Inappropriate Use Of Emergency Department Research Articles

Inter-level and Seasonal Variation in Reasons for Inappropriate Emergency Department Use: A Three Centers Study

Inter-level and Seasonal Variation in Reasons for Inappropriate Emergency Department Use: A Three Centers Study

Timely care for age-related macular degeneration: a qualitative study among retina specialists in Israel

BackgroundAge-related macular degeneration (AMD) affects quality of life and independence, and its incidence and prevalence are increasing due to ageing of the population. Access to effective timely treatment can improve vision and reduce incidence of blindness. This study aimed to explore the perspectives of ophthalmologists in the Israeli public healthcare system regarding timely treatment of AMD patients.MethodsQualitative semi-structured interviews were conducted in 2020-2021 with 22 senior ophthalmologists, from 10 general hospitals and from two HMOs, representing different geographic regions. All interviewees specialize in retinal diseases and work with AMD patients. Interviews discussed patient pathways involved in the diagnosis and treatment of AMD, access to care, and obstacles to timely care. Thematic analysis was conducted.ResultsBased on the interviews, we describe the usual referral and treatment pathways. Themes included regional disparities, long wait times in some areas, a lack of retina specialists, differences in referral pathways, inappropriate use of emergency department to obtain timely treatment, and second-line treatment not fully covered by insurance, most affecting the weakest segments of the population.ConclusionsLoss of vision incurs high health and societal costs. In the context of insufficient medical manpower in Israel, the healthcare system will need to assess future resources to cope with accumulating burden of AMD cases over time in an ageing population. Precise referral information, and simultaneous referral to imaging and retinal clinics, may minimize delays in treatment. Awareness of AMD symptoms and the importance of early intervention could be highlighted by campaigns, particularly among high-risk groups.Highlights• Interviews with hospital-based and community ophthalmologists showed regional disparities in AMD treatment, with long wait times and a lack of retina specialists in some areas.• Differences in referral pathways, inappropriate use of emergency department to obtain timely treatment, and second line treatment not fully covered by insurance were highlighted.• The healthcare system will need to assess future resources to cope with accumulating burden of AMD cases over time in an ageing population• Precise referral information, and simultaneous referral to imaging and retinal clinics, may minimize delays in treatment.• Awareness of AMD symptoms and the importance of early intervention should be emphasized in high-risk groups.

To Admit or Not to Admit to the Emergency Department: The Disposition Question at a Tertiary Teaching and Referral Hospital

Disposition decision-making in the emergency department (ED) is crucial to patient safety and quality of care. It can inform better care, lower chance of infections, appropriate follow-up care, and reduced healthcare costs. The aim of this study was to examine correlates of ED disposition among adult patients at a teaching and referral hospital based on patients' demographic, socioeconomic, and clinical characteristics. A cross-sectional study conducted at the ED of the King Abdulaziz Medical City hospital in Riyadh. A two-level validated questionnaire was used-a patient questionnaire and healthcare staff/facility survey. The survey employed a systematic random sampling technique to recruit subjects at a pre-specified interval as patients arrived at the registration desk. We analyzed 303 adult patients visiting the ED, who were triaged, consented to participate in the study, completed the survey, and admitted to a hospital bed or discharged home. We used descriptive and inferential statistics to summarize and determine the interdependence and relationships of variables. We used logistic multivariate regression analysis to establish relationships and the odds of admission to a hospital bed. The mean age of the patients was 50.9 (SD = 21.4, Range 18 to 101). A total of 201 (66%) were discharged home while the rest were admitted to a hospital bed. Results of the unadjusted analysis suggest that older patients, males, patients with low level of education, and those with comorbidities and middle-income were more likely to be admitted to the hospital. The results of the multivariate analysis suggest that patients with comorbidities, urgent conditions, prior history of hospitalization, and higher triage levels were more likely to be admitted to a hospital bed. Having proper triage and timely stopgap review measures in the admission process can help new patients to locations that best support their needs and improve the quality and efficiency of the facility. The findings may be a sentinel indicator that informs overuse or inappropriate use of EDs for non-emergency care, which is a concern in the Saudi Arabian publicly funded health system.

