Related Emergency Department Research Articles

Urology Consultation and Emergency Department Revisits for Children with Urinary Stone Disease

We determined the association between urology consultation and emergency department revisits for children with urinary stones. This retrospective cohort study included patients 18years old or younger who presented to an emergency department in South Carolina with a urinary stone from 1997 to 2015. The primary exposure was urology consultation during the index emergency department visit. The primary outcome was a stone related emergency department revisit occurring within 180days of discharge from an index emergency department visit. Secondary outcomes included computerized tomography use, inpatient admission and emergent surgery. Of 5,642 index emergency department visits for acute urinary stones 11% resulted in at least 1 stone related emergency department revisit within 180days. Of revisits 59% occurred within 30 days of discharge and 39% were due to pain. The odds of emergency department revisit were highest within the first 48 hours of discharge home (OR 22.6, 95% CI 18.0 to 28.5) and rapidly decreased thereafter. Urology consultation was associated with a 37% lower adjusted odds of emergency department revisit (OR 0.63, 95% CI 0.44 to 0.90) and 68% lower odds of computerized tomography use across all emergency department visits (OR 0.32, 95% CI 0.15 to 0.69). Among patients who revisited the emergency department the frequency of pain complaints was 27% in those with a urological consultation at the index visit and 39% in those without. Urology consultation was associated with decreased emergency department revisits and computerized tomography use in pediatric patients with urinary stones. Future studies should identify patients who benefit most from urology consultation and ascertain processes of care that decrease emergency department revisits among high risk patients.

Population-Tailored Care for Homeless Veterans and Acute Care Use, Cost, and Satisfaction: A Prospective Quasi-Experimental Trial.

IntroductionAlthough traditional patient-centered medical homes (PCMHs) are effective for patients with complex needs, it is unclear whether homeless-tailored PCMHs work better for homeless veterans. We examined the impact of enrollment in a Veterans Health Administration (VHA) homeless-tailored PCMH on health services use, cost, and satisfaction compared with enrollment in a traditional, nontailored PCMH.MethodsWe conducted a prospective, multicenter, quasi-experimental, single-blinded study at 2 VHA medical centers to assess health services use, cost, and satisfaction during 12 months among 2 groups of homeless veterans: 1) veterans receiving VHA homeless-tailored primary care (Homeless-Patient Aligned Care Team [H-PACT]) and 2) veterans receiving traditional primary care services (PACT). A cohort of 266 homeless veterans enrolled from June 2012 through January 2014.ResultsCompared with PACT patients, H-PACT patients had more social work visits (4.6 vs 2.7 visits) and fewer emergency department (ED) visits for ambulatory care-sensitive conditions (0 vs 0.2 visits); a significantly smaller percentage of veterans in H-PACT were hospitalized (23.1% vs 35.4%) or had mental health–related ED visits (34.1% vs 47.6%). We found significant differences in primary care provider–specific visits (H-PACT, 5.1 vs PACT, 3.6 visits), mental health care visits (H-PACT, 8.8 vs PACT, 13.4 visits), 30-day prescription drug fills (H-PACT, 40.5 vs PACT, 58.8 fills), and use of group therapy (H-PACT, 40.1% vs PACT, 53.7%). Annual costs per patient were significantly higher in the PACT group than the H-PACT group ($37,415 vs $28,036). In logistic regression model of acute care use, assignment to the H-PACT model was protective as was rating health “good” or better.ConclusionHomeless veterans enrolled in the population-tailored primary care approach used less acute care and costs were lower. Tailored-care models have implications for care coordination in the US Department of Veterans Affairs VA and community health systems.

Reduction in Asthma Related Emergency Department Visits and Hospitalizations Among Children Evaluated in a Specialty Asthma Clinic

Reduction in Asthma Related Emergency Department Visits and Hospitalizations Among Children Evaluated in a Specialty Asthma Clinic

Substance use patterns and in-hospital care of adolescents and young adults attending music concerts

