High Emergency Department Utilization Research Articles

Measurement of left atrial size as a predictor of severity of illness in sickle cell disease

BackgroundSickle cell disease (SCD) is characterized by microvascular occlusion which leads to multiorgan damage, including left ventricular diastolic dysfunction. Left ventricular diastolic dysfunction has been shown to be an independent risk factor for death in SCD patients. Left atrial dilation (LAD) has been used as a surrogate marker for identification of left ventricular diastolic dysfunction. ObjectiveInvestigate the association of LAD, as determined by echocardiography, with increased disease burden in SCD as reflected by increased emergency department (ED) utilization, increased hemolysis markers, and worsening anemia. MethodsA retrospective cohort study of patients from a single university hospital were selected from a national registry. Age, sickle cell phenotype, echocardiogram findings, ED utilization, baseline hemoglobin, and lab values needed for calculation of hemolytic index were recorded for each patient. Patients were then stratified into two distinct groups based on the presence or absence of LAD to compare ED utilization, baseline hemoglobin and hemolytic index between the two groups. Results129 patients met the criteria for inclusion with 88 having normal left atrial volume and 41 with LAD. There was a higher percentage of high ED utilizers in the LAD group compared to the normal left atrial volume group [34% vs. 17%, p = 0.03]. Average hemoglobin was lower in the LAD group compared with the normal left atrial volume group [mean 8.57 g/dL vs. 9.47 g/dL, p = 0.011]. The mean hemolytic index was higher in the LAD group when compared with the normal left atrial volume group [0.44 vs. −0.21, p < 0.001]. ConclusionsLAD was associated with higher ED utilization, lower hemoglobin level, and more hemolysis in patients with SCD.

Changes in Emergency Department Utilization in Vulnerable Populations After COVID-19 Shelter-in-Place Orders.

This study aims to compare emergency department (ED) utilization and admission rates for patients with a history of mental health (MH) disorders, substance use disorders (SUDs), and social determinants of health (SDOH) before and after implementing COVID-19shelter-in-place (SIP) orders. This was a retrospective, multicenter study leveraging electronic medical record (EMR) data from 20 EDs across a large Midwest integrated healthcare system from 5/2/2019 to 12/31/2019 (pre-SIP) and from 5/2/2020 to 12/31/2020 (post-SIP). Diagnoses were documented in the patient's medical records. Poisson and logistic regression models were used to evaluate ED utilization and admission rate changes. A total of 871,020 ED encounters from 487,028 unique patients were captured. Overall, 2,572 (0.53%) patients had a documented Z code for SDOH. Patients with previously diagnosed MH disorders or SUDs were more likely to seek ED care after the SIP orders were implemented (risk ratio (RR): 1.20, 95% confidence interval (CI): 1.18-1.22, p<0.001), as were patients with SDOH (RR: 2.37, 95% CI: 2.19-2.55, p<0.001). Patients with both previously diagnosed MHdisorders or SUDs and a documented SDOH had even higher ED utilization (RR: 3.31, 95% CI: 2.83-3.88, p<0.001) than those with either condition alone. Patients with MHdisorders and SUDs (OR: 0.89, 95% CI: 0.86-0.92, p<0.001) or SDOH (OR: 0.67, 95% CI: 0.54-0.83, p<0.001) were less likely to be admitted post-SIP orders, while patients with a history of diseases of physiologic systems were more likely to be admitted. Vulnerable populations with a history of MH disorders,SUDs, and SDOH experienced increased ED utilization but a lower rate of hospital admissions after the implementation of SIP orders. The findings highlight the importance of addressing these needs to mitigate the impact of public health crises on these populations.

Race/ethnicity and socioeconomic position in emergency department utilization in patients with hepatocellular carcinoma.

Aim: Evaluate the association of race/ethnicity and socioeconomic position (SEP) on emergency department (ED) visits for patients with hepatocellular carcinoma (HCC), which may reflect access to and quality of cancer care. Materials & methods: Patients with HCC identified from a commercial multi-payer claims database between 2015 and2018 were matched to near-neighborhood social determinants of health (SDOH) and stratified by race/ethnicity and SEP (proxied by annual household income). Analyses evaluated the effect of race/ethnicity and SEP on ED utilization, adjusting for SDOH, demographic and clinical characteristics using multivariable regression methods. Results: A total of22,247 patients were included. Black and Hispanic patients had 43and 18% higher ED utilization than White patients at higher-income levels (p<0.01); these differences were nonsignificant at lower-income. Regardless of income level, Asian patients had lower ED utilization. Conclusion: Further research on the intersectionality between race/ethnicity, SEP and other SDOH may guide structural-level interventions to address health inequities.