Influence of appropriate emergency department utilization and verbal communication on physicians' (dis)satisfaction with doctor-patient interactions with special consideration of migrational backgrounds.

In recent years, utilization of emergency departments (EDs) has increased continuously, both in Germany and internationally. Inappropriate use of EDs is believed to be partly responsible for this trend. The topic of doctor–patient interaction (DPI) has received little attention in research. However, successful DPI is not only important for adherence and treatment success, but also for the satisfaction of medical staff. This non-interventionl cross-sectional study attempts to identify factors influencing physicians’ satisfaction with DPIs, with a particular focus on the appropriate utilization of EDs and verbal communication. We carried out tripartite data collection in three EDs of major referral hospitals in Berlin between July 2017 and July 2018. Migration experience, communication and language problems, level of education, and a large gap between physicians’ and patients’ perceived urgency regarding the utilization of EDs influence the quality of the doctor–patient relationships and interactions.

Use and Misuse of Emergency Room for Children: Features of Walk-In Consultations and Parental Motivations in a Hospital in Southern Italy.

Objective: Inappropriate use of the emergency department (ED) represents a major worldwide issue both in pediatric and adult age. Herein, we aim to describe features of pediatric visits to the ED of Salerno University Hospital and to evaluate parental reasons behind the decision to walk in.Materials and Methods: We performed a retrospective observational study evaluating ED encounters for children from January 2014 to December 2019. The appropriateness of visits was measured with a national tool assessing every ED encounter, namely, “the Mattoni method,” which consists of the combination of the triage code assigned, the diagnostic resources adopted, and the consultation outcomes. Moreover, 64 questionnaires were collected from a sample of parents in the waiting rooms in January 2020.Results: A total number of 42,507 visits were recorded during the study period (19,126 females; mean age ± SD: 4.3 ± 3.8 years), the majority of whom were inappropriate (75.8% over the considered period; 73.6% in 2014; 74.6% in 2015; 76.3% in 2016; 76.7% in 2017; 77.9% in 2018; 75.5% in 2019). Most of the inappropriate consultations arrived at the ED by their own vehicle (94.4%), following an independent decision of the parents (97.2%), especially in the evening and at night on Saturdays/Sundays/holidays (69.7%). A multivariate analysis revealed the following: patients of younger age (OR: 1.11, 95% C.I. 1.06–1.16; p < 0.0019), night visits (OR 1.39; 95% C.I.: 1.32–1.47; p < 0.001), patients living in the municipality of Salerno (OR 1.28; 95% C.I.: 1.22–1.34; p < 0.001), weekend day visits (OR 1.48; 95% C.I.: 1.41–1.56; p < 0.001), and independent parental decision without previous contact with primary care pediatrician (OR 3.01; 95% C.I.: 2.64–3.44; p < 0.001) were all significant independent predictors of inappropriate consultation. The most frequent trigger of ED encounters was fever (51.4%). Hospital admission made up 17.6% of all consultations. The questionnaire showed that most parents were aware of the lack of urgency (20.3%) or minor urgency (53.1%) of the visit. The reasons for walking in were the impossibility to receive a home consultation (70%), the difficulty of contacting their family pediatrician during weekends and holidays (54.4%), as well as the search for a quick, effective, diagnosis and therapy (48.4%).Conclusions: The study suggests a highly inappropriate use of ED for children in our region. This issue deserves considerable attention by health care system leaders in order to optimally integrate hospitals and primary care.

The impact of the COVID-19 pandemic and governor mandated stay at home order on emergency department super utilizers.

