Reduce Emergency Department Visits Research Articles

Integrating palliative care in oncologic emergency departments: Challenges and opportunities.

Although visiting the emergency departments (EDs) is considered poor quality of cancer care, there are indications these visits are increasing. Similarly, there is growing interest in providing palliative care (PC) to cancer patients in EDs. However, this integration is not without major challenges. In this article, we review the literature on why cancer patients visit EDs, the rates of hospitalization and mortality for these patients, and the models for integrating PC in EDs. We discuss opportunities such integration will bring to the quality of cancer care, and resource utilization of resources. We also discuss barriers faced by this integration. We found that the most common reasons for ED visits by cancer patients are pain, fever, shortness of breath, and gastrointestinal symptoms. The majority of the patients are admitted to hospitals, about 13% of the admitted patients die during hospitalization, and some patients die in ED. Patients who receive PC at an ED have shorter hospitalization and lower resource utilization. Models based solely on increasing PC provision in EDs by PC specialists have had modest success, while very limited ED-based PC provision has had slightly higher impact. However, details of these programs are lacking, and coordination between ED based PC and hospital-wide PC is not clear. In some studies, the objectives were to improve care in the communities and reduce ED visits and hospitalizations. We conclude that as more patients receive cancer therapy late in their disease trajectory, more cancer patients will visit EDs. Integration of PC with emergency medicine will require active participation of ED physicians in providing PC to cancer patients. PC specialist should play an active role in educating ED physicians about PC, and provide timely consultations. The impact of integrating PC in EDs on quality and cost of cancer care should be studied.

Reducing Emergency Department Visits for Acute Gastrointestinal Illnesses in North Carolina (USA) by Extending Community Water Service

Reducing Emergency Department Visits for Acute Gastrointestinal Illnesses in North Carolina (USA) by Extending Community Water Service

Failed Attempts to Reduce Inappropriate Laboratory Utilization in an Emergency Department Setting in Cyprus: Lessons Learned

BackgroundLaboratory test ordering is a significant part of the diagnosis definition and disease treatment monitoring process. Inappropriate laboratory test ordering wastes scarce resources, places unnecessary burden on the health care delivery system, and exposes patients to unnecessary discomfort. Inappropriate ordering is caused by many factors, such as lack of guidelines, defensive medicine, thoughtless ordering, and lack of awareness of costs incurred to the system. ObjectivesThe purpose of this study is to assess two successive measures, which were introduced in a Cyprus emergency department (ED) for the purpose of synergistically reducing inappropriate laboratory ordering: the introduction of a copayment fee to reduce nonemergent visits, and the development of a Web-based protocol defining the tests emergency physicians could order. MethodsAn autoregressive integrated moving average model for interrupted time series analysis was constructed. Data include number and type of tests ordered, along with number of visits for a period of 4 years from an ED in Cyprus. ResultsCopayment fee and introduction of a revised Web-based protocol for a test ordering form did not reduce the number of ordered tests in the ED unit. Copayment fee alone resulted in a statistically significant reduction in ED visits. ConclusionsThe implementation of two consecutive measures resulted in an increase of ordered tests per patient. Laboratory ordering is a multidimensional process that is primarily supplier induced, therefore, all underlying possible causes must be scrutinized by health authorities. These include lack of guidelines, defensive medicine and thoughtless prescribing. To attain significant gains, an integrated approach must be implemented.

Does Greater Continuity of Veterans Administration Primary Care Reduce Emergency Department Visits and Hospitalization in Older Veterans?