Homelessness Among Acute Care Patients Within a Large Health Care System in Northern California.

The impacts of homelessness on health and health care access are detrimental. Intervention and efforts to improve outcomes and increase availability of affordable housing have mainly originated from the public health sector and government. The role that large community-based health systems may play has yet to be established. This study characterizes patients self-identified as homeless in acute care facilities in a large integrated health care system in Northern California to inform the development of collaborative interventions addressing unmet needs of this vulnerable population. The authors compared sociodemographic characteristics, clinical conditions, and health care utilization of individuals who did and did not self-identify as homeless and characterized their geographical distribution in relation to Sutter hospitals and homeless resources. Between July 1, 2019 and June 30, 2020, 5% (N = 20,259) of the acute care settings patients had evidence of homelessness, among which 51.1% age <45 years, 66.4% males, and 24% non-Hispanic Black. Patients experiencing homelessness had higher emergency department utilization and lower utilization of outpatient and urgent care services. Mental health conditions were more common among patients experiencing homelessness. More than half of the hospitals had >5% of patients who identified as homeless. Some hospitals with higher proportions of patients experiencing homelessness are not located near many shelter resources. By understanding patients who self-identify as homeless, it is possible to assess the role of the health system in addressing their unmet needs. Accurate identification is the first step for the health systems to develop and deliver better solutions through collaborations with nonprofit organizations, community partners, and government agencies.

Risk Factors of Emergency Department Utilization After Outpatient Surgery for Sports-Related Injuries.

The purpose of this study was to identify the most common reasons for and risk factors associated with postoperative emergency department (ED) utilization after orthopaedic procedures for sports-related injuries. Using the 2014 to 2016 New York and Florida State Databases from the Healthcare Cost and Utilization Project, outpatient procedures for sports-related injuries were identified. Patient records were tracked across care settings within each state to determine the rate and reasons of postoperative ED utilization within 90 days after the index surgery. Multiple logistic regression models were used to identify risk factors associated with ED visits at 0 to 7 days, 8 to 30 days, 31 to 90 days postoperatively. A total of 28,192 surgery visits for sports-related injuries were identified, with knee arthroscopy with partial meniscectomy (18.48%) and arthroscopic anterior cruciate ligament reconstruction (17.04%) as the two most common procedures treating sports injuries. The overall postoperative ED utilization rates were 1.6% (0 to 7 days postoperative), 1.3% (8 to 30 days) and 2.1% (31 to 90 days). The main cause of ED visits was markedly different during each postoperative period: mainly musculoskeletal pain (36.3%) during 0 to 7 days, either musculoskeletal pain (17%) or injury (16.6%) during 8 to 30 days, and injury (24.2%) during 31 to 90 days. Sports with the highest ED utilization in descending order were basketball, football, ice/snow sports, walking/running, cycling, and soccer. Relative to open procedures, arthroscopic procedures were 0.71 times as likely to result in a postoperative ED visit. Independent predictors of ED utilization up to 90 days postoperatively included renal failure, chronic pulmonary disease, psychosis, diabetes, and alcohol abuse. Rate of ED utilization after outpatient surgery for sports-related injuries is low (<2.2%), with postoperative musculoskeletal pain and reinjury as the two most common causes, highlighting the importance of postoperative pain management and injury prevention. Arthroscopic procedures showed markedly lower ED utilization compared with open surgery, although not indicative of overall superiority. III, Retrospective Cohort Study.

Rural disparities in emergency department utilization for migraine care.