BackgroundDespite the trend of rising Emergency Department (ED) visits over the past decade, researchers have observed drastic declines in number of ED visits due to the COVID-19 pandemic. The purpose of the current study was to examine the impact of the COVID-19 pandemic and governor mandated Stay at Home Order on ED super utilizers.MethodsThis was a retrospective chart review of patients presenting to the 12 emergency departments of the Franciscan Mission of Our Lady Hospital System in Louisiana between January 1, 2018 and December 31, 2020. Patients who were 18 years of age or older and had four ED visits within a one-year period (2018, 2019, or 2020) were classified as super-utilizers. We examined number and category of visits for the baseline period (January 2018 – March 2020), the governor's Stay at Home Order, and the subsequent Reopening Phases through December 31, 2020.ResultsThe number of visits by super utilizers decreased by over 16% when the Stay at Home Order was issued. The average number of visits per week rose from 1010.63 during the Stay at Home Order to 1198.09 after the Stay at Home Order was lifted, but they did not return to Pre-COVID levels of approximately 1400 visits per week in 2018 and 2019. When categories of visits were examined, this trend was found for emergent visits (p < 0.001) and visits related to injuries (p < 0.001). Non-emergent visits declined during the Stay at Home Order compared to the baseline period (p < 0.001), and did not increase significantly during reopening compared to the Stay at Home Order (p = 0.87). There were no changes in number of visits for psychiatric purposes, alcohol use, or drug use during the pandemic.ConclusionsSignificant declines in emergent visits raise concerns that individuals who needed ED treatment did not seek it due to COVID-19. However, the finding that super utilizers with non-emergent visits continued to visit the ED less after the Stay at Home Order was lifted raises questions for future research that may inform policy and interventions for inappropriate ED use.

Regulatory involvement of the PerR and SloR metalloregulators in the Streptococcus mutans oxidative stress response.

Streptococcus mutans is a commensal of the human oral microbiome that can promote dental caries under conditions of dysbiosis. This study investigates metalloregulators and their involvement in the S. mutans oxidative stress response. Oxidative stress in the human mouth can derive from temporal increases in reactive oxygen species (ROS) after meal consumption and from endogenous bacterial ROS-producers that colonize the dentition. We hypothesize that the S. mutans PerR (SMU.593) and SloR (SMU.186) metalloregulatory proteins contribute to the regulation of oxidative stress genes and their products. Expression assays with S. mutans UA159 wild type cultures exposed to H2O2 reveal that H2O2 upregulates perR, and that PerR represses sloR transcription upon binding directly to Fur and PerR consensus sequences within the sloR operator. In addition, the results of Western blot experiments implicate the Clp proteolytic system in SloR degradation under conditions of H2O2-stress. To reveal a potential role for SloR in the H2O2-resistant phenotype of S. mutans GMS802 (a perR-deficient strain), we generated a sloR/perR double knockout mutant, GMS1386, where we observed upregulation of the tpx and dpr antioxidant genes. These results are consistent with GMS802 H2O2 resistance and with a role for PerR as a transcriptional repressor. Cumulatively, these findings support a reciprocal relationship between PerR and SloR during the S. mutans oxidative stress response and begin to elucidate the fitness strategies that evolved to foster S. mutans persistence in the transient environments of the human oral cavity.IMPORTANCEIn 2020, untreated dental caries, especially in the permanent dentition, ranked among the most prevalent infectious diseases worldwide, disproportionately impacting individuals of low socioeconomic status. Untreated caries can lead to systemic health problems and has been associated with extended school and work absences, inappropriate use of emergency departments, and an inability for military forces to deploy. Together with public health policy, research aimed at alleviating S. mutans -induced tooth decay is important because it can improve oral health (and overall health), especially in underserved populations. This research, focused on S. mutans metalloregulatory proteins and their gene targets, is significant because it can promote virulence gene control in an important oral pathogen, and contribute to the development of an anti-caries therapeutic that can reduce tooth decay.

New Opportunities to Improve Mental Health Crisis Systems.

National, state, and local actors seem ready to address the long-neglected mental health crisis system in the United States. Elements of an organized system of crisis care are in place in some states, including regional or statewide call centers, mobile crisis teams, and crisis care facilities. These necessary advances are not sufficient to address the urgent problems of increasing suicide rates, the inappropriate use of emergency departments to hold people in psychiatric distress, and the problematic reliance on inadequately trained law enforcement who frequently respond to mental health crises. This article describes the immediate challenges and opportunities that can launch nationwide reform in systems of care for individuals in psychiatric crisis. Five action recommendations describe clear, feasible next steps that can be taken to move these systems forward and meaningfully improve access and quality of care for people in crisis. The recommendations include a central coordinating role for Congress, an increase in federal authorization and appropriation of funds, enactment of a 5% Mental Health Block Grant set-aside, expanded funding for research and evaluation, and the pursuit of additional payment mechanisms by states and counties.