BackgroundFew studies describe medical complaints and substance use patterns related to attending music concerts. As such, the objective of this study is to describe patient demographics, substance use and intoxication patterns, and medical interventions provided to adolescents and young adults assessed in an emergency department (ED) for complaints directly related to concert attendance.MethodsA retrospective chart review of patients 13–30 years old who were transported to the ED directly from music concerts between January 2011 and December 2015 was conducted. Descriptive statistics and logistic regression were used to analyze patient demographic, intervention, and substance use data.ResultsThere were 115 concerts identified, of which 48 (42%) were linked to 142 relevant ED visits; the total number of attendees at each concert is unknown. The mean age of the 142 described patients was 19.5 years (SD 3.3) with 72% < 21 and 33% < 18; 71% of patients were female and 96% of visits were substance-use related. Mean blood alcohol level was 242 mg/dL (range 104–412, SD 70). Glasgow Coma Scale (GCS) scores ranged from 3 to 15, with a mean of 14. Two patients required intubation and 61% of patients received interventions, including medications (47%), intravenous fluids (46%), specialty consultation (20%), restraints (14%), imaging (6%), and laceration repair (3%). Attendance at pop and electronic dance music concerts was associated with the widest ranges of GCS scores (8–15 and 6–14 respectively), mass casualty incident declarations, and among the highest mean blood alcohol levels (246 and 244 mg/dL, respectively).ConclusionsSubstance use is the predominant reason for music concert related ED visits and patients may have serious levels of intoxication, receiving multiple medical interventions. These data demonstrate the need for additional large-scale studies to confirm trends and increase awareness of this important public health problem.

Abstract 18677: Increased Disease Complexity and Resource Utilization Among Heart Failure Related Visits in the Emergency Department From 2007-2014

Introduction: With increasing health care costs, complex conditions such as heart failure (HF) are becoming more resource intensive. The epidemiology of HF among pediatric patients is relatively unknown, as well as associated resource utilization. This vulnerable population is complex, with many associated comorbidities. Hypothesis: We aimed to test the hypothesis that complex chronic conditions and resource utilization among pediatric heart failure related (HFR) emergency department (ED) visits has increased over time in a nationally representative dataset. Methods: The National Emergency Department Survey (NEDS) is a nationally representative sample of approximately 135 million emergency department visits across the United States from 2007-2014. Pediatric HFR patient visits were identified via age (&lt;18 years) and ICD-9 codes for heart failure. Complex chronic conditions were coded for 7 common diagnosis groups. Demographic and clinical characteristics are reported. Sample weights are used respective to each year of data. Results: The number of HFR ED visits was stable over time with 5233 in 2007 to 4656 in 2014. In 2014, the mean age of these patients was 4.9 years(SE 0.2), 48%(SE 1.6) were females, and CHD was the diagnosis in 45%(SE 1.6), and cardiomyopathy in 10%(SE 1.0). The most common chronic condition (other than cardiac/congenital or genetic) was gastrointestinal (17.0%), followed by neuromuscular (7.9%) and metabolic (6.8%). The proportion of HFR ED visits with 3 or more complex chronic conditions rose from 12.4% in 2007 to 18.1% in 2014. Median total charges for HFR ED visit increased by 47% between 2007 to 2014 [$1296 (CI 1243-1349) to $1908 (CI 1766-2055), respectively]. For HF patients with 3+ complex chronic conditions, mean total charges increased 79% from $1360(SE 101) to $2434(SE 182). Conclusions: While the total HFR ED visits over the decade from 2007 to 2014 remained stable, the proportion of pediatric HFR ED visits with complex chronic conditions increased along with charges associated with care. These results highlight the increasing complexity of pediatric HF patients and the need for further study to develop optimal care models in this challenging population.

Home supply of emergency oral steroids and reduction in asthma healthcare utilization.

To determine if children with moderate-to-severe persistent asthma have decreased healthcare utilization after receiving a prescription and instructions to use an at home emergency supply of oral steroids during asthma exacerbations. A quasi-experimental design study with a historical control from retrospective chart review was performed for patients aged 2-18 years seen in a tertiary care pediatric pulmonary clinic for moderate to severe persistent asthma. Baseline utilization of the emergency department, inpatient hospital, and pediatric intensive care unit for asthma exacerbations was collected from 24 months prior to initial prescription for at home steroids and compared with 12 months post-intervention using Poisson Regression. A subgroup analysis was performed for ages 6-18 evaluating school age children alone. Patients (N = 132) were averaged 10 years ± 3.9 years of age and 57% of patients were male. Emergency Department visit rates significantly declined in the 12 months after receiving a prescription and instructions for home emergency steroid supply compared with the 12 months prior to this intervention (0.39 visits/patient/year vs 0.67, P < 0.01). There was a trend for a decline in inpatient (0.27 visits/patient/year vs 0.11, P = 0.09) and pediatric intensive care unit stay rates (0.11 visits/patient/year vs 0.05, P = 0.06). A subgroup analysis of ages 6-18 found similar results. Incorporation of home emergency oral steroids into the home management plan of children with moderate-to-severe asthma can reduce asthma related Emergency Department visits.

