Increase In Emergency Department Visits Research Articles

High temperatures and emergency department visits in 18 sites with different climatic characteristics in China: Risk assessment and attributable fraction identification

BackgroundHealth impacts of high temperatures on hospital emergency department visits (EDVs) have been less reported, especially from developing countries. ObjectivesTo investigate high temperature–EDVs relationship in various regions with different climatic characteristics, to explore the regional differences, to identify vulnerable populations, and to provide scientific evidence for climate change adaptation strategies in China. MethodsDaily data on weather, air pollution and EDVs were collected from 18 sites in China from June to August during 2014–2017. A quasi–Poisson generalized additive regression model was applied to examine the high temperature–EDVs relationship in each site. Site–specific risks of EDVs were pooled using a random effect meta–analysis model. Stratified analyses were performed by gender, age–groups, cause–specific EDVs and regions. Attributable fractions of EDVs due to high temperatures were calculated in different regions. Results1 °C increase in daily mean temperature was associated with 1.07% (95% CI, 0.46–1.67%) increase in EDVs across all study regions. The negative health effects from high temperatures were worse for the people living in southern China, in subtropical monsoon climate zone or in counties, with percentage change of 1.96% (95% CI, 0.92–3.02%), 1.35% (95% CI, 0.95–1.76%) and 1.41% (95% CI, 0.48–2.34%), respectively. People under 18 were more vulnerable to high temperatures. Exposure to high temperatures increased EDVs risks from endocrine, respiratory, and digestive diseases and injury. The attributable fraction due to high temperatures was 8.64% for overall EDVs, 11.70% for the people living in southern China, 10.80% for people living in subtropical monsoon climate zone and 12.65% for the county population. ConclusionsExposure to high temperatures resulted in extra burden to China’s already overloaded hospital emergency departments. More resources are needed to meet increasing demands and effective preventative measurements are warranted to tackle such a challenge. Further studies should pay more attention to both heat and cold-related EDVs risks and socioeconomic cost for better climate change adaptation.

P036 Socioeconomic Disparities in IBD: Outcomes in Emergency Department Utilization and Outpatient Follow-Up

BACKGROUND: The association of socioeconomic status, emergency department (ED) utilization, and access to outpatient gastroenterology care in inflammatory bowel disease (IBD) remains underexplored. We sought to identify associations between overall socioeconomic deprivation and these outcomes in IBD patients. METHODS: Our historical cohort included 743 unique IBD patients with a total of 6,036 all-cause ED visits during a 51-month period (January 1, 2015 to April 1, 2019). Detailed demographic variables were recorded for all subjects. Zip codes were used to approximate the level of socioeconomic deprivation via the Area Deprivation Index (ADI), a comprehensive score developed at the University of Wisconsin based on a composite score including 17 different factors related to income, education, employment, and housing quality (1). ADI scores of these IBD patients were divided into quartiles (quartile 4 = most deprived) and then compared with outcomes, including average number of ED visits, average hours spent in ED per visit, acuity level of ED visits (by Emergency Severity Index levels 1–5, with level 1 = highest acuity), admission rates, total outpatient GI visits and IBD-specialist visits, percent attending any outpatient GI visit or IBD specialist visit, and initiation of any outpatient steroid-sparing therapies. Univariate comparisons were performed using analysis of variance (ANOVA) for continuous variables and chi-square tests for categorical variables. Statistical significance was set at P < 0.05. RESULTS: 743 IBD patients (60% female, age 48 ± 18 yrs, 446 with Crohn's disease (CD), 297 with ulcerative colitis (UC)) were evaluated. Basic demographics were similar overall, with significant differences noted in race (P < 0.001) and insurance coverage (P < 0.001). Increased ED visits were noted with increased ADI in IBD patients overall (P = 0.003) as well as in the subgroup with CD (P = 0.040). Patients with increased ADI averaged fewer hours in the ED (P = 0.043), although they presented with significantly higher acuity (P = 0.007). There was a trend towards decreased GI clinic visits with increased ADI, but this did not reach statistical significance (p = 0.055). There was a significant difference between ADI quartiles in terms of those who successfully attended at least one GI clinic follow-up visit for all IBD patients (P = 0.007) and specifically for those with CD (P = 0.012). Patients with increased ADI attended fewer IBD-specific clinic follow up (P = 0.044). Significant differences regarding access to outpatient steroid-sparing therapy were seen across ADI quartiles (P = 0.044). CONCLUSION(S): Our study demonstrates increased ED utilization and decreased access to outpatient gastroenterology and IBD specialty care in IBD patients with lower socioeconomic status. Limitations include minor differences in baseline demographics including race and insurance coverage, although confounding was minimized by utilization of a comprehensive assessment of socioeconomic status through the ADI model. Our findings highlight the need for better access to outpatient IBD care in more economically deprived areas, and community health intervention programs to improve awareness of specialty care.