To evaluate differences in emergency department (ED) utilization and quality of care for migraine in patients with rural and nonrural residences. Migraine is a significant problem in the United States with direct health-care utilization cost amounting to US $4.2 billion annually. A considerable portion of this cost is attributed to more than 4 million annual ED visits for migraine and headache. Previous research has documented health disparities among rural populations in other disease states, which can be influenced by factors such as socioeconomic status and health-care access. Given these associations, it was hypothesized that patients with rural residence in a national sample would have increased ED utilization for migraine compared to patients with nonrural residence. This was a cross-sectional epidemiologic study to evaluate rural disparities in ED utilization and quality of care for migraine in the United States in 2019. ED encounter data were collected from the Healthcare Cost and Utilization Project (HCUP) Nationwide Emergency Department Sample (NEDS) and Kentucky State Emergency Department Database (KY-SEDD). The primary outcome was crude and age-adjusted rates of ED encounters for migraine per 10,000 population. ED encounters were included if they had a primary International Classification of Diseases, Tenth Revision, Clinical Modification diagnosis code of G43.xx. ED encounters lacking sufficient data to classify into a geographic group were excluded. Secondary outcomes examined differences in quality of care, including mean ED charges and the proportion of encounters with medication administration, imaging, and nerve block service codes between groups. One hundred eighty-three thousand two hundred eleven national ED discharges were classified as rural patient encounters and 627,176 were classified as nonrural. The rural group had significantly higher crude and age-adjusted rates of ED utilization for migraine (crude: rural 39.8, 95% confidence interval [CI] 36.9-42.7; nonrural 22.2, 95% CI 21-23.5 and age-adjusted: rural 41.8, 95% CI 38.8-44.8; nonrural 23.4, 95% CI 22.1-24.7). Opioid utilization was higher in rural encounters (rural n = 26,764, 14.6%; nonrural n = 50,367, 8%; p < 0.001). A Kentucky sub-analysis found 5210 ED discharges were classified as Appalachian and 12,551 as non-Appalachian. The Appalachian group had significantly higher ED utilization rates for migraine compared to the non-Appalachian and national rural groups (crude: Appalachian 44.9, 95% CI 43.7-46.2; age-adjusted: Appalachian 47.4, 95% CI 46.1-48.8). The Kentucky Appalachian group also demonstrated significantly higher opioid analgesia use compared to the national rural group (Appalachian n = 1031, 19.8%; p < 0.001). This study suggests rural populations, particularly in Appalachia, may experience significantly higher ED utilization for migraine compared to nonrural patients. Moreover, rural populations were more likely to receive suboptimal migraine management with opioid analgesia. Multimodal health-care interventions should be developed to improve access to outpatient migraine care and further investigate potential risk factors in the rural population. With high ED utilization, the Appalachian population may benefit most from such an intervention.

Patterns of Emergency Department Utilization of Adolescents and Young Adults Living with Sickle Cell in North Carolina

Introduction Despite improvements in survival and life expectancy in high-income countries, adolescent and young adults (AYAs) living with sickle cell disease (SCD) remain at significant risk for morbidity and mortality. Our previous work using group-based trajectory modeling (GTBM) has demonstrated that a subset of AYAs with SCD are at risk for significant morbidity with SCD with increased healthcare utilization, vasoocclusive pain episodes, and death, particularly after transition to adult care (Kayle et al., Pediatric Blood &amp; Cancer, 2018). Yet, there is limited insight into which AYAs with SCD are at high risk for poor outcomes. The objective of this study was to identify patterns of emergency department (ED) utilization of AYAs with SCD in NC as individuals age, with the overarching future goal of better predicting which individuals are at highest risk. Methods The NC Hospital Discharge Data (Inpatient, Ambulatory Surgery/Outpatient and ED Databases), 2013-2020 were used. A patient with SCD was defined as a patient who had three or more visits (inpatient, ambulatory surgery, or ED visit) with International Classification of Diseases 9 or 10 codes for SCD within a 5-year period. Date of birth, sex and zip code were used to link patients across the datasets. Demographic variables including age, sex, race and ethnicity were extracted from visit level data. ED visits were defined as all ambulatory ED visits and ED visits that resulted in inpatient admissions between 2013 and 2019. Descriptive statistics were calculated to describe the sample characteristics such as sex and race. The number of ED visits per year across age 14 to 30 years were used as longitudinal variables in GTBM to identify trajectories of latent classes of ED visits. The number of latent classes was determined by model-fit indices such as BIC and entropy. Results There were 3643 participants included in this study. Participants were 95% Black or African American, 53.8% female and 46.2% male, with age ranging from 14-30 years. Our GTBM models identified three latent classes of participants (Figure 1) with similar ED utilization at age 14 years, but divergent predicted annual ED trajectories beginning around 18 years of age. Class 1, comprising 95% of the participants (n=3463) and 54% female, had minimal ED utilization throughout all the years. Class 2, comprising 4% of the participants (n=150) and 51.3% female, had a steady increase in annual ED use, peaking at 20 visits per year by at age 24 years. Class 3, comprising 0.8% of the participants (n=30) and 47% female, had more extreme ED utilization, up to 80 visits per year at age 24 years. Conclusions Using a large longitudinal dataset, we demonstrate distinct patterns of ED utilization among AYAs with SCD by age. Although ED utilization was similar between the groups at age 14 years, a small proportion (~5%) of individuals accounted for the highest ED utilization at older ages. Additionally, amongst the patients with highest ED utilization, there was a marked increase in ED utilization from age 18-24 years, highlighting the highest risk ages within the AYA population, when there is often a transition from pediatric to adult care. There were slightly more males in the highest ED utilization class, highlighting potential gender differences in ED utilization. Our next steps will be to assess which clinical and social factors predict ED utilization trajectory. Limitations in this study include the use of hospital discharge datasets, which may have limited the capture of patients with infrequent acute care visits and limited our ability to examine the role of SCD genotypes and disease-modifying therapy use on ED utilization patterns. Despite these limitations, the study identifies distinct classes of ED use among AYAs with SCD. Understanding and predicting patterns of ED utilization are critical in targeting early interventions towards individuals with the highest risk of healthcare utilization and disproportionate risk for future morbidity.