Real-time surveillance of heat-related morbidity: Relation to excess mortality associated with extreme heat.

The impact of heat on mortality is well documented but deaths tend to occur after (or lag) extreme heat events, and mortality data is generally not available for timely surveillance during extreme heat events. Recently, systems for near-real time surveillance of heat illness have been reported but have not been validated as predictors of non-external cause of deaths associated with extreme heat events. We analyzed associations between daily weather conditions, emergency medical system (EMS) calls flagged as heat-related by EMS dispatchers, emergency department (ED) visits classified as heat-related based on chief complaint text, and excess non-external cause mortality in New York City. EMS and ED data were obtained from data reported daily to the city health department for syndromic surveillance. We fit generalized linear models to assess the relationships of daily counts of heat related EMS and ED visits to non-external cause deaths after adjustment for weather conditions during the months of May-September between 1999 and 2013. Controlling for temporal trends, a 7% (95% confidence interval (CI): 2–12) and 6% (95% CI: 3–10) increase in non-external cause mortality was associated with an increase from the 50th percentile to 99th percentile of same-day and one-day lagged heat-related EMS calls and ED visits, respectively. After controlling for both temporal trends and weather, we observed a 7% (95% CI: 3–12) increase in non-external cause mortality associated with one-day lagged heat-related EMS calls and a 5% mortality increase with one-day lagged ED visits (95% CI: 2–8). Heat-related illness can be tracked during extreme heat events using EMS and ED data which are indicators of heat associated excess non-external cause mortality during the warm weather season.

Trends in Adult Cancer–Related Emergency Department Utilization

ImportanceThe emergency department (ED) is used to manage cancer-related complications among the 15.5 million people living with cancer in the United States. However, ED utilization patterns by the population of US adults with cancer have not been previously evaluated or described in published literature.ObjectiveTo estimate the proportion of US ED visits made by adults with a cancer diagnosis, understand the clinical presentation of adult patients with cancer in the ED, and examine factors related to inpatient admission within this population.Design, Setting, and ParticipantsNationally representative data comprised of 7 survey cycles (January 2006-December 2012) from the Nationwide Emergency Department Sample were analyzed. Identification of adult (age ≥18 years) cancer-related visits was based on Clinical Classifications Software diagnoses documented during the ED visit. Weighted frequencies and proportions of ED visits among adult patients with cancer by demographic, geographic, and clinical characteristics were calculated. Weighted multivariable logistic regression was used to examine the associations between inpatient admission and key demographic and clinical variables for adult cancer–related ED visits.Main Outcomes and MeasuresAdult cancer–related ED utilization patterns; identification of primary reason for ED visit; patient-related factors associated with inpatient admission from the ED.ResultsAmong an estimated 696 million weighted adult ED visits from January 2006 to December 2012, 29.5 million (4.2%) were made by a patient with a cancer diagnosis. The most common cancers associated with an ED visit were breast, prostate, and lung cancer, and most common primary reasons for visit were pneumonia (4.5%), nonspecific chest pain (3.7%), and urinary tract infection (3.2%). Adult cancer–related ED visits resulted in inpatient admissions more frequently (59.7%) than non–cancer-related visits (16.3%) (P < .001). Septicemia (odds ratio [OR], 91.2; 95% CI, 81.2-102.3) and intestinal obstruction (OR, 10.94; 95% CI, 10.6-11.4) were associated with the highest odds of inpatient admission.Conclusions and RelevanceConsistent with national prevalence statistics among adults, breast, prostate, and lung cancer were the most common cancer diagnoses presenting to the ED. Pneumonia was the most common reason for adult cancer–related ED visits with an associated high inpatient admission rate. This analysis highlights cancer-specific ED clinical presentations and the opportunity to inform patient and system-directed prevention and management strategies.