ObjectivesTo evaluate the association between longitudinal continuity of primary care and use of emergency department (ED) and inpatient care in older veterans.DesignRetrospective cohort study.SettingDepartment of Veterans Affairs (VA) primary care clinics in 15 regional health networks, ED and inpatient facilities.ParticipantsMedicare‐eligible veterans aged 65 and older with three or more VA primary care visits during fiscal year 2007–08 (baseline period) (N = 243,881).MeasurementsTwo measures of longitudinal continuity were estimated using merged VA–Centers for Medicare and Medicaid Services administrative data: Usual Provider of Continuity (UPC) and Modified Modified Continuity Index (MMCI). Negative binomial and multivariable logistic regression models were used to predict ED use and inpatient hospitalization during fiscal year 2009, controlling for sociodemographic characteristics, medical and psychiatric comorbidity, and baseline use of health services.ResultsThe incidence rate ratio (IRR) of ED visits was greater in patients with high (IRR = 1.05, 95% confidence interval (CI) = 1.02–1.07), intermediate (IRR = 1.04, 95% CI = 1.02–1.07), and low (IRR = 1.06, 95% CI = 1.03–1.09) UPC than in those with very high UPC (0.9–1.0). Patients with high (odds ratio (OR) = 1.04, 95% CI = 1.01–1.07), intermediate (OR = 1.03, 95% CI = 1.00–1.06), and low (OR = 1.04, 95% CI = 1.01–1.07) UPC were also more likely to be hospitalized during follow‐up. Results were similar for MMCI continuity scores.ConclusionEven slightly lower primary care provider (PCP) continuity was associated with modestly greater ED use and inpatient hospitalization in older veterans. Additional efforts should be made to schedule older adults with their assigned PCP whenever possible.

Does Increasing Home Care Nursing Reduce Emergency Department Visits at the End of Life? A Population-Based Cohort Study of Cancer Decedents

ContextDespite being commonplace in health care systems, little research has described home care nursing's effectiveness to reduce acute care use at the end of life. ObjectivesTo examine the temporal association between home care nursing rate on emergency department (ED) visit rate in the subsequent week during the last six months of life. MethodsWe conducted a retrospective cohort study of end-of-life cancer decedents in Ontario, Canada, from 2004 to 2009 by linking administrative databases. We examined the association between home care nursing rate of one week with the ED rate in the subsequent week closer to death, controlling for covariates and repeated measures among decedents. Nursing was dichotomized into standard and end-of-life care intent. ResultsOur cohort included 54,576 decedents who used home care nursing services in the last six months before death, where 85% had an ED visit and 68% received end-of-life home care nursing. Patients receiving end-of-life nursing at any week had a significantly reduced ED rate in the subsequent week of 31% (relative rate [RR] 0.69; 95% confidence interval [CI] 0.68, 0.71) compared with standard nursing. In the last month of life, receiving end-of-life nursing and standard nursing rate of more than five hours/week was associated with a decreased ED rate of 41% (RR 0.59, 95% CI 0.58, 0.61) and 32% (RR 0.68, 95% CI 0.66, 0.70), respectively, compared with standard nursing of one hour/week. ConclusionOur study showed a temporal association between receiving end-of-life nursing in a given week during the last six months of life, and of more standard nursing in the last month of life, with a reduced ED rate in the subsequent week.

Recreational motor vehicle use and facial trauma.

The use of recreational motorized vehicles (RMVs), including all-terrain vehicles (ATVs), snowmobiles, and go-carts, has increased in recent decades. Because RMVs are lightly regulated, there are numerous safety concerns. This analysis examines a nationally representative resource to estimate the incidence of craniofacial trauma secondary to RMV accidents, evaluating injury and demographic patterns. The Consumer Product Safety Commission's National Electronic Injury Surveillance System was examined for facial trauma resulting in emergency department (ED) visits stemming from the use of ATVs, motorbikes/scooters, snowmobiles, and utility vehicles. Characteristics including demographics, anatomic sites, mechanism, and location of injury were evaluated, as well as details regarding helmet and alcohol use. There were 1,464 entries extrapolating to an estimated 61,312 ED visits over a 5-year period for facial trauma from RMV use. From 2009 to 2013, there was a 28% reduction in ED visits. The majority of patients were male, and the median age was 17 years. Lacerations (45.1%), contusions/abrasions (26.7%), and fractures (24%) were the most frequent injuries. Among fractures, the most common types were nasal (29%), followed by mandible (20%) and orbital (8%) fractures. All-terrain vehicles (62%) were the most common vehicles. Alcohol consumption resulted in a higher rate of facial fractures (48.5% vs. 22.8%). As there is a significant potential for injury, familiarity with injury patterns associated with RMVs is useful in the management of facial trauma. Recreational motorized vehicles facial trauma results in tens of thousands of ED visits annually. This data reinforces the importance of pursuing further efforts to raise public awareness and improve safety measures.