206 – Increased Emergency Department Visits and Hospitalizations for Infectious Diseases in Patients with Elderly-Onset Inflammatory Bowel Disease: A Population-Based Matched Cohort Study

206 – Increased Emergency Department Visits and Hospitalizations for Infectious Diseases in Patients with Elderly-Onset Inflammatory Bowel Disease: A Population-Based Matched Cohort Study

An Examination of Factors Affecting Quality of Life for Children With Asthma and Their Caregivers in Southeastern Georgia

IntroductionDespite effective treatments and interventions, asthma continues to affect children's health-related quality of life (QOL). This study explored factors affecting QOL of children with asthma and their caregivers. MethodsA mixed-model design was used. Children (7–17 years) completed the Paediatric Asthma Quality of Life Questionnaire, and parents/caregivers completed the Paediatric Asthma Caregiver's Quality of Life Questionnaire. These surveys focused on activity limitations, emotional function, and child symptoms. ResultsThe sample included 104 children and 104 caregivers. Analysis showed emergency department (ED) visits as a significant predictor of QOL for children in the domains of Physical Activity, Emotional, and Symptoms. Increased ED visits and reliever medication use predicted lower emotional QOL and physical QOL for parents, whereas increased use of controller medications predicated improved physical QOL. DiscussionFactors contributing to QOL, along with characteristics of those with the lowest QOL indicators, have been determined. Identification of interventions to reduce ED visits warrants further investigation.

Characteristics and Costs of Pediatric Emergency Department Visits for Sports- and Recreation-Related Concussions, 2006-2014.

Although concussion-related emergency department (ED) visits increased after the passage of concussion laws, little is known about how the laws may disproportionately impact ED utilization and associated health care costs among children in different demographic groups. Our aim was to examine the patient and clinical characteristics of pediatric ED visits and associated health care costs for sports- and recreation-related concussions (SRRCs) before and after concussion law enactment. We retrospectively analyzed ED visits for SRRCs by children ages 5-18years between 2006 and 2014 in the Pediatric Health Information System database (n=123,220). ED visits were categorized as "pre-law," "immediate post-law," and "post-law" according to the respective state concussion law's effective date. Multinomial logistic regression models were used to assess the impact of the law on ED utilization. The majority of visits were by males (n=83,208; 67.6%), children aged 10-14years (n=49,863; 40.9%), and privately insured patients (n=62,376; 50.6%). Female sex, older age, and insured by Medicaid/Medicare were characteristics associated with increased ED visits during the immediate post-law and post-law periods compared to their counterparts. A significant decrease in proportion of imaging use was observed from pre-law to post-law (adjusted odds ratio 0.49; 95% confidence interval 0.47-0.50; p<0.0001). While annual adjusted costs per ED visits decreased, annual total adjusted costs per hospital for SRRCs increased from pre-law to post-law (p<0.0001). Concussion laws might have impacted pediatric concussion-related ED utilization, with increased annual total adjusted costs. These results may have important implications for policy interventions and their effects on health care systems.