Characterizing the Effects of Extreme Cold Using Real-time Syndromic Surveillance, Ontario, Canada, 2010-2016.

Morbidity and mortality from exposure to extreme cold highlight the need for meaningful temperature thresholds to activate public health alerts. We analyzed emergency department (ED) records for cold temperature-related visits collected by the Acute Care Enhanced Surveillance system-a syndromic surveillance system that captures data on ED visits from hospitals in Ontario-for geographic trends related to ambient winter temperature. We used 3 Early Aberration Reporting System algorithms of increasing sensitivity-C1, C2, and C3-to determine the temperature at which anomalous counts of cold temperature-related ED visits occurred in northern and southern Ontario from 2010 to 2016. The C2 algorithm was the most sensitive detection method. Results showed lower threshold temperatures for Acute Care Enhanced Surveillance alerts in northern Ontario than in southern Ontario. Public health alerts for cold temperature warnings that are based on cold temperature-related ED visit counts and ambient temperature may improve the accuracy of public warnings about cold temperature risks.

Using Sydromic Surveillance to Track E-cigarette Related Emergency Department Visits

ObjectiveTo explore the use of emergency department syndromicsurveillance data to identify adverse health events related to electroniccigarettes in order in enhance existing surveillance.IntroductionThe North Dakota Department of Health (NDDoH) investigatedthe feasibility of using syndromic surveillance (SyS) data to identifyhealth care visits due to electronic cigarette (e-cigarette) use.E-cigarettes have been associated with injuries and fatalities in allage groups, including young children attracted to the colorful liquidnicotine carriage packaging [1]. Previously, poison control data wasthe only resource available to the NDDoH for e-cigarette adverseoutcomes surveillance.MethodsData for all visits from June 28, 2014 to June 28, 2015 weredownloaded using the BioSense 2.0 SyS analytic tool. Excel was usedto identify visits containing key words related to e-cigarettes in line-level data. We initially searched for visits using variations of the term“e-cigarette.” After meeting with NDDoH subject matter experts, weexpanded our search to include other related terms: nicotine, clouding,vaping and variations of “electronic nicotine delivery system(ENDS)”. No diagnosis codes were used as none refer specifically toe-cigarettes. Visits were identified solely through searching free textchief complaint and triage notes fields. Not all facilities participatingin the NDDoH SyS program during this time period submitted freetext data.ResultsOut of 650,069 unique visits, four e-cigarette-related visits wereidentified in rich-text data fields searching for “E-cig” and “E cig.”An additional visit was identified using the search term “nicotine,”although this search primarily identified visits including referencesto nicotine patches. Of the five visits identified, two were poisoningsresulting from small children sucking on liquid nicotine cartridges,one referred to eye irritation as a result of accidentally using liquidnicotine as eye drops, and two referred to cardiac issues (chestpain, heart palpitations) after e-cigarette use. Searches includingterms “clouding” and “vaping,” street terms related to e-cigarettes,did not result in the identification of any additional visits related toe-cigarettes; nor did searches related to ENDS. Poison control datafrom the same time period yielded two calls related to e-cigaretteadverse events.ConclusionsIt is possible to identify emergency department visits associatedwith e-cigarette use utilizing SyS data. More visits were identifiedusing SyS data than poison control data, although neither sourceidentified many occurrences of adverse outcomes related toe-cigarettes. E-cig, e cig and nicotine were the most useful searchterms, although a search for “nicotine” must exclude the word “patch”to avoid false identifications. The NDDoH receives free-text data fora majority of the visits in our system, but not all facilities submitfree-text fields, and the number that did varied over the study period.Because no drop-down chief complaints or diagnosis codes relatedto e-cigarettes exist, data from facilities that did not provide free textdata were not helpful in identifying e-cigarette-related visits. Thisinvestigation emphasizes the need for free text fields when using SySto investigate emerging issues.