Outpatient surgery postoperative ambulation and emergency department utilization.

The ability to ambulate is an important indicator for wellness and quality of life. A major health event, such as a surgery, can derail this ability, and return to preoperative walking ability is a marker for recovery. Self-reported walking measurements by patients are subject to bias, thus wearable technology such as activity monitors have risen in popularity. We evaluated postoperative ambulation using an accelerometer in outpatient general surgery procedures with the hypothesis that those patients with less postoperative ambulation were at risk for adverse outcomes. A retrospective review of patients undergoing outpatient abdominal surgeries from November 2016 to July 2019 at a Veteran Affairs Medical Center. Patients wore an accelerometer preoperatively and postoperatively to measure their ambulation (steps/day). Outcome measures were 30-day readmissions and Emergency Department (ED) utilization. Postoperative ambulation was defined as daily percentages of their preoperative baseline. Patients without preoperative baseline data, > 3 missing days or any missing days prior to reaching baseline were excluded. One-hundred-six patients underwent outpatient abdominal surgery. Twenty-two patients were excluded. Patients stratified into adult (18-64 years, 44 patients, 52%) and geriatric (≥ 65 years, 40 patients, 48%) cohorts. Geriatric patients were less likely to meet their preoperative baseline by postoperative day 7, 35% vs 61%, p = 0.016. Adult patients who failed to meet their preoperative baseline in first postoperative week had higher ED utilization; 4 (24%) vs 1 (4%), p = 0.04. Geriatric patients who failed to meet their baseline trended toward increased ED utilization; 5 (19%) vs. 1 (7%), p = 0.31. Patients aged < 65 who fail to return to their preoperative daily step count within one week of outpatient abdominal surgery are 6× more likely to be seen in the ED. Postoperative ambulation may be able to predict ED utilization and recovery after outpatient surgery.

Disparities in adherence and emergency department utilization among people with epilepsy: A machine learning approach.

We used a machine learning approach to identify the combinations of factors that contribute to lower adherence and high emergency department (ED) utilization. Using Medicaid claims, we identified adherence to anti-seizure medications and the number of ED visits for people with epilepsy in a 2-year follow up period. We used three years of baseline data to identify demographics, disease severity and management, comorbidities, and county-level social factors. Using Classification and Regression Tree (CART) and random forest analyses we identified combinations of baseline factors that predicted lower adherence and ED visits. We further stratified these models by race and ethnicity. From 52,175 people with epilepsy, the CART model identified developmental disabilities, age, race and ethnicity, and utilization as top predictors of adherence. When stratified by race and ethnicity, there was variation in the combinations of comorbidities including developmental disabilities, hypertension, and psychiatric comorbidities. Our CART model for ED utilization included a primary split among those with previous injuries, followed by anxiety and mood disorders, headache, back problems, and urinary tract infections. When stratified by race and ethnicity we saw that for Black individuals headache was a top predictor of future ED utilization although this did not appear in other racial and ethnic groups. ASM adherence differed by race and ethnicity, with different combinations of comorbidities predicting lower adherence across racial and ethnic groups. While there were not differences in ED use across races and ethnicity, we observed different combinations of comorbidities that predicted high ED utilization.