3247 Implementing an Interdisciplinary, Student-Run Consult Service for Homeless Patients: The Critical Role of Community Partnerships

OBJECTIVES/SPECIFIC AIMS: Elucidate the unique challenges associated with hospital discharge planning for patients experiencing homelessness. Assess the impact of robust community partnerships and strong referral pathways on participating patients’ health care utilization patterns in an interdisciplinary, student-run hospital consult service for patients experiencing homelessness. Identify factors (both patient-level and intervention-level) that are associated with successful warm hand-offs to outside social agencies at discharge. METHODS/STUDY POPULATION: To assess the impact of participation in HHL on patients’ health care utilization, we conducted a medical records review using the hospital’s electronic medical record system comparing patients’ health care utilization patterns during the nine months pre- and post- HHL intervention. Utilization metrics included number of ED visits and hospital admissions, number of hospital days, 30-day hospital readmissions, total hospital costs, and follow-up appointment attendance rates, as well as percentage of warm hand-offs to community-based organizations upon discharge. Additionally, we collected data regarding patient demographics, duration of homelessness, and characteristics of homelessness (primarily sheltered versus primarily unsheltered, street homeless versus couch surfing, etc) and intervention outcome data (i.e. percentage of warm hand-offs). This study was reviewed and approved by the Tulane University Institutional Review Board and the University Medical Center Research Review Committee. RESULTS/ANTICIPATED RESULTS: For the first 41 patients who have been enrolled in HHL, participation in HHL is associated with a statistically significant decrease in hospital admissions by 49.4% (p &lt; 0.01) and hospital days by 47.7% (p &lt; 0.01). However, the intervention is associated with a slight, although not statistically significant, increase in emergency department visits. Additionally, we have successfully accomplished warm hand-offs at discharge for 71% percent of these patients. Over the next year, many more patients will be enrolled in HHL, which will permit a more finely grained assessment to determine which aspects of the HHL intervention are most successful in facilitating warm hand-offs and decreased health care utilization amongst patients experiencing homelessness. DISCUSSION/SIGNIFICANCE OF IMPACT: Providing care to patients experiencing homelessness involves working within complex social problems that cannot be adequately addressed in a hospital setting. This is best accomplished with an interdisciplinary team that extends the care continuum beyond hospital walls. The HHL program coordinators believe that ED visits amongst HHL patients and percentage of warm hand-offs are closely related outcomes. If we are able to facilitate a higher percentage of warm hand-offs to supportive social service agencies, we may be able to decrease patient reliance on the emergency department as a source of health care, meals, and warmth. Identifying the factors associated with successful warm hand-offs upon discharge from the hospital may assist us in building on the HHL program’s initial successes to further decrease health care utilization while offering increased interdisciplinary educational opportunities for medical students.

Neurological illnesses associated with Florida red tide (Karenia brevis) blooms

Human respiratory and gastrointestinal illnesses can result from exposures to brevetoxins originating from coastal Florida red tide blooms, comprising the marine alga Karenia brevis (K. brevis). Only limited research on the extent of human health risks and illness costs due to K. brevis blooms has been undertaken to date. Because brevetoxins are known neurotoxins that are able to cross the blood-brain barrier, it is possible that exposure to brevetoxins may be associated with neurological illnesses. This study explored whether K. brevis blooms may be associated with increases in the numbers of emergency department visits for neurological illness. An exposure-response framework was applied to test the effects of K. brevis blooms on human health, using secondary data from diverse sources. After controlling for resident population, seasonal and annual effects, significant increases in emergency department visits were found specifically for headache (ICD-9 784.0) as a primary diagnosis during proximate coastal K. brevis blooms. In particular, an increased risk for older residents (≥55 years) was identified in the coastal communities of six southwest Florida counties during K. brevis bloom events. The incidence of headache associated with K. brevis blooms showed a small but increasing association with K. brevis cell densities. Rough estimates of the costs of this illness were developed for hypothetical bloom occurrences.

