Reduce Emergency Department Visits Research Articles

Emergency department visits by nursing home residents. A retrospective Italian study of administrative databases from 2015 to 2019

BackgroundVisits to Emergency Departments (ED) can be traumatic for Nursing Home (NH) residents. In Italy, the rate of ED visits by NH residents was recently calculated as 3.3%. The reduction of inappropriate ED visits represents a priority for National Healthcare Systems worldwide. Nevertheless, research on factors associated with ED visits is still under-studied in the Italian setting. This study has two main aims: (i) to describe the baseline characteristics of NH residents visiting ED at regional level; (ii) to assess the characteristics, trends, and factors associated with these visits.MethodsA retrospective study of administrative data for five years was performed in the Piedmont Region. Data from 24,208 NH residents were analysed. Data were obtained by merging two ministerial databases of residential care and ED use. Sociodemographic and clinical characteristics of the residents, trends, and rates of ED visits were collected. A Generalized Linear Model (GLM) regression was used to evaluate the factors associated with ED visits.ResultsIn 5 years, 12,672 residents made 24,609 ED visits. Aspecific symptoms (45%), dyspnea (17%) and trauma (16%) were the most frequent problems reported at ED. 51% of these visits were coded as non-critical, and 58% were discharged to the NH. The regression analysis showed an increased risk of ED visits for men (OR = 1.61, 95% CI 1.51–1.70) and for residents with a stay in NH longer than 400 days (OR = 2.19, 95% CI 2.08–2.31).ConclusionsOur study indicates that more than half of NH residents’ ED visits could potentially be prevented by treating residents in NH. Investments in the creation of a structured and effective network within primary care services, promoting the use of health technology and palliative care approaches, could reduce ED visits and help clinicians manage residents on-site and remotely.

Hospital usage for oral and dental conditions in Hawaii: A cross-sectional study using the 2021 Hawaii statewide hospital data.

To investigate the frequency of emergency department (ED) usage primarily for oral/dental conditions in Hawaii and to examine social-demographic factors associated with the identified ED visits. This was a cross-sectional study of the 2021 Hawaii Statewide Hospital data. We identified records indicating ED usage and a primary diagnosis of non-traumatic dental conditions (NTDC) and other oral dental conditions (OODC). Descriptive analyses of ED visits for NTDC and OODC were performed to identify vulnerable individuals based on age, sex, race/ethnicity, primary source of payment, county of residence, and total charges per hospital record. A multivariable negative binomial regression model included age, sex, and county of residence was used to obtain adjusted rate ratios (aRR) and 95% confidence intervals (CI) of ED visits for NTDC. Among hospital records with diagnoses for oral or dental conditions (n = 12,336), 97% indicated ED, of which half had an NTDC diagnosis, and the remaining half had an OODC diagnosis. Distinct differences in the characteristics of ED visits were observed between NTDC and OODC. The median total charges per record indicating ED for NTDC and OODC were $1439 and $2439, respectively. A higher rate of ED visits for NTDC was found for those aged 21-44 (aRR [95%CI] = 3.02 [2.41, 3.80], reference: 0-9 years) and those living in a less populous county (Hawaii: 1.73 [1.43, 2.07]; Kauai: 1.78 [1.45, 2.19], reference: Honolulu). Continued effort to improve dental health is required to reduce ED visits for oral and dental conditions among Hawaii residents, especially for vulnerable individuals.

Caring for caregivers and persons living with dementia under home-based primary care: protocol for an interventional clinical trial