Community paramedicine in Central Oregon: A promising model to reduce non-urgent emergency department utilization among medically complex Medicaid beneficiaries.

Community paramedicine has emerged as a promising model to redirect persons with nonmedically emergent conditions to more appropriate and less expensive community-based health care settings. Outreach through community paramedicine to patients with a history of high hospital emergency department (ED) use and chronic health conditions has been found to reduce ED use. This study examined the effect of community paramedicine implemented in 2 rural counties in reducing nonemergent ED use among a sample of Medicaid beneficiaries with complex medical conditions and a history of high ED utilization. A cluster randomized trial approach with a stepped wedge design was used to test the effect of the community paramedicine intervention. ED utilization for non-urgent care was measured by emergency medicine ED visits and avoidable ED visits. The community paramedicine intervention reduced ED utilization among a sample of 102 medically complex Medicaid beneficiaries with a history of high ED utilization. In the unadjusted models, emergency medical ED visits decreased by 13.9% (incidence rate ratio [IRR], 0.86; 95% confidence interval [CI], 0.76-0.98) or 6.1 visits saved for every 100 people. Avoidable emergency department visits decreased by 38.9% (IRR, 0.61; 95% CI, 0.44-0.84) or 2.3 visits saved for every 100 people. Our results suggest community paramedicine is a promising model to achieve a reduction in ED utilization among medically complex patients by managing complex health conditions in a home-based setting.

Emergency department utilization and hospital admissions for ambulatory care sensitive conditions among people seeking a primary care provider during the COVID-19 pandemic.

Primary care attachment improves health care access and health outcomes, but many Canadians are unattached, seeking a provider via provincial wait-lists. This Nova Scotia-wide cohort study compares emergency department utilization and hospital admission associated with insufficient primary care management among patients on and off a provincial primary care wait-list, before and during the first waves of the COVID-19 pandemic. We linked wait-list and Nova Scotian administrative health data to describe people on and off wait-list, by quarter, between Jan. 1, 2017, and Dec. 24, 2020. We quantified emergency department utilization and ambulatory care sensitive condition (ACSC) hospital admission rates by wait-list status from physician claims and hospital admission data. We compared relative differences during the COVID-19 first and second waves with the previous year. During the study period, 100 867 people in Nova Scotia (10.1% of the provincial population) were on the wait-list. Those on the wait-list had higher emergency department utilization and ACSC hospital admission. Emergency department utilization was higher overall for individuals aged 65 years and older, and females; lowest during the first 2 COVID-19 waves; and differed more by wait-list status for those younger than 65 years. Emergency department contacts and ACSC hospital admissions decreased during the COVID-19 pandemic relative to the previous year, and for emergency department utilization, this difference was more pronounced for those on the wait-list. People in Nova Scotia seeking primary care attachment via the provincial wait-list use hospital-based services more frequently than those not on the wait-list. Although both groups have had lower utilization during COVID-19, existing challenges to primary care access for those actively seeking a provider were further exacerbated during the initial waves of the pandemic. The degree to which forgone services produces downstream health burden remains in question.

Impact of monoclonal antibody therapy for head and neck cancer on end-of-life care utilization and costs.

The impact of monoclonal antibody therapy (mAB) for advanced head and neck cancer on end-of-life health care utilization and costs has yet to be adequately studied. Retrospective cohort study of patients aged 65 and over with a diagnosis of head and neck cancer between 2007 and 2017 within the SEER-Medicare registry assessing the impact of mAB therapy (i.e., cetuximab, nivolumab, or pembrolizumab) on end-of-life health care utilization (ED visits, inpatient admissions, ICU admissions, and hospice claims) and costs. Of 12 544 patients with HNC, 270 (2.2%) utilized mAB therapy at the end-of-life period. On multivariable analyses adjusting for demographic and clinicopathologic characteristics, there was a significant association between mAB therapy and emergency department visits (OR: 1.38, 95% CI: 1.1-1.8, p = 0.01) and healthcare costs (β: $9760, 95% CI: 5062-14 458, p < 0.01). mAB use is associated with higher emergency department utilization and health care costs potentially due to infusion-related and drug toxicity expenses.