Care plans reduce ED visits in those with drug-seeking behavior

Patients with drug-seeking behavior can be both labor and resource intensive to the emergency department (ED). ObjectiveTo determine the effectiveness of ED care plans for individuals at high risk for drug-seeking behavior on ED visits. MethodsA retrospective, cohort observational study. LocationA suburban teaching hospital with an annual census of 80,000 patients. The number of ED visits was determined 1 year before and 2 subsequent years following care plan initiation. Exclusion criteriaUnclaimed letter, incomplete data, and/or non–drug-seeking care plan. StatisticsTwo-tailed Wilcoxon signed-rank test with significance of P < .05. ResultsSixty patients were enrolled and 7 were excluded, leaving 53 patients for analysis. Mean annual visits before care plan initiation were 7.6 (95% confidence interval [CI], 6.3-9.1). One year following implementation, mean visits decreased to 2.3 (95% CI, 1.5-3.1) (P ≤ .0001). Two years following implementation, mean visits continued to decline to 1.5 (95% CI, 0.9-2.1) (P ≤ .0001). A significant reduction in visits occurred 1 and 2 years following care plan implementation. ConclusionsEmergency department care plans are an effective method to reduce ED visits in those with drug-seeking behavior.

Factors Predictive of Emergency Department Visits and Hospitalization Following Thyroidectomy and Parathyroidectomy.

This study aimed to determine the incidence and risk factors for emergency department (ED) visits and unplanned hospitalization after thyroid and parathyroid surgery. A retrospective study of all patients who underwent thyroidectomy or parathyroidectomy from 2007 to 2014 was conducted to assess for ED visits or unplanned hospitalization within 30 days after surgery. Uni- and multivariate analyses were used to identify risk factors for ED visits and hospitalization. Of 864 patients who underwent thyroidectomy (n = 673) or parathyroidectomy (n = 191), 96 (11.1 %) had an ED visit and 41 (4.7 %) were hospitalized within 30 days after surgery. Univariate analysis showed hypocalcemia (p = 0.001), younger age (p = 0.02), total thyroidectomy (p = 0.01), and lack of private health insurance (p = 0.005) to be predictive of an ED visit and hypocalcemia (p = 0.0001), Hashimoto's thyroiditis (p = 0.049), total thyroidectomy (p = 0.005), and African American race (p = 0.03) were predictive of hospitalization after thyroidectomy. Multivariate analysis showed younger age (odds ratio [OR] 1.5 per 10-year decrease in age; p = 0.002; 95 % confidence interval [CI] 1.1-1.8) and Medicare insurance (OR 2.7; p = 0.01; 95 % CI 1.3-5.7) to be independently associated with an ED visit, and hypocalcemia (OR 4.7; p < 0.001; 95 % CI 2.2-11.0) was the only independent factor associated with hospitalization after thyroidectomy. Univariate analysis showed hypocalcemia, renal hyperparathyroidism, and multiglandular disease to be predictive of an ED visit and hospitalization after parathyroidectomy. The sample size for parathyroidectomy was too small for multivariate analysis. Targeted strategies for transitions of care for patients with postoperative hypocalcemia may help to reduce ED visits and hospitalization after thyroidectomy and parathyroidectomy.

Mobile Integrated Health Care and Community Paramedicine: An Emerging Emergency Medical Services Concept

Mobile integrated health care and community paramedicine are models of health care delivery that use emergency medical services (EMS) personnel to fill gaps in local health care infrastructure. Community paramedics may perform in an expanded role and require additional training in the management of chronic disease, communication skills, and cultural sensitivity, whereas other models use all levels of EMS personnel without additional training. Currently, there are few studies of the efficacy, safety, and cost-effectiveness of mobile integrated health care and community paramedicine programs. Observations from existing program data suggest that these systems may prevent congestive heart failure readmissions, reduce EMS frequent-user transports, and reduce emergency department visits. Additional studies areneeded to support the clinical and economic benefit of mobile integrated health care and community paramedicine.

Symptom-related emergency department visits and hospital admissions during ambulatory cancer treatment.

