa comparison group (n=1,420) using a validated risk scoring model. Overall, average age was 78, 62% were female, 2% were ED high-utilizers in 2021. Increased enrollment in Papa occurred post hospitalization. The case-mix adjusted 30-day readmission rate in 2021 was 12.6% for Papa users (compared to 14.1% for non-Papa; and 14.5% for Papa users before enrollment), revealing a 1.5% to 2% decline in readmission rate after enrollment in Papa. Using case-mix adjusted relativities, Papa members had 0.89 readmissions for every 1.00 readmission for non-Papa users. Compared to the matched cohort, the Papa cohort had 34% fewer ED high-utilizers during the intervention year. Results provide preliminary evidence that a social companionship service may reduce readmissions and frequent ED use, and can inform future trials on companion-based interventions.

Caregiver Perceptions of Change in Pediatric Asthma Control During the COVID-19 Pandemic.

Although several indicators suggest that pediatric asthma control in the United States improved early in the pandemic, other indicators suggest not. Missing are reports from caregivers of the experiences of their children with asthma early in the pandemic. Using the PP-ACT and other measures that we specifically constructed for our research, we conducted a cross-sectional national survey of US caregivers of children with asthma (N=595) to examine perceived change in their child's asthma control and changes in reports of ED visits and use of emergency relief medicine and controller medicine pre-pandemic (January to March 2020) versus early-pandemic (June to September 2020). Caregivers fell into three groups: most caregivers perceived that their child's asthma control was improved (50.3%) or unchanged (41.2%), and few reported worse control (8.5%). Surprisingly, all three groups of caregivers reported similar frequencies of early-pandemic and pre-pandemic ED visits and use of emergency relief medicine. Also surprising, caregivers who perceived their child's asthma as more controlled (compared with the other two groups) reported more frequent ED visits and use of emergency relief medicine, yet also more use of controller medicine at both early-pandemic and pre-pandemic. The mismatch between caregivers' perceptions of their child's early-pandemic asthma control and their reports of ED visits and use of emergency relief medicine suggests that caregivers may rely on a gist (a global evaluation that can include nonbiomedical evidence) when estimating their child's asthma control. Caregivers and their families could benefit from help from clinicians in understanding the discrepancy between subjective asthma control and asthma control indicators and in understanding what well-controlled asthma looks and feels like.