Rates of unplanned hospital care in Black Americans with pancreatic cancer.

666 Background: Individuals with cancer are more likely to visit an emergency department (ED) for issues both related and unrelated to their cancer than individuals without cancer, but data are lacking regarding what subpopulations are most vulnerable. Here, we assessed the characteristics of patients with pancreas cancer across the Northwell Health system who had multiple ED visits. Methods: An IRB-approved retrospective chart review of patients with pancreas cancer diagnosed between 2015 through 2021 was conducted. Patients with &gt; 3 ED visits were defined as high utilization and patients with 0 ED visits were defined as low utilization. Demographic and clinical features were recorded. Median income was extrapolated by zip code using data from the US Census Bureau. Generalized logistic regression models were constructed to analyze characteristics associated with high ED utilization. Results: The cohort consisted of 658 patients, among whom 181 individuals met criteria for high utilization and 140 met criteria for low utilization. Stage, age, gender, ethnicity, history of pancreatitis, median income, preferred language, establishment with primary care provider, and establishment with medical oncologist had no significant association with high utilization. Race (OR: 2.8; p = 0.002) and substance abuse (OR: 4.43; p = 0.02) were the strongest predictors of high ED utilization. We observed that 14% of the individuals who were Black had a history of substance abuse. Conclusions: Our analysis identified a striking and concerning association between high utilization of the ED and patients who are Black or who have a history of substance abuse. Substance abuse may contribute to high ED utilization among Black Americans, however, 86% had no history of substance abuse, suggesting that other causal factors are at play. These results compel further investigation into these casual factors to guide the development of health equity interventions to address these disparities.[Table: see text]

Interactive association of chronic illness and food insecurity with emergency department utilization among school-age children in the United States: A cross-sectional study.

Food insecurity combined with chronic disease conditions is a risk factor for Emergency Department (ED) utilization, an indicator of poor quality of care. However, such an association is not certain among school-age children with chronic conditions. Therefore, we aim to determine the association of food insecurity, chronic conditions, and ED utilization among school-age children in the United States. We analyzed the data from the 2017 Medical expenditure panel survey (MEPS) among children aged 6-17 years (N = 5518). MEPS data was released electronically by the Agency for Healthcare Research and Quality (AHRQ). We identified four groups of school-age children based on the presence of food security and chronic conditions: 1) with food insecurity and chronic conditions; 2) no food insecurity and chronic conditions; 3) with food insecurity and no chronic conditions; and 4) no food insecurity and no chronic conditions. We compared ED utilization among these four groups using incidence rate ratios (IRR) after adjusting children's age, sex, race and ethnicity, household income, insurance coverage, obesity, and geographic region using count data model, specifically multivariable Poison regression. We used SAS 9.4 and STATA 14.2 for all the data analyses. There were unweighted 5518 school-age children who represented weighted 50,479,419 school-age children in the final analysis. Overall, 6.0% had food insecurity with chronic conditions. These children had higher ED utilization (19.7%) than the other three groups (13.3%, 8.8%, and 7.2%, p < 0.001). The adjusted IRR of ED utilization among school-age children with food insecurity and chronic conditions was 1.90 (95% confidence interval 1.20-3.01, p = 0.007) compared with those with food security and chronic conditions. One in 16 school-age children has both food insecurity and chronic conditions. Food insecurity was positively associated with frequent ED visits in the presence of chronic conditions. Therefore, addressing food insecurity may reduce the risk of ED visits.

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.