BackgroundApproximately 7.5 million older adults are homebound, who have difficulty and/or need assistance to leave their homes. In this growing population, the prevalence of people living with dementia (PLWD) is approximately 50%. Current dementia care models in the USA were developed for traditional office-based primary care and have not been tailored to home-based primary care (HBPC) delivery models. Literature has shown that office-based collaborative interventions can improve caregiver outcomes including caregiver stress, well-being, and morbidity and patient outcomes including improved quality of life and reduced emergency department visits (Possin KL, Merrilees JJ, Dulaney S, Bonasera SJ, Chiong W, Lee K, JAMA Int Med 179:1658, 2019). To date, the evidence for HBPC dementia interventions is lacking. Though HBPC has demonstrated benefit in homebound older adults, there is limited literature on the effects of HBPC on persons living with dementia (Nguyen HQ, Vallejo JD, Macias M, Shiffman MG, Rosen R, Mowry V, J Am Geriatr Soc 70:1136–46, 2021). Our goal is to develop a HBPC-focused dementia care intervention that integrates the components of two previously developed dementia care models and test the feasibility of implementing it in HBPC practices to improve the quality of life and wellbeing of homebound PLWD and their caregivers.MethodsWe will first conduct qualitative focus groups at two HBPC practice sites, one in the Southeast and one in Hawaii in order to obtain preliminary feedback on the proposed intervention. At each site, there will be one focus group with caregivers of PLWD and another with HBPC clinicians and staff to help develop and refine our intervention. We will then conduct an open-pilot trial of the refined intervention at the two HBPC practices. A total of up to 25 patient/caregiver dyads will be recruited at each site (N = 50 total). Outcomes measured through pre-and-post assessments and exit interviews will include (a) feasibility for the caregiver to engage with and complete baseline assessments and access educational materials and community resources and (b) feasibility for the practice to identify potential caregivers/patients, assess eligible patient/caregiver dyads, use patient and caregiver assessments, recruit patient/caregiver dyads, recruit racial and ethnic minorities, use care modules, and engage with the tele-video case conference, (c) net promoter score, (d) acceptability of the intervention to caregivers and patients to participate in the intervention, (e) caregivers feeling heard and understood, and (f) caregiver well-being.DiscussionTesting the feasibility and acceptability of the adapted intervention in these two HBPC practices will provide the basis for future testing and evaluation of a fully powered intervention for PLWD and their caregivers cared for in HBPC with the goal of disseminating high-quality and comprehensive dementia-care focused interventions into HBPC practices.Trial registrationThis trial was registered with ClinicalTrials.gov NCT05849259 in May 2023.

Cumulative Update of a Systematic Overview Evaluating Interventions Addressing Polypharmacy

Polypharmacy is associated with mortality, falls, hospitalizations, and functional and cognitive decline. The study of polypharmacy-related interventions has increased substantially, prompting the need for an updated, more focused systematic overview. To systematically evaluate and summarize evidence across multiple systematic reviews (SRs) examining interventions addressing polypharmacy. A search was conducted of MEDLINE, the Cochrane Database of Systematic Reviews, and the Database of Abstracts of Reviews of Effects for articles published from January 2017-October 2022, as well as those identified in a previous overview (January 2004-February 2017). Systematic reviews were included regardless of study design, setting, or outcome. The evidence was summarized by 4 categories: (1) medication-related process outcomes (eg, potentially inappropriate medication [PIM] and potential prescribing omission reductions), (2) clinical and functional outcomes, (3) health care use and economic outcomes, and (4) acceptability of the intervention. Fourteen SRs were identified (3 from the previous overview), 7 of which included meta-analyses, representing 179 unique published studies. Nine SRs examined medication-related process outcomes (low to very low evidence quality). Systematic reviews using pooled analyses found significant reductions in the number of PIMs, potential prescribing omissions, and total number of medications, and improvements in medication appropriateness. Twelve SRs examined clinical and functional outcomes (very low to moderate evidence quality). Five SRs examined mortality; all mortality meta-analyses were null, but studies with longer follow-up periods found greater reductions in mortality. Five SRs examined falls incidence; results were predominantly null save for a meta-analysis in which PIMs were discontinued. Of the 8 SRs examining quality of life, most (7) found predominantly null effects. Ten SRs examined hospitalizations and readmissions (very low to moderate evidence quality) and 4 examined emergency department visits (very low to low evidence quality). One SR found significant reductions in hospitalizations and readmissions among higher-intensity medication reviews with face-to-face patient components. Another meta-analysis found a null effect. Of the 7 SRs without meta-analyses for hospitalizations and readmissions, all had predominantly null results. Two of 4 SRs found reductions in emergency department visits. Two SRs examined acceptability (very low evidence quality), finding wide variation in the adoption of polypharmacy-related interventions. This updated systematic overview noted little evidence of an association between polypharmacy-related interventions and reduced important clinical and health care use outcomes. More evidence is needed regarding which interventions are most useful and which populations would benefit most.

Effect of COVID-19 on the dynamics of pediatric emergency department visits and admissions

Objective: This study aimed to evaluate how the pandemic and social constraints have affected the number of pediatric emergency department (ED) visits and hospitalizations at the current study institution. Methods: In the pediatric emergency department of the Maternity and Children Hospital in AlAhsa, Saudi Arabia, a retrospective, single-centered, observational comparison study was carried out between January and February 2020, prior to the COVID-19 outbreak, and between January and February 2021, during the COVID-19 outbreak. Comparisons were made between dispositions, diagnoses, visit information, and demographics. Results: Compared to the same period in 2016, the COVID-19 outbreak resulted in a significant decline in ED referrals (from 16,047 to 12,608) and a decrease in hospital admission rates (from 458 to 371). During the pandemic, there was a notable drop in ED visits for respiratory symptoms, despite the fact that fever and/or respiratory symptoms were the most frequently reported symptoms both times. Among the possible causes were a decreased risk of infection spread overall as a result of isolation and self-protective measures, avoiding needless hospital stays in the absence of severe symptoms, and parental anxiety about their children being exposed to COVID-19. Conclusion: During the COVID-19 epidemic, there were major changes in patterns of care seeking. Reduced ED visits should spur attempts to understand these occurrences, encourage appropriate care seeking, and monitor for morbidity and mortality that might arise from delayed or deferred therapy.

