Frequent Emergency Department Research Articles

Factors Affecting Treatment Compliance of Patients With COPD During the COVID-19 Pandemic

Objective: This study aimed to investigate the effects of difficulties experienced in the follow-up and treatment during the Coronavirus 2019 pandemic (COVID-19p), which included COVID-19 phobia and depression, on treatment compliance in patients with Chronic Obstructive Pulmonary Disease (COPD). Methods: This study included 123 patients with COPD. The COVID-19 Phobia Scale (C19P-S), Beck Depression Inventory (BDI), and Medication Adherence Report Scale (MARS) were used to assess the patients. Results: The mean age of patients with COPD was 64.56 ± 9.31 years. It was determined that our patients did not maintain regular outpatient follow-up mostly because of the fear of COVID-19 transmission (78.8%). Overall, 24% of our patients showed treatment noncompliance. A statistically significant relationship was found between COPD stages B and D and treatment compliance (p=0.01). Patients with frequent emergency department admissions (p = 0.01) and those with high BDI (p = 0.01) and C19P-S (p = 0.02) scores during the pandemic were found to have reduced treatment compliance. Conclusion: Patients with COPD with COVID-19 phobia, and depression had reduced treatment compliance. İt is necessary to be aware of these conditions and to plan appropriate interventions.

Effects of Air Pollution on Respiratory Events and Pain Crises Among Children with Sickle Cell Disease in New York City

Introduction: Sickle cell disease (SCD) has the highest U.S. disease burden among Black and Hispanic populations, who more commonly live in urban areas with poor ambient air quality. The effect of air pollution exposure and social environmental factors on health outcomes in SCD have not been extensively studied, especially among children, and may further contribute to health disparities. Objectives: This study aims to examine the associations between air pollution exposure and acute respiratory and pain events and to determine whether neighborhood-level social disadvantage would modify their associations. Methods: We collected retrospective data on unscheduled outpatient visits, emergency department (ED) visits, and hospital admissions for respiratory events (i.e., respiratory tract infections, asthma exacerbation, acute chest syndrome) and vaso-occlusive pain crises requiring hospitalization (VOCs) for children with SCD in a tertiary care center in New York City (NYC) from 2015-2018. A total of 114 children with SCD (Table 1) were included in this study and had between 1-4 annual repeated measures of annual average air pollutants (i.e., black carbon (BC), fine particulate matter (PM 2.5), and nitrogen dioxide (NO 2)) with a total of 425 visits. Using home addresses, modeled data from the NYC Community Air Survey data were used to estimate street-level, annual average exposure to air pollution. The area deprivation index (ADI), a composite index of neighborhood-level social disadvantage, was dichotomized at the upper tertile (higher vs lower). Multivariable Poisson regression in generalized estimating equation (GEE) models were used to estimate relative risks (RR), after adjusting for potential covariates. Results: Overall, there were no significant associations between air pollution levels and acute respiratory and pain events among children with SCD. When stratified by ADI, increased exposure to PM 2.5 and NO 2, but not BC, was significantly associated with more frequent respiratory outpatient and ED visits among children residing in higher ADI neighborhoods (RR (95%CI)= 1.13 (1.00, 1.28) and 1.43 (1.01, 2.02) for PM 2.5 and NO 2, respectively, p<0.05 for all), but not among those in lower ADI neighborhoods (P-value for interaction=0.2 and 0.02 for PM 2.5 and NO 2, respectively) (Figure 1). Associations of air pollution with hospital admissions and VOCs were not observed for neither high ADI nor low ADI neighborhoods (p-value>0.05). Conclusions: Exposure to air pollutants increased respiratory complications among children living in deprived neighborhoods.

Examining management plans for patients who frequently presented to the emergency department

BackgroundPatients who frequently present to Emergency Department (ED) experience complex health and social needs. While research has examined interventions that aim to decrease frequent ED attendances, there is a need to understand the types of interventions provided to patients by hospital clinicians during presentations. MethodsUsing qualitative content analysis, 82 management plans were evaluated to understand the scope and type of interventions provided by clinicians for patients frequently presenting to the ED at the Royal Melbourne Hospital, Australia. ResultsPatients often presented to the ED due to mental and psychological distress, substance use and physical health concerns alongside psychosocial vulnerabilities. The goals of care documented in plans focussed on management of health issues, aggression within the ED, and coordinating care with community services. Recommended interventions addressed presenting needs with multi-disciplinary approach to respond to distress and aggression. Finally, the plans provided insight into service coordination dynamics between the ED and community-based health and social care services. ConclusionsThe plans recommended interventions that sought to provide holistic care for patients in collaboration with relevant community-based services. The findings suggest that clinicians in the ED can provide appropriate and meaningful care for patients who experience frequent presentations.