Affordable Care Act did not reduce inappropriate use of emergency room services

Abstract Background The US Patient Protection and Affordable Care Act of 2010 (ACA) has several provisions to increase access to health insurance among Americans. Prior to ACA, emergency departments (ED) served as a safety net to uninsured as most hospitals are required to provide stabilizing treatment to patients with emergency medical conditions regardless of their ability to pay. The ACA increased the number of insured, improved access to primary care and was expected to reduce high cost ED utilization Methods This retrospective cross-sectional study used ED data from a US Midwest suburban medium size hospital (November 2009 - January 2017) to analyze the patterns of ER utilization pre- and post-ACA. The data (n = 423,548) excluded ambulance deliveries; 5-level Emergency Severity Index was re-coded as urgent/non-urgent for each visit. Analysis included age, sex, race, mode of arrival, disposition, insurance, visit day and time as other predictors in binary logistic regression. Results Non-urgent visit proportion increased from 34.5% in 2009 to 49.1% in 2016; odds of a visit being urgent are lower after ACA (Exp(B)=0.684; 95%CI 0.675,0.694) with stronger effect for pediatric (age&amp;lt;18) population (Exp(B)=0.487, CI 0.471, 0.503). ACA did not change ED utilization by working population, however, in comparison to people with commercial insurance, patients without recorded insurance are less likely to have a true urgent visit (Exp(B)=0.845; CI 0.83, 0.86). Among other factors predicting ED visit urgency are race and insurance type. Conclusions Expensive ER care is still provided for non-urgent care. Access to alternative type of care and public health awareness efforts should focus on subpopulations with high inappropriate ED use. Key messages Affordable Care Act (2010) did not improve efficiency of emergency room utilization. Additional effort are needed to increase access to primary care and awareness of ER use for specific subpopulations.

Rapid referral for headache management from emergency department to headache centre: four years data

BackgroundHeadache is one of the most common reason for medical consultation to emergency department (ED). The inappropriate use of ED for non-emergency conditions is a problem in terms of overcrowding of emergency facilities, unnecessary testing and treatment, increased medical costs, burden on medical service providers and weaker relationships between patient and primary care provider. The aim of this study was to analyze the different stages of ED management of headache to identify those deficiencies that can be overcome by a fast referral to a headache clinic.MethodsThe study is a retrospective analysis of the electronic medical records of patients discharged from an academic ED between January 1, 2015 and December 31, 2018 and referred to the tertiary level headache centre of the same hospital. We analyzed all aspects related to the permanence in ED and also assessed whether there was a match between the diagnosis made in ED and ours.ResultsAmong our sample of 244 patients, 76.2% were admitted as “green tag”, 75% underwent a head computed tomography, 19.3% received a neurological consultation, 43% did not receive any pharmacological treatment and 62.7% still had headache at discharge. The length of stay in ED was associated with reporting the first aura ever (p = 0.014) and whether patients received consultations (p < 0.001). The concordance analysis shown a significant moderate agreement only for the diagnosis of migraine and only between triage and headache centre.ConclusionsMost patients who went to ED complaining of headache received the same treatment regardless of their diagnosis and in many cases the headache had not yet resolved at the time of discharge. Given the many shortcomings in headache management in ED, rapid referral to the headache centre is of paramount importance to help the patient achieve a definiteve diagnosis and appropriate treatment.

Factors associated with inappropriate use of emergency departments: findings from a cross-sectional national study in France

BackgroundInappropriate visits to emergency departments (EDs) could represent from 20% to 40% of all visits. Inappropriate use is a burden on healthcare costs and increases the risk of ED overcrowding....