All Medicaid Expansions Are Not Created Equal: The Geography and Targeting of the Affordable Care Act

We use comprehensive patient-level discharge data to study the effect of Medicaid on the use of hospital services. Our analysis relies on cross-state variation in the Affordable Care Act’s Medicaid expansion, along with within-state variation across ZIP Codes in exposure to the expansion. We find that the Medicaid expansion increased Medicaid visits and decreased uninsured visits. The net effect is positive for all visits, suggesting that those who gain coverage through Medicaid consume more hospital services than they would if they remained uninsured. The increase in emergency department visits is largely accounted for by “deferrable” medical conditions. Those who gained coverage under the Medicaid expansion appear to be those who had relatively high need for hospital services, suggesting that the expansion was well targeted. Lastly, we find significant heterogeneity across Medicaid-expansion states in the effects of the expansion, with some states experiencing a large increase in total utilization and other states experiencing little change. Increases in hospital utilization were larger in Medicaid-expansion states that had more residents gaining coverage and lower pre-expansion levels of hospital uncompensated care costs.

Decreased Temperature Associated with Increased ED Visits By Patients with Sickle Cell Disease

Introduction: Sickle cell disease (SCD) is a genetic disorder diagnosed at birth, characterized by repeated acute complications leading to significant morbidity and mortality. Patients subjectively state extreme temperatures trigger sickle cell complications such as vaso-occlusive crisis (VOC) and acute chest syndrome (ACS), leading previous studies to examine the relationship between environmental factors and rates of acute SCD complications with mixed results. Dessap et al. found a correlation between SCD admissions and daily temperature change but not mean daily temperature, whereas Nolan et al. found only windspeed to have a significant correlation. We hypothesized an association exists between temperature, windspeed, and humidity and ED visits for VOC and ACS.Methods: We designed a retrospective observational study utilizing the Chicago Sickle Cell Disease Research Group clinical registry of patients with SCD (HbSC, HbSB0, HbSB+, or HbSS) seen in the emergency department (ED) from May 1, 2014 to May 31, 2016 at two pediatric hospitals in Chicago, Illinois. Encounters were included if a final diagnosis of VOC or ACS was recorded based on ICD-9 or ICD-10 codes. Weather data were obtained through the University of Chicago's Center for Data Intensive Science using data from the Environmental Data Commons, collected at Midway Airport. We used Spearman's rank correlation coefficient with n-2 degrees of freedom for correlations between frequency of ED encounters and daily weather conditions including mean temperature, relative humidity, and maximum windspeed. Encounter rates by weather marker were calculated using the number of encounters by unique individuals divided by the total number of days. Our analysis included encounters by unique individuals as multiple encounters from the same subject within a defined weather marker are likely to be correlated and can introduce bias.Results: During the 2 year study period there were 139 unique individuals, ranging in age from 10 months to 23 years, with SCD (72.7% Hgb SS, 16.5% Hgb SC, and 10.8% Hgb Sβ+/0). There were a total of 618 ED encounters with a qualifying final diagnosis. Mean daily temperature ranged from 0.4 - 84.8 degrees Fahrenheit, maximum daily windspeed ranged from 6.9 - 42.5 miles per hour, and daily relative humidity ranged from 17.1% - 90.2%. In our analysis, there was a correlation between lower mean daily temperature and increased number of ED encounters for VOC (ρ= -0.791, p<0.001) and for total ED encounters, which included both VOC and ACS (ρ= -0.757, p<0.001). A similar correlation was not seen in the analysis for relative humidity (ρ= 0.252, p=0.43) or for maximum windspeed (ρ= 0.318, p=0.23).Conclusion: Our study demonstrates a correlation between lower mean daily temperature and increased number of ED visits for SCD complications when examining encounters by unique individuals. There was no significant correlation found for daily windspeed or daily humidity. Prior studies of temperature effects on SCD in France, Brazil and various sites in the United States have shown mixed results, with several showing no correlation. Our findings of low temperatures correlating with increased ED visits could be due to our location having a wider range of temperatures when compared with prior studies. This finding could significantly impact the advice given to patients in areas with periods of prolonged low temperatures as this could increase the rate of ED visits. In Chicago, our study conclusions could be utilized to make policy recommendations on school attendance and accommodations when the temperatures decrease during the frigid winter months, allowing for improved access to homebound instruction for patients with SCD.Future directions include evaluating pertinent clinical markers such as hemoglobin change from baseline, hydroxyurea use at presentation, and ED disposition, which may show that weather change affects some children with SCD more severely than others. We believe continued investigation is warranted to attempt to more accurately characterize the effects of weather change on clinical outcomes of the pediatric sickle cell population. DisclosuresNo relevant conflicts of interest to declare.