Monitoring child mental health related emergency department visits in New York City

ObjectiveTo assess the use of syndromic surveillance to assess trends inmental health-related emergency department (ED) visits amongschool-aged children and adolescents in New York City (NYC).IntroductionFrom 2001-2011, mental health-related hospitalizations and EDvisits increased among United States children nationwide [1]. Duringthis period, mental health-related hospitalizations among NYCchildren increased nearly 23% [2]. To estimate mental health-relatedED visits in NYC and assess the use of syndromic surveillance chiefcomplaint data to monitor these visits, we compared trends from anear real-time syndromic system with those from a less timely, codedED visit database.MethodsThe NYC ED syndromic surveillance system receives anonymizedpatient chief complaint and basic demographic data for nearly everyED visit citywide to provide timely surveillance information tohealth authorities. Using NYC ED syndromic surveillance datafrom 2003-2015, we applied previously developed definitions forgeneral psychiatric syndromes. We aggregated ED visits by agegroup (5-12 years, 13-17 years, and 18-20 years), geography, andtemporality. Syndromic data were compared with Statewide Planningand Research Collaborative System (SPARCS) data from 2006-2014which reported mental health diagnosis (ICD-9), treatment, service,and basic demographics for patients visiting facilities in NYC. Usingthese two data sources, we compared daily visit patterns and annualtrends overall as well as stratified by age group, area-based poverty(ZIP code), and time of visit.ResultsBoth syndromic surveillance and SPARCS data for NYC showedan increasing trend during the period. While both showed relativeincreases with similar slopes, mental health-related chief complaintdata captured fewer overall visits than the ICD-9 coded SPARCSdata. Trends in syndromic data during 2003-2015 differed by age-group and area-based poverty, e.g., among children ages 5-12 yearsthe annual proportion of mental health-related ED visits increasedroughly 3-fold from 1.2% to 3.8% in the poorest areas, which wasgreater than the increase in the richest areas (1.7% to 2.6%). Seasonal,day-of-week, and school holiday patterns found far fewer visits duringthe periods of NYC public school breaks (Figure).ConclusionsWe conclude that syndromic surveillance data can provide areliable indicator of mental health-related ED visit trends. Thesefindings suggest potential benefit of syndromic surveillance data asthey may help capture temporal and spatial clustering of events in amuch more timely manner than the &gt;1 year delay in availability ofED discharge data. Next steps include a qualitative study exploringthe causes of these patterns and the role of various factors drivingthem, as well as use of patient disposition and matched data to bettercharacterize ED visit patient outcomes.

Sharp Rise in Concurrent Benzodiazepine and Opioid Use in the U.S.

Opioid overdose–related deaths have risen dramatically in recent years, and many of those deaths involved benzodiazepines (NEJM JW Gen Med Sep 1 2015 and BMJ 2015; 350:h2698). In this retrospective analysis of U.S. claims data, researchers assessed concurrent opioid and benzodiazepine use and its effect on opioid overdose–related emergency department (ED) …

Child Injury: Does home matter?

ABSTRACTObjectivesTo examine the relationship between home risk and hospital treated injury in Australian children up to five years of age. ApproachWomen with children between two and four years of age enrolled in an Australian longitudinal birth cohort study, Environments for Healthy Living (EFHL) between 2009 and 2011, were invited to complete a Home Injury Prevention survey. A total home risk score (HRS) was calculated and linked to EFHL baseline demographic survey and perinatal data. The child’s injury related state-wide hospital emergency department and admissions data was extracted from the child’s date of birth until 31 December 2013. Multiple imputation methods were used to impute incomplete multivariate exposure factors. Zero-inflated poisson regression was used to estimate crude and adjusted rate ratios (RRs) between exposure (HRS quartiles) and outcome (count of injury related episodes of care) for child participants, accounting for individual person-years of exposure time.ResultsData from 566 child participants were included with outcomes data available for 97% of the cohort. Using data linkage of administrative health records with multiple survey data sources, we found an inverse relationship between home risk and child injury, with children living in homes with the least injury risk (based on the absence of hazardous structural features of the home and safe practices reported) having 1.90 times the injury rate of children living in high risk homes (95% CI 1.15-3.14). Whilst this appears counter-intuitive, families in the lowest risk homes were more likely to be socio-economically disadvantaged than families in the highest risk homes (more sole parents, lower maternal education levels, younger maternal age and lower income). After adjusting for demographic and socio-economic factors, the relationship between home risk and injury was no longer significant (p&gt;0.05). Discussion and conclusionsThrough the use of comprehensive linkage of five years of state-wide administrative health data, combined with individual survey data methods, this study overcame the most significant threat to longitudinal research – loss to follow-up. Our results demonstrated that children in socio-economically deprived families have higher rates of injury, despite living in a physical environment that contains substantially fewer injury risks than their less deprived counterparts. These findings support continued efforts to implement societal-wide, long term policy and practice changes to address the socioeconomic differentials in child health outcomes.