Using Chronic Care Management Visits to Reduce the Number of Frequent Emergency Department Visits: A Pilot Study.

Background Emergency department (ED) visits are increasing in number and cost and becoming a major way patients are interacting with the healthcare system. Patients who frequently visit the ED are deemed "super-utilizers" who visit for a variety of reasons, including, but not limited to, multiple chronic medical illnesses, homelessness, and substance use disorder, but fail to have an established long-term treatment plan. Methodology We enrolled our hospital's top 50 super-utilizing patients into the Chronic Care Management Program. These patients received monthly telehealth visits to discuss concerns, chronic medical conditions, barriers to care, and support systems unique to each patient's living and social situation (i.e., social determinants of health). Telehealth visits also connected patients to community resources and helped them initiate advanced care services. Results The t-test investigating the frequency of avoidable visits pre- and post-intervention revealed a statistically significant decrease in the number of avoidable visits between the pre-intervention and post-intervention. Results also revealed a non-statistically significant difference in the cost of avoidable visits before and after the intervention. Conclusions The findings revealed a statistically significant decrease in patients' frequency of avoidable visits before and after the intervention.

State-Level Adverse Outcomes Among Long-Term Services and Supports Users With Alzheimer's Disease and Related Dementias.

Home- and community-based services (HCBS) users, on average, experience hospitalizations more frequently than nursing facility residents. However, little is known about state-level variation in such adverse events among these groups. Using 2018 Medicare and Medicaid claims for dual-eligible beneficiaries with Alzheimer's disease and related dementias, we described hospitalization and emergency department (ED) visit rates among HCBS users and nursing facility residents and observed substantial state-level variation. In addition, consistent with prior evidence, we found more frequent hospitalizations and ED visits among HCBS users than nursing facility residents. The magnitude of this difference varied considerably across states, and the degree of variation was greatest among beneficiaries with six or more comorbid conditions. Our findings represent a crucial initial exploration of the state-level variation in adverse events among HCBS users and nursing facility residents, paving the way for further investigations into factors that contribute to this variability.

Profiles of patients with substance-related disorders who dropped out or not from addiction treatment

This longitudinal study identified profiles of patients with substance-related disorders (SRD) who did or did not drop out of specialized addiction treatment, integrating various patterns of outpatient service use. Medical administrative databases of Quebec (Canada) were used to investigate a cohort of 16,179 patients with SRD who received specialized addiction treatment. Latent class analysis identified patient profiles, based on multi-year outpatient service use. Four patient profiles related to treatment dropout were identified: patients who did not drop out and were low service users (Profile 1); patients who did not drop out and were high service users (Profile 2); patients who dropped out and were low service users (Profile 3); patients who dropped out and were high service users (Profile 4). Profile 1 had the best health and social conditions, while Profile 4 had the worst. The risks of being frequent emergency department users, being hospitalized or dying were highest in Profile 4, followed by Profiles 3, 2 and 1. Assertive treatment programs may be suited to Profile 4 and intensive case management programs to Profile 3. Collaborative care with higher psychosocial interventions and regularity of care may be extended to Profile 2 and interventions integrating motivational treatment to Profile 1.

357 The Effects of Patterns of Polysubstance Use on Frequent Emergency Department Utilization and One-Year Mortality

357 The Effects of Patterns of Polysubstance Use on Frequent Emergency Department Utilization and One-Year Mortality

Keeping It "Current": A Review of Treatment Options for the Management of Supraventricular Tachycardia.