The Association of Nurse Practitioner Scope-of-Practice Laws With Emergency Department Use

Overuse and inappropriate use of emergency departments (EDs) remains an important issue in health policy. After implementation of Medicaid expansion, many states experienced an increase in ED use, but the magnitude varied. Differential access to primary care might explain such variation. To determine whether the increase in ED use among Medicaid enrollees following Medicaid expansion was smaller in states that allowed greater access to primary care providers by permitting nurse practitioners (NPs) to practice without physician oversight. Examining data on ED use by Medicaid beneficiaries, we estimated random effects models to examine changes in ED visits. Models for 8 different clinical conditions were estimated, with each model including a linear time trend, indicators for Medicaid expansion and for the absence of physician oversight requirements, and an interaction between these 2 indicators. States requiring physician oversight of NPs had a 28% increase in ED visits relative to the preexpansion period, while states allowing NP practice without physician oversight had only a 7% increase. The increase in the share of visits covered by Medicaid in no-oversight states was 40% of the size of the increase in oversight states. Allowing NPs to practice without physician oversight was associated with a reduction in the magnitude of increase in ED use following Medicaid expansion. States that restrict NP practice should weigh the costs of maintaining these restrictions against the potential benefits of lower ED use. States considering Medicaid expansion should also consider relaxing NP scope-of-practice laws.

Inappropriate use of the emergency department for nonurgent conditions: Patient characteristics and associated factors at a Japanese hospital.

BackgroundThe purpose of this study was to investigate the primary factors associated with inappropriate out‐of‐hours emergency department (ED) use by patients with nonurgent conditions.MethodsWe compared patients with nonurgent conditions who made inappropriate, out‐of‐hours ED visits to patients who visited an acute care hospital during daytime consultation hours between May 30 and October 16, 2014, in terms of patient characteristics and reasons for consultation. Our goal was to identify factors associated with inappropriate ED use, defined as an out‐of‐hours, nonurgent, and unnecessary visits.ResultsWe analyzed data from 84 patients who made inappropriate use of out‐of‐hours emergency care and 147 patients who sought care during regular consultation hours. In the inappropriate use group, “desire to be cured quickly” was the most common reason. Acute upper respiratory infection, acute gastroenteritis, and primary headache comprised 51.1% of diagnoses in the inappropriate use group. One factor associated with inappropriate use was two or more previous out‐of‐hours ED visits (odds ratio (OR) 3.19; 95% confidence interval (CI) 1.22‐8.31) (reference: 0 visits).ConclusionsPatients with two or more previous out‐of‐hours ED visits were more than three times as likely to inappropriately use the ED compared to patients who had not visited the ED at all in the past 3 years.

Interventions to improve emergency department use for mental health reasons: protocol for a mixed-methods systematic review

BackgroundHealthcare resources are limited and unnecessary, and inappropriate emergency department use is now a highly visible healthcare priority. Individuals visiting the emergency department for mental health-related reasons are often amongst the most frequent presenters. In response, researchers and clinicians have created interventions to streamline emergency department use and several primary studies describe the effects of these interventions. Yet, no consensus exists on the optimal approach, and information on the quality of development, effectiveness, acceptability, and economic considerations is hard to find. The purpose of this study is to systematically review interventions designed to improve appropriate use of the emergency department for mental health reasons.MethodA mixed-method systematic review using Joanna Briggs Methodology. Search combining electronic databases (EMBASE, MEDLINE, PsycINFO, CINAHL, HealthSTAR, PROQUEST, Cumulative Index to Nursing and Allied Health) and secondary searches (grey literature and hand search with consultation). Two independent reviewers will screen titles and abstracts using predetermined eligibility criteria and a third reviewer will resolve conflicts. Full texts will also be screened by two independent reviews and conflicts resolved in a consensus meeting with a third reviewer. A pilot-tested data extraction form will be used to retrieve data relevant to the study objectives. We will assess the quality and of all included studies. Data describing interventions will be summarized using logic models and reported narratively. Quality of development will be assessed using the Oxford Implementation Index. For data on intervention effectiveness, we will assess statistical heterogeneity and conduct a meta-analysis using a random effects method, if appropriate. For interventions that cannot be pooled, we will report outcomes narratively and descriptively. Qualitative data on acceptability will be synthesized using meta-aggregation and an economic evaluation of interventions will be done. The reporting of this protocol follows the PRISMA-P statement.DiscussionUsing a combined systematic review methodology and integrated knowledge translation plan, the project will provide decision makers with concrete evidence to support the implementation and evaluation of interventions to improve emergency department use for mental health reasons. These interventions reflect widespread priorities in the area of mental health care.Systematic review registrationPROSPERO CRD42018087430

Overestimation of health urgency as a cause for emergency services inappropriate use: Insights from an exploratory economics experiment in Portugal.