People with cancer experience symptoms related to the disease and treatments. Symptom distress has a negative impact on quality of life (QoL). Attending to symptoms and side effects of treatment promotes safe and effective delivery of therapies and may prevent or reduce emergency department visits (EDVs) and unplanned hospital admissions (HAs). There is limited evidence examining symptom-related EDVs or HAs (sx-EDV/HAs) and interventions in ambulatory oncology patients. To examine factors associated with sx-EDV/HAs in ambulatory oncology patients receiving chemotherapy and/or radiation. This secondary analysis used data from a randomized controlled trial of ambulatory oncology patients (n = 663) who received the web-based Electronic Self-Report Assessment – Cancer intervention (symptom self-monitoring, tailored education, and communication coaching) or usual care with symptom self-monitoring alone. Group differences were described by summary statistics and compared by t test. Factors associated with the odds of at least 1 sx-EDV/HA were modeled using logistic regression. 98 patients had a total of 171 sx-EDV/HAs with no difference between groups. Higher odds of at least 1 sx-EDV/HA were associated with socioeconomic and clinical factors. The multivariable model indicated that work status, education level, treatment modality, and on-treatment Symptom Distress Scale-15 scores were signifcantly associated with having at least 1 sx-EDV/HA. This is a secondary analysis not sized to determine cause and effect. The results have limited generalizability. Most patients did not experience a sx-EDV/HA. Demographic and clinical factors predicted a sx-EDV/HA.

Effect of a diuretic adjustment algorithm and nonpharmacologic management in patients with heart failure: study protocol for a randomized controlled trial.

BackgroundOne of the challenges in treating patients with heart failure (HF) is achieving clinical stability and reducing the hospital readmission rate. A diuretic dose adjustment algorithm developed in the United States (Diuretic Treatment Algorithm, DTA) and later validated for use in Brazil (as the Algoritmo de Ajuste de Diurético, AAD) has proved feasible and readily applicable, but its effect on clinical outcomes has yet to be assessed. This report aims to describe a randomized clinical trial protocol designed to assess the effectiveness of the AAD and of nonpharmacologic management in improving clinical stability and reducing the readmission rate at 90 days in patients with HF.Methods/DesignA PROBE (prospective randomized open blinded endpoint) parallel-group design will be used. Adult patients with a diagnosis of reduced ejection fraction HF, who are being treated at a specialized HF clinic are being recruited. Those with indications for loop diuretic dose adjustment during routine clinic visits will be randomized to take part in the trial. Participants in the intervention group (IG) shall have their diuretic doses adjusted in accordance with the AAD and receive four telephone calls (one per week) over 30 days to reinforce guidance on nonpharmacological management (fluid and sodium restriction). Participants in the control group (CG) shall have their diuretic doses adjusted by a physician during the first trial visit and shall not receive any telephone calls. Patients in both groups shall return at 1 month for face-to-face reassessment. The study endpoints shall comprise readmission and/or emergency department visits due to HF decompensation within 90 days and clinical instability. All participants shall be required to have a scale at home (or easy access to one), a telephone number, agree to telephone-based follow-up, and be available to return for a 1-month trial visit. Overall, 135 patients are expected to be enrolled in each group.DiscussionThis trial shall assess the effectiveness of the AAD algorithm and non-pharmacologic management by early identification of clinical deterioration and establishment of a combined intervention to reduce emergency department visits, readmission rate, or a composite endpoint thereof.Trial registration numberClinicalTrials.gov Identifier, NCT02068937 (23 February 2014).

Health outcomes for HIV-infected persons released from the New York City jail system with a transitional care-coordination plan.

We sought to assess 6-month outcomes for HIV-infected people released from New York City jails with a transitional care plan. Jail detainees in New York City living with HIV who accepted a transitional care plan during incarceration were asked to participate in a multi-site evaluation aimed at improving linkages to community-based care. The evaluation included a 6-month follow-up; HIV surveillance data were used to assess outcomes for those considered lost to follow-up. Participants (n=434) completed baseline surveys during incarceration in a jail in New York City. Of those seen at 6 months (n=243), a greater number were taking antiretroviral medications (92.6% vs 55.6%), had improved antiretroviral therapy adherence (93.2% vs 80.7%), and reported significant reductions in emergency department visits (0.20 vs 0.60 visits), unstable housing (4.15% vs 22.4%), and food insecurity (1.67% vs 20.7%) compared with baseline. Transitional care coordination services facilitate continuity of care and improved health outcomes for HIV-positive people released from jail.