Temporal analysis of determinants for respiratory emergency department visits in a large German hospital

IntroductionAssociations between air pollutants, meteorological conditions and respiratory diseases have been extensively shown. The aim of this study was to investigate associations between daily meteorological data, data on air pollution...

Factors Associated With Emergency Department Use by Patients With and Without Mental Health Diagnoses

An association between frequent use of the emergency department (ED) and mental health diagnoses is frequently documented in the literature, but little has been done to more thoroughly understand why mental illness is associated with increased ED use. To determine which factors were associated with higher ED use in the near future among patients with and without mental health diagnoses. A retrospective case-control study of all patients presenting to the ED in California in 2013 using past ED data to predict future ED use. Data from January 1, 2012, through December 31, 2014, from California's Office of Statewide Health Planning and Development were analyzed. Factors associated with higher ED use in the year following an index visit for patients with vs without a mental health diagnosis. Among the 3 446 338 individuals in the study (accounting for 7 678 706 ED visits), 44.6% (1 537 067) were male; 31.6% (1 089 043) were between the ages of 18 and 30 years, 40.3% (1 338 874) were between the ages of 31 and 50 years, and 28.1% (968 421) were between the ages of 51 and 64 years. The mean (SD) number of ED visits per patient per year was 1.69 (2.56), and 29.1% of patients (1 002 884) had at least 1 mental health diagnosis. Previous hospitalization and high rates of lagged ED visits were associated with higher future ED use. The severity of the mental health diagnosis (mild, moderate, or severe) was associated with increased ED visits (incidence rate ratio [IRR], 1.029; 95% CI, 1.02-1.04 for mild; IRR, 1.121; 95% CI, 1.11-1.13 for moderate; and IRR, 1.226; 95% CI, 1.22-1.24 for severe). Little evidence was found for interaction effects between mental health diagnoses and other diagnoses in predicting increased future ED use. Certain classes of mental health diagnoses were associated with higher ED use. The presence of a mental illness diagnosis did not appear to interact with other patient-level factors in a way that meaningfully altered associations with future ED use.

Decreased Admission Rate From the Emergency Department With Increased Emergency Department Visits—The Good and the Bad

Decreased Admission Rate From the Emergency Department With Increased Emergency Department Visits—The Good and the Bad

Differential effects of size-specific particulate matter on emergency department visits for respiratory and cardiovascular diseases in Guangzhou, China

BackgroundStudies differentiating the cardiorespiratory morbidity effects of PM2.5, PM10, and PM2.5∼10 (i.e. coarse PM or PMc) are still limited and inconsistent. ObjectiveTo estimate the acute, cumulative, and harvesting effects of exposure to the three size-specific PM on cardiorespiratory morbidity, and their concentration-response relations. MethodsA total of 6,727,439 emergency department (ED) visits were collected from 16 public teaching hospitals in Guangzhou, from January 1st 2012 to December 31st 2015, among which over 2.1 million were asthma, COPD, pneumonia, respiratory tract infection (RTI), hypertension, stroke, and coronary heart disease (CHD). Distributed lag non-linear models (DLNM) was used to estimate the associations between the three size-specific PM and ED visits for the cardiovascular diseases. Long-term trends, seasonality, influenza epidemics, meteorological factors, and other gas pollutants, including SO2, NO2, and O3, were adjusted. We stratified the analyses by gender and age. ResultsElevated PM2.5 and PM10 were significantly associated with increased ED visits for pneumonia, RTI, and CHD at both lag0 and lag0-3. A 10 μg/m3 increment of PMc (at lag0-14) was estimated to increase ED visits for pneumonia by 6.32% (95% CI, 4.19, 8.49) and for RTI by 4.72% (95% CI, 3.81, 5.63), respectively. PMc showed stronger cumulative effects on asthma in children than elderly. We observed significant harvesting effects (i.e. morbidity displacements) of the three size-specific PM on respiratory but very little on cardiovascular ED visits. The concentration-response curves suggested non-linear relations between exposures to the three different sizes of PM and respiratory morbidity. ConclusionsOverall, the three size-specific PM demonstrated distinct acute and cumulative effects on the cardiorespiratory diseases. PM2.5 and PMc would have significant effects on pneumonia and RTI. Strategies should be considered to further reduce levels of ambient PM2.5 and PMc.