Increasing visits to emergency departments add strain to public healthcare systems. The misperception of symptoms' severity can partly explain inappropriate use of hospitals' emergency departments by non-urgent patients. This paper focuses on the misperception of symptoms' severity as a cause for the inappropriate use of emergency departments. It explores the role that informing potential patients of the correct severity level can play in correcting this inefficiency. We implement in an incentivised manner an exploratory economic experiment to elicit the degree of severity of five sets of symptoms, corresponding to frequent causes of emergency department visits. The study was setup in Braga, Northern Portugal, recruiting voluntary participants through civic local organisations. We ask participants to indicate the more suitable health service, before and after revealing the true degree of severity. Results show that there is an overestimation of the degree of severity of some clinical profiles, and when confronted with the real severity, in only half of the cases are choices changed to other health services. Although exploratory, this study provides insights into the potential role of health education policies concerning symptoms' severity but it also highlights the limits of such policies. Furthermore, the use of economic experiments can provide meaningful insights for the design of policies addressing demand-side healthcare inefficiencies.

Quality of Primary Care Provided to Medicare Beneficiaries by Nurse Practitioners and Physicians.

To examine differences in the quality of care provided by primary care nurse practitioners (PCNPs), primary care physicians (PCMDs), or both clinicians. Medicare part A and part B claims during 2012-2013. Retrospective cohort design using standard risk-adjustment methodologies and propensity score weighting assessing 16 claims-based quality measures grouped into 4 domains of primary care: chronic disease management, preventable hospitalizations, adverse outcomes, and cancer screening. Continuously enrolled aged, disabled, and dual eligible beneficiaries who received at least 25% of their primary care services from a random sample of PCMDs, PCNPs, or both clinicians. Beneficiaries attributed to PCNPs had lower hospital admissions, readmissions, inappropriate emergency department use, and low-value imaging for low back pain. Beneficiaries attributed to PCMDs were more likely than those attributed to PCNPs to receive chronic disease management and cancer screenings. Quality of care for beneficiaries jointly attributed to both clinicians generally scored in the middle of the PCNP and PCMD attributed beneficiaries with the exception of cancer screening. The quality of primary care varies by clinician type, with different strengths for PCNPs and PCMDs. These comparative advantages should be considered when determining how to organize primary care to Medicare beneficiaries.

LO65: Safety and satisfaction of a new program redirecting low-acuity emergency department patients to medical clinic: a prospective cohort study

Introduction: Overcrowding in emergency departments (EDs) is a constant problem. One of the major factors contributing to this situation is the inappropriate ED use by patients with low-acuity problems. In order to reduce overuse, EDs have developed agreements with clinics to reorient low-acuity ambulatory patients toward them. These agreements often leave the burden of decision on the triage personnel as to which patients can be safely redirected. The aim of this study was to evaluate the safety of redirecting patients to nearby medical clinics and to evaluate their satisfaction with this program. Methods: In the ED of a tertiary care facility, a computer-based algorithm allowing triage personnel to reorient patients presenting with one of 52 medical complaints, was implemented in 2016. Our prospective cohort study was composed of reorientation admissible ED patients between March 2017 and August 2017. Patient safety was evaluated with patient follow-up phone interviews one week after their visit to the ED to identify the number of patients who needed to return to a medical facility after their reorientation. Patient satisfaction with the reorientation program was evaluated during the same follow-ups. Results: Of the 980 reoriented patients interviewed, only 57 (5.9%; 95% confidence interval [CI] 4.57.5) had to unexpectedly go back to a health care facility. None of these returns were for severe complications. Over 84% of the reoriented patients were satisfied with their reorientation and 89% say they would use this program again. Having a transportation problem was most common reason mentioned by patients for refusing to be reoriented. Conclusion: Reorientation to medical clinics using a new computer-based algorithm was safe and no case of urgent return was seen during the 6-month study period. In addition, patients who were reoriented to medical clinics were satisfied by their treatment experience.