The relationship between diabetes mellitus and 30-day readmission rates

BackgroundIt is estimated that 9.3% of the population in the United States have diabetes mellitus (DM), 28% of which are undiagnosed. The high prevalence of DM makes it a common comorbid condition in hospitalized patients. In recent years, government agencies and healthcare systems have increasingly focused on 30-day readmission rates to determine the complexity of their patient populations and to improve quality. Thirty-day readmission rates for hospitalized patients with DM are reported to be between 14.4 and 22.7%, much higher than the rate for all hospitalized patients (8.5–13.5%). The objectives of this study were to (1) determine the incidence and causes of 30-day readmission rates for patients with diabetes listed as either the primary reason for the index admission or with diabetes listed as a secondary diagnosis compared to those without DM and (2) evaluate the impact on readmission of two specialized inpatient DM services: the Hyperglycemic Intensive Insulin Program (HIIP) and Endocrine Consults (ENDO).MethodsFor this study, DM was defined as any ICD-9 discharge diagnosis (principal or secondary) of 250.xx. Readmissions were defined as any unscheduled inpatient admission, emergency department (ED) visit, or observation unit stay. We analyzed two separate sets of patient data. The first pilot study was a retrospective chart review of all patients with a principle or secondary admission diagnosis of diabetes admitted to any adult service within the University of Michigan Health System (UMHS) between October 1, 2013 and December 31, 2013. We then did further uncontrolled analysis of the patients with a principal admitting diagnosis of diabetes. The second larger retrospective study included all adults discharged from UMHS between October 1, 2013 and September 30, 2014 with principal or secondary discharge diagnosis of DM (ICD-9-CM: 250.xx).ResultsIn the pilot study of 7763 admissions, the readmission rate was 26% for patients with DM and 22% for patients without DM. In patients with a primary diagnosis of DM on index admission, the most common cause for readmission was DM-related. In the larger study were 37,702 adult inpatient discharges between October 1, 2013 and September 30, 2014. Of these, 20.9% had DM listed as an encounter diagnosis. Rates for all encounters (inpatient, ED and Observation care) were 24.3% in patients with DM compared to 17.7% in those without DM (p < 0.001). The most common cause for readmission in patients with DM as a secondary diagnosis to the index admission was infection-related.During the index hospital stay, only a small proportion of patients with DM (approximately 12%) received any DM service consult. Those who received a DM consult had a higher case mix index compared to those who did not. Despite the higher acuity, there was a lower rate of ED /observation readmission in patients followed by the DM services (6.6% HIIP or ENDO vs. 9.6% no HIIP or ENDO, p = 0.0012), though no difference in the inpatient readmission rates (17.6% HIIP or ENDO vs. 17.4% no HIIP or ENDO, p = 0.89) was noted.ConclusionsPatients with both a primary or secondary diagnosis of DM have higher readmission rates. The reasons for readmission vary; patients with a principal diagnosis of DM have more DM related readmissions and those with secondary diagnosis having more infection-related readmissions. DM services were used in a small proportion of patients and may have contributed to lower DM related ED revisits. Further prospective studies evaluating the role of these services in terms of glucose management, patient education and outpatient follow up on readmission are needed to identify interventions important to reducing readmission rates.

Challenges of Treating Methamphetamine-Positive Patients

Methamphetamines are addictive stimulants that induce dopamine release, a sense of euphoria, and increased libido. The effects of methamphetamine in inhibiting control of cognitive behavior and increasing arousability are thought to augment the potential for violence. Withdrawal from methamphetamine produces symptoms such as depression, fatigue, hypersomnolence, irritability, and agitation. Per the National Survey of Drug Use and Health (NSDUH), abuse of methamphetamine has increased in the past few years from 440,000 in 2012 to 569,000 in 2014. Wider use in the general population has led to an escalation in related emergency department visits and mounting expenditures due to prolonged length of hospitalization.