Changing high-risk asthma in Memphis through partnership: Results from the CHAMP program

BackgroundChildren in metro Shelby County, Tennessee, have disproportionally high asthma-related health care resource use (HRU) compared with those in other regions in Tennessee. ObjectiveTo describe the goals, logistics, and outcomes of the Changing High-Risk Asthma in Memphis through Partnership (CHAMP) program implemented to improve pediatric asthma care in Shelby County. MethodsCHAMP established a multidisciplinary team with dedicated medical staff and community health workers, implemented a 24/7 call line to improve access to care, established a patient data registry to address fragmented care, assigned community health educators to improve asthma education and social needs, and partnered with services to address environmental triggers and social determinants of health. Patients eligible for CHAMP are Shelby County residents aged 2 to 18 years with high-risk asthma enrolled in Tennessee's Medicaid managed care program. Health care resource use outcomes 1-year pre- and post-CHAMP enrollment were analyzed for patients who had completed 1 year of CHAMP between January 2013 and December 2022. The 24/7 call line data between November 2013 and December 2022 were analyzed. ResultsCHAMP has enrolled 1348 children; 945 have completed 1 year (63% male; 90% identified as Black). At 1-year post-CHAMP enrollment, patients had 58%, 68%, 42%, and 53% reductions in emergency department visits, inpatient and observation visits, urgent care visits, and total asthma exacerbations, respectively. The number of asthma exacerbations per patient significantly decreased from 2.97 to 1.40 at 1-year post-CHAMP enrollment. Of the calls made to the 24/7 call line, 58% occurred after hours and 52% led to issue resolution without a medical facility visit. ConclusionCHAMP successfully decreased asthma HRU in children with high-risk asthma in Shelby County by implementing initiatives that targeted barriers to asthma care.

Medical advice lines offering on-demand access to providers reduced emergency department visits

Abstract Instant access to clinicians through virtual care is designed to allow patients to receive care they need while avoiding high-cost visits in acute-care settings. This study investigates the effect of offering patients the option to instantly connect with emergency care providers instead of being referred to the emergency department (ED) following calls to a medical advice line. We used a staggered rollout design to assess the effects of implementing this program on key outcomes among Veterans Affairs enrollees. Analyzing over 1 million calls from 2019 to 2022, we found that access to a provider reduced the proportion of patients who subsequently visited the ED compared with those with access to the standard medical advice line (38% vs 36%). There was no significant difference observed in subsequent inpatient admissions or 30-day mortality. We found that a majority of callers (65%) achieved issue resolution or were directed to lower acuity settings for further evaluation. Although substantial direct cost savings were not evident, our findings demonstrate that on-demand access to a virtual provider can effectively decrease ED visits.

The most common types of nontraumatic dental conditions among emergency department visits in North Carolina before and during the COVID-19 pandemic

BackgroundThis study aimed to identify the most common types of nontraumatic dental conditions (NTDCs) before and during the COVID-19 pandemic and assess the variations in the most common NTDCs by patient age groups and rural or urban locations and the impact of COVID-19 on emergency department (ED) visits for NTDCs in North Carolina. MethodsThe authors conducted a retrospective data analysis of ED data from the North Carolina Disease Event Tracking and Epidemiology Collection Tool. The authors estimated the proportions of NTDCs of all ED visits in 2019 and 2021 and ranked the proportions of the major categories of NTDCs by age groups and rural or urban locations. They used a multiple logistic regression model to assess the impact of COVID-19 on NTDCs. ResultsBy the first diagnosis, the proportion of NTDCs dropped from 1.1% in 2019 to 0.99% in 2021 (P < .001). Caries was specified as the third most common NTDC. Oral infection was the top NTDC among young (≤ 17 years) and older patients (≥ 65 years). No significant differences were found in NTDCs between rural and urban areas (P = .68). Children younger than 2 years (adjusted odds ratio, 4.36) and adults aged 18 through 44 years (adjusted odds ratio, 4.54) were more likely to visit the ED for NTDCs than those 75 years and older. ConclusionsThe proportion of NTDCs seen at the ED was lower during the COVID-19 pandemic in 2021 than in 2019. The common NTDCs varied by age group but were similar in rural and urban areas. The most common NTDCs were related to toothache, oral infection, and caries. Practical ImplicationsMore efforts are needed to reduce ED visits for NTDCs.