To review treatment options and updates that exist for the management of paroxysmal supraventricular tachycardia (PSVT). A literature search of PubMed was performed including articles from 1974 to June 2023 using the terms: arrhythmias, adenosine, verapamil, diltiazem, esmolol, propranolol, metoprolol, beta-blockers, amiodarone, PSVT, synchronized cardioversion, methylxanthines, dipyridamole, pediatrics, heart transplant, and pregnancy. Primary literature and guidelines were reviewed. Studies were considered if they were available in English and conducted in humans. PSVT is a subset of supraventricular tachycardia (SVT) that presents as a rapid, regular tachycardia with an abrupt onset and termination. Due to frequent emergency department (ED) visits annually with symptoms of PSVT, appropriate and efficient management of these patients is vital. This review provides an overview of the pathophysiology of PSVT, while also describing the literature behind nonpharmacologic and pharmacologic management of PSVT. This review describes new literature regarding the improved success of the modified Valsalva maneuver as a nonpharmacologic therapy in PSVT. In addition, it describes a new technique in administration of adenosine that has improved outcomes, defines dose adjustments needed for drug interactions with adenosine, compares the utilization of nondihydropyridine calcium channel blockers with adenosine, and provides management recommendations for patients in special populations. With high annual rates of ED visits for SVT, providers should be aware of the data behind management and modifications of therapy based on patient-specific factors (ie, patient preference, pharmacokinetics/pharmacodynamics, drug interactions, and special populations).

Moderating effects of psychological factors and frequency of experiences in the emergency department: The role of perceived quality of healthcare.

The aim of this study is to identify the main moderators in the relationship between antecedents/predictors (doctors, privacy, accessibility, and availability, perceived waiting time to be called back by the doctor after the examinations and/or tests) and the perceived quality of healthcare (PQHC) in the emergency department (ED). Patients admitted to the ED of a public hospital in Lisbon, Portugal, between January and December 2016 were included in this study, with a representative sample size of 382 patients. A 5% margin of error and a 95% confidence interval were used, and all data were collected between May and November 2017. We used a stepwise multiple linear regression analysis to test the moderation models. We identified 3 main moderators with different moderating roles between the antecedents (predictors) and PQHC: level of life satisfaction, level of happiness, and frequency of ED experiences. Overall satisfaction with doctors is more likely to influence the PQHC among patients with lower levels of life satisfaction. Moreover, privacy and perceived waiting time to be called back by the doctor after an examination and/or test are more likely to influence the PQHC among patients with lower levels of life satisfaction and happiness. Finally, accessibility and availability are more likely to influence the PQHC among patients with more frequent ED experiences. Thus, knowing the moderating effects of psychological factors and the frequency of ED experiences may help to better understand the relationship between PQHC and certain predictors.

Determinants and Outcomes Associated With Skilled Nursing Facility Use After Coronary Artery Bypass Grafting: A Statewide Experience.

Skilled nursing facility (SNF) care is frequently used after cardiac surgery, but the patterns and determinants of use have not been well understood. The objective of this study was to evaluate determinants and outcomes associated with SNF use after isolated coronary artery bypass grafting. A retrospective analysis of Medicare Fee-For-Service claims linked to the Society of Thoracic Surgeons clinical data was conducted on isolated coronary artery bypass grafting patients without prior SNF use in Michigan between 2011 and 2019. Descriptive analysis evaluated the frequency, trends, and variation in SNF use across 33 Michigan hospitals. Multivariable mixed-effects regression was used to evaluate patient-level demographic and clinical determinants of SNF use and its effect on short- and long-term outcomes. In our sample of 8614 patients, the average age was 73.3 years, 70.5% were male, and 7.7% were listed as non-White race. An SNF was utilized by 1920 (22.3%) patients within 90 days of discharge and varied from 3.2% to 58.3% across the 33 hospitals. Patients using SNFs were more likely to be female, older, non-White, with more comorbidities, worse cardiovascular function, a perioperative morbidity, and longer hospital lengths of stay. Outcomes were significantly worse for SNF users, including more frequent 90-day readmissions and emergency department visits and less use of home health and rehabilitation services. SNF users had higher risk-adjusted hazard of mortality (hazard ratio, 1.41 [95% CI, 1.26-1.57]; P<0.001) compared with non-SNF users and had 2.7-percentage point higher 5-year mortality rate in a propensity-matched cohort of patients (18.1% versus 15.4%; P<0.001). The use of SNF care after isolated coronary artery bypass grafting was frequent and variable across Michigan hospitals and associated with worse risk-adjusted outcomes. Standardization of criteria for SNF use may reduce variability among hospitals and ensure appropriateness of use.