Abstract MP021: Identification of “At Risk” and “Resilient” CVD Census Tracts in the Morehouse-Emory Cardiovascular (MECA) Study

The MECA study is unique in that it will study CVD resilience in blacks at both the individual and community (census tract) level in the Atlanta Metropolitan Area. It is well established that blacks suffer from greater cardiovascular morbidity and mortality than whites in the United States. Not all blacks suffer from poor cardiovascular health, some individuals manage to live long healthy lives without ever developing cardiovascular conditions. The causes of this resilience are not known. Both individual and community level factors may be responsible for cardiovascular risk and resilience in blacks. The first stage of the MECA study was to identify “at risk” and resilient communities based on their rates of CVD related ED visits, hospitalizations and mortality. Objectives: To determine if in fact a wide distribution of CVD rates exist among Blacks in census tracts in Metro Atlanta. To determine if there were still large differences in rates when black household income was controlled for. Methods: Count data on CVD related emergency department and hospitalizations for blacks aged 35-64 living in census tracts in the Atlanta--Athens-Clarke--Sandy Springs combined statistical area during 2010-2014 were obtained from the Georgia Hospital Association. CVD mortality data for the same population for the same time period were obtained from the Georgia Department of Public Health. In order to control for the socioeconomic status, age and gender distribution of the neighborhoods, negative binomial regression models controlling for median black household income, percent of 5-year age groupings, and percent male were estimated for each of the outcomes. Residuals in top 25% were considered to be “at risk tracts (high rate) while residuals in the bottom 25% were considered resilient (low rate tracts). Results: 106 tracts were resilient for at least 2 of the 3 outcomes, 188 were “at risk” for 2 out of 3 outcomes. Both types of tracts were located throughout the Atlanta metropolitan area. Mean black household income in the tracts are similar (resilient: $46,335, “at risk”: $44,721). Black CVD hospitalization event rate was 28 vs. 132 per 1000 population(p&lt;.0001) for resilient tracts vs “at risk” tracts. Black CVD ED visit event rate and CVD mortality rate was also lower in resilient (ED: 33 per 1000 pop; Mortality: 8 deaths per 1000 pop) than “at risk” (ED: 147/ 1000 pop; Mortality: 14 deaths per 1000 pop) census tracts. Conclusion: We have identified census tracts in Metro Atlanta that have large differences in premature CVD outcomes for Blacks despite having similar mean income levels. The next phase of the MECA study will examine census tract and survey data to elucidate what contextual (demographic, food environment, reported neighborhood characteristics) and individual level (behavioral, psychological, social) factors may be associated with the different rates of CVD in resilient and “at risk” census tracts.

Individual and county level predictors of asthma related emergency department visits among children on Medicaid: A multilevel approach

ABSTRACTObjective: Disparities in asthma outcomes are well documented in the United States. Interventions to promote equity in asthma outcomes could target factors at the individual and community levels. The objective of this analysis was to understand the effect of individual (race, gender, age, and preventive inhaler use) and county-level factors (demographic, socioeconomic, health care, air-quality) on asthma emergency department (ED) visits among Medicaid-enrolled children. This was a retrospective cohort study of Medicaid-enrolled children with asthma in 29 states in 2009. Multilevel regression models of asthma ED visits were constructed utilizing individual-level variables (race, gender, age, and preventive inhaler use) from the Medicaid enrollment file and county-level variables reflecting population and health system characteristics from the Area Resource File (ARF). County-level measures of air quality were obtained from Environmental Protection Agency (EPA) data. Results: The primary modifiable risk factor at the individual level was found to be the ratio of long-term controller medications to total asthma medications. County-level factors accounted for roughly 6% of the variance in the asthma ED visit risk. Increasing county-level racial segregation (OR=1.04, 95% CI=1.01-1.08) was associated with increasing risk of asthma ED visits. Greater supply of pulmonary physicians at the county level (OR=0.81, 95% CI=0.68-0.97) was associated with a reduction in risk of asthma ED visits. Conclusions: At the patient care level, proper use of controller medications is the factor most amenable to intervention. There is also a societal imperative to address negative social determinants, such as residential segregation.