Constipation in Children with Autism Spectrum Disorder Associated with Increased Emergency Department Visits and Inpatient Admissions

To evaluate whether constipation in children with autism spectrum disorder (ASD) is associated with increased emergency department (ED) visits and inpatient admissions compared with constipation in children without ASD. The Nationwide Emergency Department Sample was used to retrospectively examine demographic data, clinical characteristics, and outcomes of children with ASD and children without ASD who visited the ED for constipation between 2006 and 2014. ED visits by children with ASD were more likely to be constipation-related compared with visits by children with other chronic conditions or children with no chronic conditions (1.9% vs 0.6% vs 0.9%; P < .001). Children with ASD were more likely than children with other chronic conditions or no chronic conditions to be admitted to the hospital after an ED visit for constipation (15.0% vs 10.6% vs 1.2%; P < .001). Hospital charges were higher in children with ASD than in those without chronic conditions. Constipation is responsible for a large proportion of ED visits and more inpatient admissions resulting from these ED visits. These findings suggest a need for developing more effective outpatient therapies for constipation in children with ASD.

Trends in Preventable Inpatient and Emergency Department Utilization in California Between 2012 and 2015: The Role of Health Insurance Coverage and Primary Care Supply.

Expansions of health insurance coverage tend to increase hospital emergency department (ED) utilization and inpatient admissions. However, provisions in the Affordable Care Act that expanded primary care supply were intended in part to offset the potential for increased hospital utilization. To examine the association between health insurance coverage, primary care supply, and ED and inpatient utilization, and to assess how both factors contributed to trends in utilization in California between 2012 and 2015. Population-based measures of ED and inpatient utilization, insurance coverage, and primary care supply were constructed for California counties for the years 2012 through 2015. Fixed effects regression analysis is used to examine the association between health insurance coverage, primary care supply, and rates of preventable ED and inpatient utilization. Higher levels of Medicaid coverage in a county are associated with higher levels of preventable ED and inpatient utilization, although greater numbers of primary care practitioners and Federally Qualified Health Centers reduce this type of utilization. Increases in coverage accelerated a long-term increase in ED visits and prevented an even larger decrease in inpatient admissions, but changes in coverage do not fully explain these underlying trends. Increases in primary care supply offset the effects of coverage changes only modestly. Policymakers should not overstate the impact of the Affordable Care Act on increasing ED visits, and should focus on better understanding the underlying factors that are driving the trends.

Narcotics and Knee Arthroscopy: Trends in Use and Factors Associated With Prolonged Use and Postoperative Complications

To (1) examine trends in the prevalence of preoperative and prolonged postoperative narcotic use in patients undergoing knee arthroscopy, (2) characterize factors associated with prolonged narcotic use after knee arthroscopy, and (3) explore the association of preoperative and prolonged postoperative narcotic use with complications after knee arthroscopy. The PearlDiver database was reviewed for patients who underwent knee arthroscopy from 2007 to 2015 with a minimum of 6months' follow up. Patients with preoperative or prolonged postoperative narcotic use were identified and analyzed for trends. Predictors for prolonged postoperative use were identified, and regression analysis was used to calculate odds ratios (ORs) and 95% confidence intervals (CIs). A total of 75,372 patients were included, of which 23.9% used narcotics preoperatively and 22.6% used narcotics for a prolonged period postoperatively. There was no statistically significant trend on a year-to-year basis in preoperative (P= .744) or prolonged postoperative (P= .304) narcotic use. The most significant predictor for prolonged postoperative use was preoperative use (OR 5.33, CI 5.11-5.56, P<.0001), with the odds increasing as the number of preoperative prescriptions increased. Preoperative narcotic use was associated with increased emergency department visits (OR 1.25, CI 1.15-1.36, P < .0001), hospital admission (OR 1.15, CI 1.00-1.33, P= .046), and infection (OR 1.31, CI 1.07-1.59, P= .007). Prolonged postoperative narcotic use was associated with subsequent ipsilateral knee arthroscopy (OR 1.64, CI 1.45-1.86, P < .0001) as well as subsequent knee arthroplasty (OR 1.98, CI 1.83-2.14, P < .0001). The results of this study did not show a trend in the use of narcotics, preoperatively or on a prolonged basis postoperatively, during the study period. The degree of preoperative narcotic use is correlated with prolonged narcotic use. The use of narcotics preoperatively and for a prolonged period postoperatively is associated with increased complications. Level IV, case series, therapeutic.