Rapid Access Addiction Medicine Clinics for People With Problematic Opioid Use

New approaches are needed to provide care for individuals with problematic opioid use (POU). Rapid access addiction medicine (RAAM) clinics offer a flexible, low-barrier, rapid access care model for this population. To assess the associations of RAAM clinics with emergency department (ED) visits, hospitalizations, and mortality for people with POU. A retrospective cohort study involving a matched control group was performed using health administrative data from Ontario, Canada. Anonymized data from 4 Ontario RAAM clinics (cities of Ottawa, Toronto, Oshawa, and Sudbury) were linked with health administrative data. Analyses were performed on a cohort of individuals who received care at participating RAAM clinics and geographically matched controls who did not receive care at a RAAM clinic. All visits occurred between October 2, 2017, and October 30, 2019, and data analyses were completed in spring 2023. A propensity score-matching approach was used to balance confounding factors between groups, with adjustment for covariates that remained imbalanced after matching. Individuals who initiated care through the RAAM model (including assessment, pharmacotherapy, brief counseling, harm reduction, triage to appropriate level of care, navigation to community services and primary care, and related care) were compared with individuals who did not receive care through the RAAM model. The primary outcome was a composite measure of ED visits for any reason, hospitalization for any reason, and all-cause mortality (all measured up to 30 days after index date). Outcomes up to 90 days after index date, as well as outcomes looking at opioid-related ED visits and hospitalizations, were also assessed. In analyses of the sample of 876 patients formed using propensity score matching, 440 in the RAAM group (mean [SD] age, 36.5 [12.6] years; 276 [62.7%] male) and 436 in the control group (mean [SD] age, 36.8 [13.8] years; 258 [59.2%] male), the pooled odds ratio (OR) for the primary, 30-day composite outcome of all-cause ED visit, hospitalization, or mortality favored the RAAM model (OR, 0.68; 95% CI, 0.50-0.92). Analysis of the same outcome for opioid-related reasons only also favored the RAAM intervention (OR, 0.47; 95% CI, 0.29-0.76). Findings for the individual events of hospitalization, ED visit, and mortality at both 30-day and 90-day follow-up also favored the RAAM model, with comparisons reaching statistical significance in most cases. In this cohort study of individuals with POU, RAAM clinics were associated with reductions in ED visits, hospitalizations, and mortality. These findings provide valuable evidence toward a broadened adoption of the RAAM model in other regions of North America and beyond.

Emergency Department Overcrowding: An Environmental Scan of Contributing Factors and a Summary of Systematic Review Evidence on Interventions

&#x0D; Emergency department (ED) overcrowding occurs when the demand for health services in the ED exceeds the capacity of the ED, hospital, or community to deliver quality care in a reasonable amount of time. Overcrowding is worsening in jurisdictions across Canada and there is a need to address its many causes and identify potential solutions.&#x0D; This report uses a modified version of a conceptual model developed by Asplin et al. (2003) that organizes the emergency care system into 3 interdependent parts: input (arrival to the ED), throughput (flowing through the ED), and output (leaving the ED). We also examined an additional fourth part related to contextual factors and systems that affect overcrowding but lay outside of input, throughout, and output.&#x0D; &#x0D; Examples of factors include, but are not limited to, increased complexity of needs (input), diagnostic testing and procedures (throughput), boarding (output), and limited resources for mental health and substance use (outside the ED).&#x0D; Examples of interventions that were effective in some settings include, but are not limited to, prehospital decision-making by first responders, which reduced ED visits (input); short stay crisis units for people experiencing mental health challenges, which improved emergency department length of stay, wait times, boarding, and patient safety (throughput); ED-based discharge planning, which reduced ED return visits (output); and time-based policy reforms, which reduced ED length of stay (outside the ED).&#x0D; &#x0D; &#x0D; Most of the factors we identified in the published literature existed either outside of the ED or at the interface of the ED and other health care services (input and output), whereas most of the interventions we identified existed within the ED (throughput).&#x0D; We heard from participants (during multistakeholder dialogue sessions) and content experts that ED overcrowding is a complex health system issue for which the causes, impacts, and solutions extend beyond the ED. Specifically, the novel insights we heard included:&#x0D; &#x0D; ED overcrowding is better viewed as a problem of hospital overcrowding and strained resources in the broader social and health care systems. Contributing factors both within and outside the ED influence and interact with each other and are affected by economic, cultural, and institutional realities.&#x0D; Solving the issue requires addressing accountability and implementing multifaceted solutions in which several systems and voices work collaboratively.&#x0D; Existing technologies and data use and collection are not being used to their full potential; they can be better leveraged to alleviate this issue.&#x0D; &#x0D; &#x0D; In the identified literature, there was a lack of explicit reporting around equity and ethical considerations for factors contributing to, and interventions to alleviate, ED overcrowding. Future work should strive to deliberately and explicitly include ethical considerations inherent in research, planning, and policy-making; considerations of equity-deserving groups; and dedicate the time needed to consider the various facets of this issue.&#x0D; This CADTH report and our series of reports on ED overcrowding are a starting point to bridge the literature, stakeholder discussion, and expert opinion to help decision-makers understand the various parts of the issue and consult the relevant updated evidence to inform their work.&#x0D;