The ED use and non-urgent visits of elderly patients

ObjectiveTo evaluate the use of the emergency department (ED) by elderly patients, their non-urgent visits and the prevalence of main disease for ED visits. MethodsThis cross-sectional study was conducted on patients aged 65 years and over who visited the ED of a tertiary care university hospital in Turkey between January 2015 and January 2016 retrospectively. ResultsA total of 36,369 elderly patients who visited the ED were included in the study. The rate of ED visits by elderly patients was higher than their representation within the general population (p < 0.001). While the rate of elderly patients visiting polyclinics was 15.8%, the rate of elderly patients visiting the ED was 24.3% (p < 0.001). For both genders, the rates of ED visits for patients between 65 and 74 years old was higher than for other elderly age groups (p < 0.001). The prevalence of upper respiratory tract infection (URTI) was the highest within the elderly population (17.5%, CI: 17.1–17.9). The proportion of ED visits for non-urgent conditions was 23.4%. Most of the ED visits were during the non-business hours (51.1%), and they were highest in the winter season (25.9%) and in January (10.2%). The hospitalization rate was 9.4%, and 37.9% of hospitalized patients were admitted to intensive care units. ConclusionThe proportion of ED visits by elderly patients was higher than their representation within the general population. Elderly patients often visited the ED instead of a polyclinic. The rate of inappropriate ED use by elderly patients in this hospital was higher than in other countries.

Does the extension of primary care practice opening hours reduce the use of emergency services?

Overcrowding in emergency departments generates potential inefficiencies. Using regional administrative data, we investigate the impact that an increase in the accessibility of primary care has on emergency visits in Italy. We consider two measures of avoidable emergency visits recorded at list level for each General Practitioner. We test whether extending practices' opening hours to up to 12 hours/day reduces the inappropriate utilization of emergency services. Since subscribing to the extension program is voluntary, we account for the potential endogeneity of participation in a count model for emergency admissions in two ways: first, we use a two-stage residual inclusion approach. Then we exploit panel methods on data covering a three-year period, thus accounting directly for individual heterogeneity. Our results show that increasing primary care accessibility acts as a restraint on the inappropriate use of emergency departments. The estimated effect is in the range of a 10–15% reduction in inappropriate admissions.

Implementation of a hospital-integrated general practice--a successful way to reduce the burden of inappropriate emergency-department use.

Emergency departments (EDs) are overcrowded by lower acuity patients, which might be more efficiently treated by general practitioners (GPs). This study evaluated the impact of triaging lower acuity patients to a new hospital-integrated general practice (HGP) on ED case-load and the reasons for choosing the ED/HGP. Patients were consecutively assessed according to the emergency severity index (ESI) to triage lower acuity patients to the HGP. Consultation numbers at the emergency centre (ED and HGP) increased by 43% between 2007 (n = 16 974) and 2011 (n = 24 331) (implementation of HGP in 2009). Although self-referrals increased significantly at the emergency centre from 54% to 63% (p <0.001), the proportion of self-referrals at the ED was significantly reduced to 48% (p = 0.007). The HGP was able to reduce the burden of increasing total consultations by 36%; 4.6% were referred back to the ED after triaging to the HGP. Overall, 95% of HGP patients were self-referred, Swiss nationals (65%) and with a personal GP (82%) they attended regularly (69%). The most common reason for presenting at the emergency centre was not being able to reach the GP (60%). Diagnoses were injury- (29%) and infection- (23%) related problems affecting the musculoskeletal (27%) system and skin (21%). The HGP succeeded in reducing the burden of inappropriate ED use: the majority of low acuity self-referred patients were conclusively treated at the HGP. The HGP does not represent competition to the GP out-of-hours care service, since the main reason for presenting at the hospital was not lacking a relationship but the GPs' inaccessibility.