Role of the general practitioner in improving rural healthcare access: a case from Nepal

BackgroundThere is a global health workforce shortage, which is considered critical in Nepal, a low-income country with a predominantly rural population. General practitioners (GPs) may play a key role improving access to essential health services in rural Nepal, though they are currently underrepresented at the district hospital level. The objective of this paper is to describe how GPs are adding value in rural Nepal by exploring clinical, leadership, and educational roles currently performed in a rural district-level hospital.Case presentationWe perform a descriptive case study of clinical and non-clinical services offered at Bayalpata Hospital prior to and following the initiation of GP-level services in 2013. Bayalpata is a district-level public hospital managed through a public private partnership by the nonprofit healthcare organization Possible. We found that after general practitioners were hired, additional clinical services included continuous emergency obstetric care, major orthopedic surgeries, appendectomy, tubal ligation, and vasectomy. This time period was associated with increased emergency department visits, inpatient admissions, and institutional birth rate in the hospital’s catchment area. Non-clinical contributions included the development of a continuing medical education curriculum and implementation of a series of quality improvement initiatives.ConclusionsGPs have potential to bring significant value to rural district hospitals in Nepal. Clinical impact may include expanded access to surgical and emergency obstetric services, which would more fully align with local health needs, and could further reduce Nepal’s maternal mortality rate. Task-shifting and structured training programs would be required to increase orthopedic surgery capacity, but this would contribute to meeting local healthcare needs. Non-clinical impact may include supervision of health workers and leadership in continuing medical education and quality improvement initiatives. These changes can lead to improved health worker recruitment and retention in rural posts. Limitations include generalizability of our results to other district hospitals in Nepal and lack of data from control hospitals. This analysis provides an additional perspective on the potential value GPs can add in rural Nepal, through provision of a wide range of clinical and non-clinical services. It supports the expansion of GPs to additional district hospitals in Nepal’s public sector.

Medicaid and Moral Hazard: Covering Emergency Department Visits Increases Emergency Department Visits…or Not?: Answers to the November 2017 Journal Club Questions

Medicaid and Moral Hazard: Covering Emergency Department Visits Increases Emergency Department Visits…or Not?: Answers to the November 2017 Journal Club Questions

Increasing Emergency Department Visits for Anaphylaxis, 2005-2014

MS Motosue, G Bellolio, HK Van Houten, ND Shah, RL Campbell. J Allergy Clin Immunol Pract. 2017;5(1):171–175 To identify trends regarding anaphylaxis-related emergency department (ED) visits from 2005 to 2014. Population data were drawn from OptumLabs Data Warehouse, a national administrative claims database of >100 000 000 pediatric and adult patients in the United States (including those with Medicare Advantage and private insurance) and with a higher representation from the Midwest and the South. ED visits between 2005 and 2014 were included if patients had medical insurance for at least 30 days before the visit. International Classification of Diseases, Ninth Revision, …

Medicaid and Moral Hazard: Covering Emergency Department Visits Increases Emergency Department Visits…or Not?: November 2017 Annals of Emergency Medicine Journal Club

Medicaid and Moral Hazard: Covering Emergency Department Visits Increases Emergency Department Visits…or Not?: November 2017 Annals of Emergency Medicine Journal Club