Physician-to-physician universal electronic consultation program (e-consultation) in a Cardiology Department: Impact on elapsed time to cardiology care and cardiovascular outcomes

Abstract Background Many health systems have initiated electronic consultation programs, although little is known about their impact on accessibility, safety and satisfaction. In 2019, we began to analyse our model1. The first results showed that it was an efficient model2 and safe, with a reduction in emergency department visits, mortality and hospitalization3. In the last 3 years we have live a lot of changes. In one hand, all models need a continuous evaluation of their results, and confirm that the outcomes are similar to the beginning. In the other hand, we lived a world pandemic and our health models have changed in these years. In an e-consultation, the Primary Care Physician, who referred the patient, uses the shared electronic records and the Cardiologist who answer also uses the same electronic records to review all the clinical information and to send an answer. The Cardiologist can resolve directly the referral or to make an appointment with the patient in person in cases where it is necessary4. Purpose The aim of this study is to assess the clinical impact of the implementation of a model of ambulatory care that includes an initial electronic consultation (e-consultation), comparing it with a face-to-face single act model. Methods We selected patients with at least one visit to the Cardiology Service between 2010 and 2021. Using an interrupted time series regression model, we analysed the impact of incorporating the e-consultation into the healthcare model (started in 2013), evaluating: waiting time for care, hospitalizations and mortality in the first year. Results We analysed 61,306 patients: 66,0% attended by incorporating the e-consultation and 34,0% in the one-time face-to-face consultation model. The delay time for care in the e-consultation model (mean [SD]: 8.4 days [9.1]) was shorter than in the face-to-face model (mean [SD]: 50.6 days [72.2]), p &amp;lt; 0.001. The regression model for interrupted time series showed that the incorporation of e-consultation contributed a very important decrease in the delay of attention, remaining around 8 days, although with slight oscillations. The e-consultation model represented a reduction in hospitalizations (iRR [95%CI]: 0.635 [0.635-0.641]), cardiovascular hospitalizations (iRR [95%CI]: 0.857 [0.846-0.868]), Figure 1, mortality (iRR [95%CI]: 0.936 [0.923-0.951]) and cardiovascular mortality (iRR [95%CI]: 0.979 [0.964-0.996]), Figure 2. Conclusions An outpatient care program that includes an e-consultation has shown to reduce waiting times significantly and is a safe model with a lower rate of hospitalizations and mortality in the first year.Figure 1Figure 2

Emergency department visits in Parkinson's disease: The impact of comorbid conditions

IntroductionOlder adults have complex, often overlapping, medical conditions requiring careful management that may lead to increased emergency department usage compared to younger adults. Parkinson's disease (PD), a progressive neurodegenerative disorder characterized by distinct motor and nonmotor features, frequently occurs with additional comorbid disease. Classifying comorbid conditions into clinical subgroups allows for further understanding of the heterogeneity in outcomes in patients with PD. The current study examines the reasons for emergency department (ED) visits in a cohort of patients with PD and identifies comorbidities that are potential risk factors for specific ED presenting conditions. MethodsUsing data from Optum's de-identified Integrated Claims-Clinical dataset years 2010–2018, patients with PD were identified based on ICD-9/10 diagnosis codes. We identified all ED visits occurring after the first observed diagnosis code for PD. Comorbid conditions were classified using the AHRQ Clinical Classification Software (CCS). We classified patients using Latent Class Analysis (LCA) and conducted multiple logistic regression models with the outcome of reason-for-visit to examine the associations with comorbidity-profile class, patient demographics, and socio-economic characteristics. ResultsThe most common reasons for ED admission were injuries such as fractures and contusions, diseases of the circulatory system, and general signs and symptoms, including abdominal pain, malaise, and fatigue. Comorbid medical conditions often observed in this patient population include depression, diabetes mellitus, and chronic pulmonary disease. Patients in the “Poorest Health” classification of the LCA had greater odds for ED admission for diseases related to the gastrointestinal system, musculoskeletal system, and injury/poisoning categories and reduced odds for admission for diseases of the circulatory system. DiscussionPatients with PD who present to the emergency department with injuries are more likely to be in poor health overall with a high comorbidity burden. Clarifying the complex medical needs of patients with PD is the first step to further individualize care, which may reduce ED visits in this population, improve quality of life, and lessen the footprint on the healthcare system.