LBSUN211 The Importance Of Early Opportunities To Identify And Treat Prediabetes Or Even Change The Diagnostic Threshold For Diabetes

Abstract Introduction 34.5% of US adults meet criteria for prediabetes, while 13% of US adults have diabetes. Diabetes increases the risk for many serious conditions. Recommendations for early screening and management of prediabetes have recently been updated. Hypothesis Diabetes has been associated with higher frequency use of emergency department (ED) services and inpatient admission, leading to higher costs associated with diabetes. We compare patients with diabetes or prediabetes for use of ED and inpatient care hypothesizing that prediabetic patients will have fewer visits to the ED and hospital. We additionally described differences in characteristics between these two groups to identify health inequities. Research Design: Data on people with Type 2 diabetes (DM) or prediabetes (PD) who seen in the ED March 2018 and December 2019 were extracted from an EHR. Descriptive statistics were compared between people with DM and PD using t-test or chi square tests. Linear and logistic regression analyses were conducted to compare DM to PD frequency of ED visits, high utilization of ED (3+ ED visits per year), admission to inpatient care. A p-value of 0. 05 or less is considered significant. Major Results PD patients were younger, and female compared to DM patients. Bivariate analysis show PD patients had fewer ED visits per year on average (1.2 v 1.5, (p&amp;lt;. 0001) compared to DM, and were less than half as likely to have 4+ visits per year (2. 0% v 5.4%, p &amp;lt;. 0001). Several comorbidities were examined, and all were significantly higher amongst DM patients. PD patients were more likely to have 0 or 1 comorbidities (69.6% vs. 55.3%, p &amp;lt;. 0001) compared to DM. In the linear regression analysis, PD was negatively associated with ED visits (-0.2 (-0.3, -0.1, p &amp;lt;. 0001) after adjusting for age, gender, race, and poverty, as well as multiple comorbidities. Similar findings emerged in a logistic regression analysis of high ED utilization, and linear regression analysis of inpatient admission. Interpretation of Results and Conclusions Our data suggest that adverse outcomes of hyperglycemia accrue prior to current HgA1c cut-off for the diagnosis of diabetes, deserve therapy, and even changing the threshold of diagnosis of diabetes to HgA1c= 5.7. Considering previously reported costs associated with ED visits (averaging $2200 per visit nationally) and inpatient care, early management of prediabetes represents an important health economic priority. Management of PD offers an opportunity to improve outcomes and reduce morbidity and early mortality associated with DM. Our study found that PD was associated with fewer ED visits, fewer debilitating comorbidities such as retinopathy, COPD, CKD, and CHF. PD patients were less likely to have any comorbidities in comparison to DM patients. Presentation: Sunday, June 12, 2022 12:30 p.m. - 2:30 p.m.

Neighborhood Child Opportunity and Emergency Department Utilization.

The Child Opportunity Index (COI) is a multidimensional measure of structural neighborhood context that may influence a child's healthy development. Our objective was to determine if COI is associated with children's emergency department (ED) utilization using a national sample. This was a retrospective cohort study of the Pediatric Health Information Systems, a database from 49 United States children's hospitals. We analyzed children aged 0 to 17 years with ED visits from January 1, 2018, to December 31, 2019. We modeled associations between COI and outcomes using generalized regression models that adjusted for patient characteristics (eg, age, clinical severity). Outcomes included: (1) low-resource intensity (LRI) ED visits (visits with no laboratories, imaging, procedures, or admission), (2) ≥2 or ≥3 ED visits, and (3) admission. We analyzed 6 810 864 ED visits by 3 999 880 children. LRI visits were more likely among children from very low compared with very high COI (1 LRI visit: odds ratio [OR] 1.35 [1.17-1.56]; ≥2 LRI visits: OR 1.97 [1.66-2.33]; ≥3 LRI visits: OR 2.4 [1.71-3.39]). ED utilization was more likely among children from very low compared with very high COI (≥2 ED visits: OR 1.73 [1.51-1.99]; ≥3 ED visits: OR 2.22 [1.69-2.91]). Risk of hospital admission from the ED was lower for children from very low compared with very high COI (OR 0.77 [0.65-0.99]). Children from neighborhoods with low COI had higher ED utilization overall and more LRI visits, as well as visits more cost-effectively managed in primary care settings. Identifying neighborhood opportunity-related drivers can help us design interventions to optimize child health and decrease unnecessary ED utilization and costs.