Evaluating barriers and facilitators to healthcare providers’ use of an emergency department electronic referral portal for high-risk children with asthma using the Theoretical Domains Framework

Objective Urban children with asthma are at risk for frequent emergency department (ED) visits and suboptimal asthma management. ED visits provide an opportunity for referrals to community-based asthma management services. Electronic medical record-based referral portals have been shown to improve quality of care but use of these portals by healthcare providers (HCPs) is variable. The purpose of the study was to investigate facilitators, barriers, and recommendations to improve the use of an electronic referral portal to connect children presenting with asthma exacerbations in an urban pediatric ED to community-based education and case management services. Methods The study was grounded in the Theoretical Domains Framework, an implementation provided the theoretical basis of the study. All ED HCPs were invited to complete qualitative interviews; twenty-three HCPs participated. Interviews were coded using directed content analysis. Results Facilitators to portal use included its relative ease of use and HCP beliefs regarding the importance of such referrals for preventive asthma care. Barriers included insufficient time to make referrals, lack of information regarding the community agency and challenges communicating the value of the referral to patients and/or their caregivers. Conclusions Successfully engaging HCPs working in ED settings to use electronic portals to refer children with asthma to community agencies for health services may involve helping providers increase their comfort and knowledge of the external provider agency, ensuring organizational leaders support the need for preventive asthma care and provision of feedback to HCPs on the success of such referrals in meeting the needs of those families served.

The 2023 Impact of Inflammatory Bowel Disease in Canada: Direct Health System and Medication Costs.

Healthcare utilization among people living with inflammatory bowel disease (IBD) in Canada has shifted from inpatient management to outpatient management; fewer people with IBD are admitted to hospitals or undergo surgery, but outpatient visits have become more frequent. Although the frequency of emergency department (ED) visits among adults and seniors with IBD decreased, the frequency of ED visits among children with IBD increased. Additionally, there is variation in the utilization of IBD health services within and between provinces and across ethnocultural and sociodemographic groups. For example, First Nations individuals with IBD are more likely to be hospitalized than the general IBD population. South Asian children with Crohn's disease are hospitalized more often than their Caucasian peers at diagnosis, but not during follow-up. Immigrants to Canada who develop IBD have higher health services utilization, but a lower risk of surgery compared to individuals born in Canada. The total direct healthcare costs of IBD, including the cost of hospitalizations, ED visits, outpatient visits, endoscopy, cross-sectional imaging, and medications are rising rapidly. The direct health system and medication costs of IBD in Canada are estimated to be $3.33 billion in 2023, potentially ranging from $2.19 billion to $4.47 billion. This is an increase from an estimated $1.28 billion in 2018, likely due to sharp increases in the use of biologic therapy over the past two decades. In 2017, 50% of total direct healthcare costs can be attributed to biologic therapies; the proportion of total direct healthcare costs attributed to biologic therapies today is likely even greater.

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.

Does a Community Care programme reach a high health need population and high users of acute care hospital services in Melbourne, Australia? An observational cohort study

ObjectiveThe Community Care programme is an initiative aimed at reducing hospitalisations and emergency department (ED) presentations among patients with complex needs. We aimed to describe the characteristics of the programme...

Predictors of frequent emergency department visits among hospitalized cancer patients: a comparative cohort study using integrated clinical and administrative data to improve care delivery

BackgroundFrequent emergency department (FED) visits by cancer patients represent a significant burden to the health system. This study identified determinants of FED in recently hospitalized cancer patients, with a particular focus on opioid use.MethodsA prospective cohort discharged from surgical/medical units of the McGill University Health Centre was assembled. The outcome was FED use (≥ 4 ED visits) within one year of discharge. Data retrieved from the universal health insurance system was analyzed using Cox Proportional Hazards (PH) model, adopting the Lunn-McNeil approach for competing risk of death.ResultsOf 1253 patients, 14.5% became FED users. FED use was associated with chemotherapy one-year pre-admission (adjusted hazard ratio (aHR) 2.60, 95% CI: 1.80–3.70), ≥1 ED visit in the previous year (aHR: 1.80, 95% CI 1.20–2.80), ≥15 pre-admission ambulatory visits (aHR 1.54, 95% CI 1.06–2.34), previous opioid and benzodiazepine use (aHR: 1.40, 95% CI: 1.10–1.90 and aHR: 1.70, 95% CI: 1.10–2.40), Charlson Comorbidity Index ≥ 3 (aHR: 2.0, 95% CI: 1.2–3.4), diabetes (aHR: 1.60, 95% CI: 1.10–2.20), heart disease (aHR: 1.50, 95% CI: 1.10–2.20) and lung cancer (aHR: 1.70, 95% CI: 1.10–2.40). Surgery (cardiac (aHR: 0.33, 95% CI: 0.16–0.66), gastrointestinal (aHR: 0.34, 95% CI: 0.14–0.82) and thoracic (aHR: 0.45, 95% CI: 0.30–0.67) led to a decreased risk of FED use.ConclusionsCancer patients with higher co-morbidity, frequent use of the healthcare system, and opioid use were at increased risk of FED use. High-risk patients should be flagged for preventive intervention.