Smartphone App PACOM to Provide Advice Regarding Self-Triage for the Acute Primary Care Needs of Children: Accuracy of Algorithms.

We developed a phone app, PACOM (Parents Application Conseils et Orientation Médicale), to provide medical advice to caregivers based on several algorithms and a series of binary questions related to children's symptoms. We compared the recommendations of the PACOM algorithms and clinicians for children visiting the emergency department (ED). Between January and February 2022, we prospectively recruited French-speaking parents of children without any chronic disease who presented to the pediatric ED with any complaint except for mental health problems or trauma. Isolated head trauma was included. They completed questionnaires and the various PACOM algorithms. The first algorithm, called "Quick Look," was developed to identify children with life-threatening emergencies. The standard reference was the advice of the ED clinicians who were blinded to the parental responses to the PACOM algorithm questions. The recommendations included "call urgent medical support," "visit the ED," "visit your general practitioner within 24 hours," and "visit your general practitioner in the next days." The study included 269 parents. The response rate was 75%. The median age of the children was 3 years with interquartile range: 1 to 7 years. In total, 268 children completed the "Quick Look," 141 "fever," 83 "abdominal pain," 72 "cough," 70 "vomiting," 130 questionnaires relative to other proposed symptoms, and 70 "other symptom" questionnaires. The PACOM recommendations were "call urgent medical assistant" for 98 children, "ED visit" for 131, "visit general practitioner within 24 hours" for 13, and "visit general practitioner during the next days" for 24. The sensitivity and specificity of the PACOM recommendation to "call urgent medical support or visit the ED" were 98.1% (95% confidence interval, 95.5-100.00) and 22.1% (95% confidence interval, 15.3-28.8), respectively. The PACOM algorithms has high sensitivity but low specificity for reducing ED visits and calls for urgent medical support.

Socio-Economic Status in Risk of Acute Adverse Events Following Radiotherapy

Socio-economic status (SES) are known to influence cancer patient outcomes. The purpose of this study is to evaluate whether SES affected the short-term clinical experience of patients treated with radiotherapy (RT) during the pandemic. This was a single institution, retrospective cohort quality improvement study. The primary endpoint consisted of adverse events (AEs) defined as an unplanned admission to a drop-in radiation-nursing clinic (RNC) or the institution's emergency department (ED) within 90 days of a radiation course. Adult cancer patients who received external beam RT from April 1, 2019, to March 31, 2022 were included. Patients were classified into two periods: treated prior to the pandemic (pre-COVID), and during the pandemic (COVID era), with a cutoff date of March 31, 2020. SES, age, RT intent (curative, palliative, SBRT), regimen (conventional fractionation and hypofractionation), disease site, and sex were included as co-variables. SES was obtained by matching a patient's postal code with a provincial data tool with four distinct dimensions: 1) residential instability, 2) material deprivation, 3) ethnic concentration, and 4) dependency. For each SES dimension, a score of 1-5 (best-worst) is assigned to individuals. A backward stepwise multivariable logistic regression analysis was performed to analyze the variables and identify the factors that were significantly associated (p<0.05) with increased risk of AEs. Institutional ethics review board exemption was obtained. Across the 3-year period, 15715 patients (5499 pre-COVID and 10216 COVID era patients) were identified and included in the analyses, and 5756 AEs were observed. The analyses revealed that patient age (p<0.001), disease site (p<0.001), treatment intent (p<0.001) and treatment regimen (p = 0.005) were associated with the risk of developing AEs. AEs risk was correlated with the treatment period (pre-COVID vs. COVID era) (p<0.001) and material deprivation (p = 0.027). Adjusting for the other variables, patients who were least materially deprived were at lower risk (Odds Ratio (OR) = 0.88, 95% CI [0.78-0.98]) of developing AEs than patients who were most materially deprived. Patient sex (p>0.1), residential instability (p = 0.069), ethnic concentration (p>0.5) and dependency (p>0.5) were not associated with AEs risk. Patients with more (SES score 1-4 vs 5) residential instability (p<0.001; OR = 0.82, 95% CI [0.74-0.90]) and less (SES score 1 vs 2-5) material deprivations (p = 0.006; OR = 0.76, 95% CI [0.66-0.88]) were at reduced the risk of ED visits. SES was not associated with RNC visits. In a universal health care system, SES (residential instability and material deprivation) were associated with the increased risk of ED within 90 days of RT. Proactive care and virtual monitoring during the 90-day period after RT in high-risk patients may reduce ED visits. ED visits beyond our tertiary institution are being gathered to address this study limitation.