Associations between Adverse Childhood Experiences and Emergency Department Utilization in an Adult Medicaid Population

Adverse childhood experiences (ACEs) are widely prevalent but unevenly distributed in the United States, with disadvantaged groups, especially those with low socioeconomic status, being more likely to experience them. ACEs have been linked to poor health outcomes in adulthood. In this study, we examined the association between ACEs and emergency department (ED) utilization using a cross-sectional life-course survey of low-income adults matched to Medicaid enrollment and claims data. Surveys were obtained from 2348 Medicaid-enrolled adults in the Portland, OR metropolitan area; 1133 were used in this analysis. We used a two-part regression model to estimate the association between ACE score and both ever using the ED and frequency of ED use in the year after survey completion. We also evaluated a set of potentially protective factors to see if they impacted the relationship between ED use and ACE score. We found that participants with a higher ACE score were more likely to obtain any emergency services care (odds ratio (OR) = 1.11, p = 0.011), but ACE score did not predict how frequently they would utilize those services. Close social relationships were found to be protective against high ED utilization for those with high ACE scores. Upstream prevention efforts that identify places to intervene in childhood and incorporate trauma-informed strategies into ED care in adulthood have the potential to decrease ED use.

The relationship between adverse childhood experiences, the frequency and acuity of emergency department utilization and primary care engagement

IntroductionA history of adverse child experiences (ACEs) is associated with increased high-risk adult behaviors, morbidity, mortality, and use of the emergency department. This study was designed to understand the relationship between ACEs and the characteristics of emergency department use and primary care engagement. MethodsAn in-person survey was conducted at an academic emergency department (ED) assessing ACE score, emergency department utilization and acuity, and primary care engagement. ResultsThe prevalence of ACEs was 71.1% with 1+ ACE and 32.5% with 4+ ACE. ACE scores of four or more were associated with three or more ED visits in the past year compared those with an ACE score of zero (OR 3.22; p < 0.05) and when adjusted for sociodemographic factors (OR 3.22; p < 0.10). Higher ACE scores were associated with lower acuity presentations as indicated by the Emergency Severity Index before (ACE score 1 OR 3.91 p < 0.05; ACE score 2–3 OR 2.35 p < 0.05; ACE score 4+ OR 3.95 p < 0.05) and after adjustment (ACE score 1 OR 3.80 p < 0.10; ACE 2–3 OR 3.50 p < 0.10; ACE 4+ OR 4.36 p < 0.05). There was no association between ACE score and having a primary care provider (PCP), frequency of PCP visits, or PCP rating. ConclusionHigher ACE scores were associated with higher emergency department utilization and lower acuity presentations but not associated with levels of primary care engagement. Additional investigations are needed to adequately characterize the discrete causal mechanisms behind these current findings.

Abstract 12392: Rethinking Re-Hospitalization in Heart Failure Care Transitions: Heterogeneity in Utilization Typologies

Introduction: Re-hospitalization for patients with heart failure (HF) is a persistent challenge. Person-oriented analysis may highlight heterogeneities and inform strategies to avert acute-care utilization. Purpose: To evaluate how outpatient utilization and sociodemographic, health behavior, and clinical factors are associated with high acute-care utilization using trajectory modeling. Methods: This retrospective cohort study used group-based trajectory modeling to identify latent groups of emergency department (ED), inpatient, and outpatient utilization one year before and after the initial HF hospitalization in adults (n= 1269) who had the index hospitalization between January 2016 and December 2018. Factors associated with high acute-care utilization were assessed by multinomial logistic regression. Results: People with medium or high outpatient utilization (44.9%) versus those with low outpatient utilization (37.7%) were associated with higher acute-care utilization after controlling for other significant factors such as insurance and comorbidities. Patients had six distinct typologies of acute-care utilization (Figure 1). Four typologies (14.3%) with higher acute-care utilization (ED or inpatient or both) accounted for 52% and 33.0% of the total ED and inpatient encounters. However, the association between outpatient and higher acute-care utilization was not significant among people with fluctuating outpatient utilization (17.4%). Conclusions: A person-oriented approach characterizing heterogeneity in acute-care utilization complements the hospital-focused 30-day readmission metric by revealing patients’ unique changes in utilization over time. High-frequency outpatient care may indicate fragmented care. Developing tailored interventions in the outpatient setting to address the small subgroup of patients with consistently high ED or inpatient utilization may improve re-hospitalization for patients with HF.