Observing Medical Insurance Claims Data in a High Risk Asthma Population and Targeting Behavioral Patterns to Improve Controller Medication Compliance and Reduce Emergency Department Visits

Observing Medical Insurance Claims Data in a High Risk Asthma Population and Targeting Behavioral Patterns to Improve Controller Medication Compliance and Reduce Emergency Department Visits

Asthma Coach Intervention to Reduce Emergency Department Visits and Inpatient Hospitalizations

Asthma Coach Intervention to Reduce Emergency Department Visits and Inpatient Hospitalizations

The Relationship Between the Use of a Worksite Medical Home and ED Visits or Hospitalizations

Worksite medical homes may be a good model for improving employee health. The aim of this study was to compare the likelihood of being seen in the emergency department (ED) or being hospitalized by level of use (no use, occasional use, or primary care) of a worksite medical home, overall and by type of user (employee, adult dependent, or pediatric dependent). This was a retrospective analysis of claims data, using covariate-adjusted logistic regression models for ED visits and inpatient hospitalizations. Secondary data for the years 2006 to 2008 from a company that offers an on-site health care center (HCC) were used. Analyses were based on a data set that combines health plan claims and human resources demographic data. Overall, people who did not use the HCC were more likely to be seen in the ED (adjusted odds ratio [OR] = 1.20, 95% confidence interval or CI [1.06, 1.37], P = .005) or to be hospitalized (adjusted OR = 1.58; 95% CI [1.34, 1.86]; P < .0001) compared with those who used the HCC for primary care. Both ED visits and hospitalizations for employees and dependents in this study were lower among those who used the worksite medical home for primary care. Worksite medical homes can improve chronic disease management and thus reduce ED visits and hospitalizations. These findings contribute to growing evidence that worksite medical homes are potentially cost-effective.

Do palliative care interventions reduce emergency department visits among patients with cancer at the end of life? A systematic review.

Frequent emergency department (ED) visits are an indicator of poor quality of cancer care. Coordination of care through the use of palliative care teams may limit aggressive care and improve outcomes for patients with cancer at the end of life. To systematically review the literature to determine whether palliative care interventions implemented in the hospital, home, or outpatient clinic are more effective than usual care in reducing ED visits among patients with cancer at the end of life. PubMed, EMBASE, and CINAHL databases were searched from database inception to May 7, 2014. Only randomized/non-randomized controlled trials (RCTs) and observational studies examining the effect of palliative care interventions on ED visits among adult patients with cancer with advanced disease were considered. Data were abstracted from the articles that met all the inclusion criteria. A second reviewer independently abstracted data from 2 articles and discrepancies were resolved. From 464 abstracts, 2 RCTs, 10 observational studies, and 1 non-RCT/quasi-experimental study were included. Overall there is limited evidence to support the use of palliative care interventions to reduce ED visits, although studies examining effect of hospice care and those conducted outside of the United States reported a statistically significant reduction in ED visits. Evidence regarding whether palliative care interventions implemented in the hospital, home or outpatient clinic are more effective than usual care at reducing ED visits is not strongly substantiated based on the literature reviewed. Improvements in the quality of reporting for studies examining the effect of palliative care interventions on ED use are needed.

Does gender matter? Exploring mental health recovery court legal and health outcomes.

BackgroundBased upon therapeutic justice principles, mental health courts use legal leverage to improve access and compliance to treatment for defendants who are mentally ill. Justice-involved women have a higher prevalence of mental illness than men, and it plays a greater role in their criminal behavior. Despite this, studies examining whether women respond differently than men to mental health courts are lacking. Study goals were to examine gender-related differences in mental health court participation, and in criminal justice, psychiatric and health-related outcomes.MethodsThis study utilized a quasi-experimental pre-posttest design without a control group. The data were abstracted from administrative records of Kalamazoo Community Mental Health and Substance Abuse agency, the county jail and both county hospitals, 2008 through 2011. Generalized estimating equation regression was used to assess gender-differences in pre-post program outcomes (jail days, psychiatric and medical hospitalization days, emergency department visits) for the 30 women and 63 men with a final mental health court disposition.ResultsProgram-eligible females were more likely than males to become enrolled in mental health court. Otherwise they were similar on all measured program-participation characteristics: treatment compliance, WRAP participation and graduation rate.All participants showed significant reductions in emergency department visits, but women-completers had significantly steeper drops than males: from 6.7 emergency department visits to 1.3 for women, and from 4.1 to 2.4 for men. A similar gender pattern emerged with medical-hospitalization-days: from 2.2 medical hospital days down to 0.1 for women, and from 0.9 days up to 1.8 for men. While women had fewer psychiatric hospitalization days than men regardless of program involvement (2.5 and 4.6, respectively), both genders experienced fewer days after MHRC compared to before. Women and men showed equal gains from successful program completion in reduced jail days.ConclusionsDespite similar participation characteristics, findings point to greater health gains by female compared to male participants, and to lower overall psychiatric acuity. Mental-health-court participation was associated with decreased psychiatric hospitalization days and emergency department visits. Successful program completion correlated to fewer jail days for both women and men.Electronic supplementary materialThe online version of this article (doi:10.1186/s40352-014-0012-0) contains supplementary material, which is available to authorized users.