Use of Care Guides to Reduce Emergency Department Visits by High-Frequency Utilizers

BackgroundHigh-frequency utilizers are defined as patients who present 10 or more times to the emergency department in a rolling 12-month period. High-frequency utilizers contribute to emergency department overcrowding and misuse of resources, and reduce the efficiency of health care systems. Care guides have proven to be an effective tool in reducing high-frequency utilizers. ObjectiveThe objective of this quality improvement project was to determine if implementing a care guide for high-frequency utilizers to address the core needs of the patient and facilitate resources through case management consultation decreases the number of visits and the cost of unreimbursed care to the emergency department from high-frequency utilizers. MethodsWe implemented care guides for high-frequency utilizers in September 2014. Prior to initiating the care guides, we educated the physicians, nurses, case managers, and social workers in the emergency department. ResultsFollowing the implementation of the care guides, there was a steady decline in the number of high-frequency utilizers (338 in 2013–68 in 2021), the number of total emergency department visits by high-frequency utilizers (6025 in 2013–1033 in 2021), and unreimbursed care ($2,068,063 in 2013–$589,298 in 2021). ConclusionThe use of care guides was a successful strategy in reducing emergency department visits and the cost of unreimbursed care by high-frequency utilizers by providing them with the education and resources they require to receive health care services in appropriate settings.

Does a Postoperative Physician Phone Call Decrease Complications, Improve Patient Satisfaction or Reduce Emergency Department Visits Following Mandibular Fracture Repair?

Does a Postoperative Physician Phone Call Decrease Complications, Improve Patient Satisfaction or Reduce Emergency Department Visits Following Mandibular Fracture Repair?

Goals, Services, and Target Patient Populations of Community Paramedicine in Rural United States

Introduction: Rural areas contain one-fifth of the US population and only 10% of the nation’s physicians. Community paramedicine (CP) is a growing healthcare delivery model in which emergency medical personnel provide non-emergent medical care. Community paramedics may help fill the primary healthcare gap for rural residents. This literature review provides an overview of the common goals, services, target populations, and setbacks of rural CP programs in the US.&#x0D; Methods: A systematic search following PRISMA protocols was completed on PubMed and Google scholar using the search terms: “community paramedicine/paramedic” and “rural, remote, frontier” between 2000-2021.&#x0D; Results: Rural CP program goals are to aid patients in chronic disease management and reduce emergency department visits, hospital admissions/readmissions, and healthcare costs. Programs target services toward patients who are chronically ill, post-hospital discharge, and frequent EMS users.&#x0D; Conclusion: CP provision of preventative and primary care services has improved health outcomes for patients with chronic disease. Programs report cost savings for the healthcare payer and patient and a reduction in ED transports and hospital readmissions. The problems identified are acquiring sustainable funding to develop CP programs and reimburse CP services, lack of consistency between CP scope of practice and educational requirements across states, role tensions with other healthcare professions, and lack of research about the safety of CP programs for patients. Future research is needed to investigate patient outcomes secondary to CP preventative and primary care services, which may identify if CPs are an effective means of helping fill the primary care gap for rural communities.

Dementia care navigation: Building toward a common definition, key principles, and outcomes.