A Randomized Controlled Trial of a Citywide Emergency Department Care Coordination Program to Reduce Prescription Opioid Related Emergency Department Visits

BackgroundIncreasing prescription overdose deaths have demonstrated the need for safer emergency department (ED) prescribing practices for patients who are frequent ED users. ObjectivesWe hypothesized that the care of frequent ED users would improve using a citywide care coordination program combined with an ED care coordination information system, as measured by fewer ED visits by and decreased controlled substance prescribing to these patients. MethodsWe conducted a multisite randomized controlled trial (RCT) across all EDs in a metropolitan area; 165 patients with the most ED visits for complaints of pain were randomized. For the treatment arm, drivers of ED use were identified by medical record review. Patients and their primary care providers were contacted by phone. Each patient was discussed at a community multidisciplinary meeting where recommendations for ED care were formed. The ED care recommendations were stored in an ED information exchange system that faxed them to the treating ED provider when the patient presented to the ED. The control arm was subjected to treatment as usual. ResultsThe intervention arm experienced a 34% decrease (incident rate ratios = 0.66, p < 0.001; 95% confidence interval 0.57–0.78) in ED visits and an 80% decrease (odds ratio = 0.21, p = 0.001) in the odds of receiving an opioid prescription from the ED relative to the control group. Declines of 43.7%, 53.1%, 52.9%, and 53.1% were observed in the treatment group for morphine milligram equivalents, controlled substance pills, prescriptions, and prescribers, respectively. ConclusionThis RCT showed the effectiveness of a citywide ED care coordination program in reducing ED visits and controlled substance prescribing.

Impact of meteorological parameters and air pollution on emergency department visits for cardiovascular diseases in the city of Zagreb, Croatia.

The aim of this study was to investigate whether nitrogen dioxide (NO2), ozone (O3), and certain meteorological conditions had an impact on cardiovascular disease (CVD)-related emergency department (ED) visits in the metropolitan area of Zagreb. This retrospective, ecological study included 20,228 patients with a cardiovascular disease as their primary diagnosis who were examined in the EDs of two Croatian University Hospitals, Sisters of Charity and Holy Spirit, in the study period July 2008-June 2010. The median of daily CVD-related ED visits during the study period was 28 and was the highest during winter. A significant negative correlation was found between CVD-related emergency visits and air temperature measured no more than three days prior to the visit, and the highest negative correlation coefficient was measured two days earlier (R=0.266, p≤0.001). The number of CVD-related emergency visits significantly correlated with the average NO2 concentration on the same day (R=0.191, p<0.001). The results of multiple stepwise regression analysis showed that the number of CVD-related emergency visits depended on air temperature, and NO2 and O3 concentrations. The higher the air temperatures, the lower the number of daily CVD-related emergency visits (p<0.001). An increase in NO2 concentrations (p=0.005) and a decrease in O3 concentrations of two days earlier (p=0.006) led to an increase in CVD-related ED visits. In conclusion, the decrease in O3 concentrations and the increase in NO2, even if below the legally binding thresholds, could be associated with an increase in CVD-related emergency visits and a similar effect was observed with lower temperature measured no more than three days prior to the visit.

Age-related trends in injury and injury severity presenting to emergency departments in New South Wales Australia: Implications for major injury surveillance and trauma systems

ObjectivesTo describe population based trends and clinical characteristics of injury related presentations to Emergency Departments (EDs). Design and settingA retrospective, descriptive analysis of de-identified linked ED data across New South Wales, Australia over five calendar years, from 2010 to 2014. ParticipantsPatients were included in this analysis if they presented to an Emergency Department and had an injury related diagnosis. Injury severity was categorised into critical (triage category 1–2 and admitted to ICU or operating theatre, or died in ED), serious (admitted as an in-patient, excluding above critical injuries) and minor injuries (discharged from ED). Main outcome measuresThe outcomes of interest were rates of injury related presentations to EDs by age groups and injury severity. ResultsA total of 2.09 million injury related ED presentations were analysed. Minor injuries comprised 85.0%, and 14.1% and 1.0% were serious and critical injuries respectively. There was a 15.8% per annum increase in the rate of critical injuries per 1000 population in those 80 years and over, with the most common diagnosis being head injuries. Around 40% of those with critical injuries presented directly to a major trauma centre. ConclusionCritical injuries in the elderly have risen dramatically in recent years. A minority of critical injuries present directly to major trauma centres. Trauma service provision models need revision to ensure appropriate patient care. Injury surveillance is needed to understand the external causes of injury presenting to hospital.