Harm Reduction at its Best: A case for Promoting Safe Injection Facilities

Injection Drug Users (IDU) represent less than 1% of Canada's the total population. Nevertheless, it is estimated that health and law enforcement costs for controlling the drug problem in Canada amount to $5 billion annually. The current strategies targeting IDU have limited efficacy with reducing emergency department visits, limiting HIV/Hep C virus transmission and providing accessible health care. This paper makes the case for safe injection facilities (SIF) as a means to improve IDU health outcomes, while reducing health care expenditures, decreasing public injecting and having no impact on crime rates. This topic is of particular concern now that the Conservative government is in the process of trying to pass bill C-2 to modify the Controlled Drugs and Substance Act making exemptions for SIF inaccessible. This is occurring while leading researchers in the field are applying for an exemption for such a facility in Ottawa.

Retaining homeless veterans in outpatient care: a pilot study of mobile phone text message appointment reminders.

We examined the feasibility of using mobile phone text messaging with homeless veterans to increase their engagement in care and reduce appointment no-shows. We sent 2 text message reminders to participants (n = 20) before each of their outpatient appointments at an urban Veterans Affairs medical center. Evaluation included pre- and postsurvey questionnaires, open-ended questions, and review of medical records. We estimated costs and savings of large-scale implementation. Participants were satisfied with the text-messaging intervention, had very few technical difficulties, and were interested in continuing. Patient-cancelled visits and no-shows trended downward from 53 to 37 and from 31 to 25, respectively. Participants also experienced a statistically significant reduction in emergency department visits, from 15 to 5 (difference of 10; 95% confidence interval [CI] = 2.2, 17.8; P = .01), and a borderline significant reduction in hospitalizations, from 3 to 0 (difference of 3; 95% CI = -0.4, 6.4; P = .08). Text message reminders are a feasible means of reaching homeless veterans, and users consider it acceptable and useful. Implementation may reduce missed visits and emergency department use, and thus produce substantial cost savings.

Patient-Centered Medical Home Impact on Health Plan Members With Diabetes

To compare costs and utilization for patients with diabetes enrolled in patient-centered medical home (PCMH) practices and non-PCMH practices. Commercial Health Maintenance Organization members with diabetes who enrolled between 2008 and 2011 in 26 Pennsylvania-based PCMH practices that were recognized by the National Committee for Quality Assurance in 2009 were compared with similar patients in 97 non-PCMH primary care practices. A difference-in-differences longitudinal research design was used to analyze differences between both groups on per-member, per-month costs and utilization. The statistical models controlled for baseline practice and patient-level characteristics through 2-step propensity score matching. The regression analysis on program effect further controlled for within-practice variation. Sensitivity analyses were also conducted on patients with type 1 and type 2 diabetes separately, and a third analysis was limited to diabetic patients enrolled in practices within Philadelphia. Adoption of the PCMH reduced overall medical costs for diabetic patients by 21% in year 1. This reduction was driven largely by inpatient costs, which fell by 44%. Reductions in emergency department visits, outpatient costs, and specialist visits were also seen in subsequent years among patients enrolled in PCMH practices. Additional sensitivity analyses indicated that adoption of the PCMH model yielded similar results when analyzing patients with type 2 diabetes as well as for diabetic patients enrolled in PCMH practices located within the city of Philadelphia. The cost of care for patients with diabetes can be reduced by securing care at a PCMH practice. Immediate results were seen in reduction of inpatient costs, which indicate that these patients enrolled in PCMH practices were using less costly inpatient services.