Using quality improvement to tackle the triple aim for children and young people with asthma: improving outcomes, experience and costs

Background/Aims Asthma in children and young people represents a substantial burden to the healthcare system, with these patients requiring frequent emergency care and having poorer health outcomes, leading to high system costs and poor patient experiences. This study used quality improvement methodology to achieve the triple aim of improved outcomes, better experience and reduced costs for those aged 0–16 years with asthma in north east London. Methods A multidisciplinary project team used quality improvement methods to implement and assess two interventions: a community high-risk asthma clinic and educational asthma-friendly school groups, both of which were delivered by a specialist asthma nurse. Population-level outcomes included asthma control test scores, accident and emergency department admissions and costs. Intervention-specific outcomes included number of clinic consultations delivered, did-not-attend rates and participant confidence ratings following the school sessions. Results Accident and emergency admissions for asthma reduced by 52%, with a 50% reduction in average monthly acute care costs. Asthma control test scores improved significantly, from an average of 18.56 to 22.34 out of a maximum score of 25 (P=0.000) following the interventions. Participants in the asthma-friendly school groups reported increased confidence in both day-to-day and emergency asthma management at the end of their sessions. Conclusions Having dedicated specialist asthma nurse input in the community and using school-based interventions can help to improve asthma care for children and young people, reducing the burden of frequent accident and emergency department admissions. Using quality improvement methods in pursuit of triple aim outcomes can help teams to work towards a shared goal.

Frequency of hyperventilation syndrome in asthma.

Objective: Hyperventilation syndrome is not only an important mimicker of asthma but it also increases perception of symptom severity in otherwise known stable asthmatic cases which may lead to increased use of asthma medication and hospital visits. Hyperventilation syndrome recognition is directly related to improvement of quality of life of an asthmatic patient. Study Design: Descriptive Cross-sectional study. Setting: Department of Pulmonology, Sahiwal Medical College Sahiwal. Period: 1st Nov 2019 to 1st May 2020. Material &amp; Methods: In 400 confirmed asthma patients diagnosis of hyperventilation syndrome was made through the use of Nijmegen score. Data was analyzed and Nijmegen scores were checked in terms of age, gender, co-morbid state. Association of Nijmegen score with number of hospital visits and frequency of use of rescue medication was also checked. Results: Younger females having asthma have the highest frequency of hyperventilation syndrome. Asthmatics with obesity and hypertension as co-morbid conditions are more prone to develop hyperventilation syndrome. Increased Nijmegen scores hence increased severity of hyperventilation syndrome is associated with poor control of asthma, increased use of reliever medicine and more frequent emergency department visits. Conclusion: Hyperventilation syndrome is a common cause of deteriorating quality of life of asthmatics however it is ignored most of the time in management of asthma. Every asthmatic with obesity, difficult to control asthma and frequent emergency visits should be looked for underlying hyperventilation syndrome and must be treated accordingly. There should be more research work on causes, diagnosis and management of hyperventilation syndrome.

Factors associated with emergency department avoidance during the COVID-19 pandemic and alternatives sought: a cross-sectional, telephone-based survey of frequent emergency department users in Beirut, Lebanon

ObjectivesTo explore avoidant behaviour of frequent emergency department (ED) users, reasons behind ED avoidance and healthcare-seeking behaviours in avoiders during the COVID-19 pandemic.Design and settingCross-sectional, telephone-based survey administered between March...

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.