As the complexity of medical treatments and patient care systems have increased, the concept of patient navigation is growing in both popularity and breadth of application. Patient navigators are trained personnel whose role is not to provide clinical care, but to partner with patients to help them identify their needs and goals and then overcome modifiable patient-, provider-, and systems-level barriers. Due to its high incidence, duration, and medical-social complexity, dementia is an ideal candidate for a patient-centric health care delivery model such as care navigation. The Alzheimer's Association formed an expert workgroup of researchers in the field of dementia care navigation to identify evidence-based guidelines. Recognizing the unique and challenging needs of persons living with dementia and their care partners, several U.S. dementia care navigation programs have been developed and assessed in recent years. Collectively these programs demonstrate that persons living with dementia and their care partners benefit from dementia care navigation. Improved care system outcomes for the person living with dementia include reduced emergency department visits, lower hospital readmissions, fewer days hospitalized, and shorter delays in long-term care placement. Well-being is also increased, as there is decreased depression, illness, strain, embarrassment, and behavioral symptoms and increased self-reported quality of life. For care partners, dementia navigation resulted in decreased depression, burden, and unmet needs. This article presents principles of dementia care navigation to inform existing and emerging dementia care navigation programs. Several U.S. dementia care navigation programs have demonstrated outcomes for persons living with dementia, care partners, and health systems.The Alzheimer's Association formed an expert workgroup of researchers in the field of dementia care navigation to create a shared definition and identify evidence-based guidelines or principles.These outlined principles of dementia care navigation can inform existing and emerging dementia care navigation programs.

Association of a Remote Blood Pressure Monitoring Program With Postpartum Adverse Outcomes.

To use administrative claims data to evaluate the association of a remote blood pressure monitoring program with adverse postpartum clinical outcomes in patients with a hypertensive disorder of pregnancy. This was a retrospective cohort study of Independence Blue Cross members with a hypertensive disorder of pregnancy diagnosis across three obstetric hospitals from 2017 to 2021. Patients who were enrolled in twice-daily text-based blood pressure monitoring for 10 days postpartum were compared with two propensity-score matched cohorts of patients who met the program criteria: an asynchronous cohort (cohort A), consisting of patients at any of the three participating hospitals before remote monitoring program implementation, and a contemporaneous cohort (cohort C), consisting of patients at other hospitals during the same time period as clinical use of the program. Patients with less than 16 months of continuous insurance enrollment before delivery were excluded. Claims for adverse clinical outcomes after delivery discharge were evaluated. Health care service utilization and total medical costs were evaluated. The 1,700 patients in remote blood pressure monitoring program were matched to 1,021 patients in cohort A and 1,276 in cohort C. Within the first 6 months after delivery, patients enrolled in remote monitoring were less likely to have the composite adverse outcome than those in cohort A (2.9% vs 4.7%; OR 0.61, 95% CI 0.40-0.98). There was no statistically significant difference relative to cohort C (3.2% vs 4.5%; OR 0.71, 95% CI 0.47-1.07). The remote monitoring group had more cardiology visits and fewer postnatal emergency department (ED) visits and readmissions compared with both comparison cohorts. Reductions in ED visits and readmissions drove overall lower total medical costs for the program cohort. Patients enrolled in a remote blood pressure monitoring program were less likely to experience an adverse outcome in the first 6 months after delivery. Reductions in ED visits and readmissions resulted in lower postpartum total medical costs compared with both control cohorts. Broad implementation of evidence-based remote monitoring programs may reduce postpartum adverse outcomes, thereby reducing morbidity and mortality in populations such as the one studied here.

Postpartum Emergency Department Visits and Risk Factors for Readmission [ID: 1363150]

INTRODUCTION: Postpartum emergency department (ED) visits complicate 12% of births. We aimed to characterize trends in ED visits and risk factors for readmission. METHODS: This was a retrospective cohort study on postpartum ED visits within 42 days of delivery at a tertiary care center over 1 year. Readmitted patients were compared to those who remained outpatient as appropriate. IRB #14-001098. RESULTS: Of 3,084 deliveries, 138 (4.5%) patients presented to the ED for total 157 encounters. 17 (12.3%) patients presented more than once. 55 (35%) ED visits resulted in readmission, with 4 patients readmitted twice. Public insurance rates in the cohort were significantly higher than baseline (16.7% versus 8.5%, P=.001). Postpartum hypertension (HTN) was the most common reason for ED visits (40%) and had four times higher likelihood of being readmitted (adjusted odds ratio [aOR] 4.076, 95% CI 2.04–8.15, P&lt;.001). Black women were six times more likely to be readmitted compared to other groups (aOR 6.53, 95% CI 1.26–33.88, P=.026). Coexistent psychiatric disease had lower likelihood of readmission (aOR 0.43, 95% CI 0.19–0.95, P=.037). Having more than one ED visit led to fivefold higher odds of readmission (aOR 5.05, 95% CI 1.66–15.32, P=.004). Median days from delivery to ED visit were 8 (interquartile range [IQR]: 5, 15). CONCLUSION: Seventy-three percent of presentations to the ED were within 2 weeks of delivery, and postpartum HTN was the leading cause. Black patients were more likely to be readmitted. Further studies are needed to evaluate whether earlier postpartum visits for high-risk groups may reduce ED visits and readmissions.