Repeat Emergency Department Visits Research Articles

342 COVID 19 Infection Is Associated With Repeat Emergency Department Visits

As COVID-19 persists and the number of people with prior infection increases, the long-term sequelae are still being discovered. These long-term effects create the potential for previously infected to seek care in the emergency department (ED). The objective this study is to determine if there is an association between COVID-19 infection and subsequent ED utilization and to describe the reason for return visits.

Increased demand for paramedic transports to the emergency department in Ontario, Canada: a population-level descriptive study from 2010 to 2019

PurposeWe examined changes in annual paramedic transport incidence over the ten years prior to COVID-19 in comparison to increases in population growth and emergency department (ED) visitation by walk-in.MethodsWe conducted a population-level cohort study using the National Ambulatory Care Reporting System from January 1, 2010 to December 31, 2019 in Ontario, Canada. We included all patients triaged in the ED who arrived by either paramedic transport or walk-in. We clustered geographical regions using the Local Health Integration Network boundaries. Descriptive statistics, rate ratios (RR), and 95% confidence intervals were calculated to explore population-adjusted changes in transport volumes.ResultsOverall incidence of paramedic transports increased by 38.3% (n = 264,134), exceeding population growth fourfold (9.4%) and walk-in ED visitation threefold (13.4%). Population-adjusted transport rates increased by 26.2% (rate ratio 1.26, 95% CI 1.26–1.27) compared to 3.4% for ED visit by walk-in (rate ratio 1.03, 95% CI 1.03–1.04). Patient and visit characteristics remained consistent (age, gender, triage acuity, number of comorbidities, ED disposition, 30-day repeat ED visits) across the years of study. The majority of transports in 2019 had non-emergent triage scores (60.0%) and were discharged home directly from the ED (63.7%). The largest users were persons aged 65 or greater (43.7%). The majority of transports occurred in urbanized regions, though rural and northern regions experienced similar paramedic transport growth rates.ConclusionThere was a substantial increase in the demand for paramedic transportation. Growth in paramedic demand outpaced population growth markedly and may continue to surge alongside population aging. Increases in the rate of paramedic transports per population were not bound to urbanized regions, but were province-wide. Our findings indicate a mounting need to develop innovative solutions to meet the increased demand on paramedic services and to implement long-term strategies across provincial paramedic systems.

Repeat Emergency Visits for Mental Health Patients: Before and during the Covid19 pandemic

IntroductionFrequent users of Emergency Departments (EDs) are a diverse group accounting for disproportionate EDs visits. Psychiatric patients are more likely to visit EDs (Slankamenac, 2020). EDs utilisation by psychiatric patients increased by 4.4% during COVID-19 pandemic.Objectivesto determine frequent users characteristics within an Ottawa University Hospital, and assess Covid19 impact on overutilization of EDs compared to other hospitals.MethodsRetrospective study of repeat visits characteristics, data extracted from EMR database. Repeat visits defined as no less than 30 days first visit to any EDs. Period of observation: March 1st, 2018 - February 28th, 2021 Results.Results64% EDS visits for MH, 35% for addictions. More men (57%), age groups: 16-34 y.o. (41%), 34-64 y.o. (51%), 65 +y.o. (8%).Top presenting reasons: suicidality, self-harm, depression (40.5%). Anxiety, situational crisis (16%), bizarre behavior (12%).Most prevalent diagnoses: schizophrenia (28.7%), stress and anxiety (25.2%), personality disorders (13.5%) and depressive episode (10.6%). Only 35.1% admitted after repeat ED visits, 35.1% came by ambulance. Increase during peak pandemic exceeding 20%. Clearly pandemic created more pressures for MH services needs.ConclusionsSchizophrenia and personality disorders made most prevalent diagnostic groups. Even when patients are in acute needs, they do not always require hospitalization. Investigating what MH conditions that got more stressed by the Covid19 pandemic will be of interest.DisclosureNo significant relationships.

Predicting emergency department utilization among children with asthma using deep learning models

Pediatric asthma is a leading cause of emergency department (ED) utilization, which is expensive and often preventable. Therefore, development of ED utilization predictive models that can accurately predict patients at high-risk of frequent ED use and subsequently steering their treatment pathway towards more personalized interventions, has high clinical utility. In this paper, we investigate the extent to which deep learning models, specifically recurrent neural networks (RNNs), coupled with routinely collected electronic health record (EHR) clinical data can predict the frequency of emergency department utilization among children with asthma.We use retrospective longitudinal EHR data of 87,413 children with asthma aged 0–18 years, who were attributed to one or more healthcare facility for at least 2 consecutive years between 2000–2013. The models were trained for the task of predicting the frequency of emergency department visits in the next 12 months. We compared prediction results of three recurrent neural network (RNN) models: bidirectional long short-term memory (BiLSTM), bidirectional gated recurrent unit (BiGRU), and reverse time attention model (RETAIN), to a baseline multinomial logistic regression model. We assessed the predictive accuracy of the models using receiver operating characteristic curve (AUC–ROC), precision–recall curve (AUC-PR), and F1-score.The results indicated that all RNN models have similar performances reaching AUC–ROC: 0.85, AUC-PR: 0.74, and F1-score: 0.61, compared to AUC–ROC: 0.81, AUC-PR: 0.69, and F1-score: 0.56 for a baseline multinomial logistic regression.Predictive models created from large routinely available EHR data using RNN models can accurately identify children with asthma at high-risk of repeated ED visits, without interacting with the patient or collecting information beyond the patient’s EHR.

Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis

ObjectivesTo identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the...

Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic.

Pediatric Mental Health Emergency Department Visits and Access to Inpatient Care: A Crisis Worsened by the COVID-19 Pandemic.

Association between primary care appointment lengths and subsequent ambulatory reassessment, emergency department care, and hospitalization: a cohort study

BackgroundTo meet increasing demand, healthcare systems may leverage shorter appointment lengths to compensate for a limited supply of primary care providers (PCPs). Limiting the time spent with patients when evaluating acute health needs may adversely affect quality of care and increase subsequent healthcare utilization; however, the impact of brief duration appointments on healthcare utilization in the United States has not been examined. This study aimed to assess for potential inferiority of shorter (15-min) primary care appointments compare to longer (≥ 30-min appointments) with respect to downstream healthcare utilization within 7 days of the initial appointment.MethodsWe performed a retrospective cohort study using electronic health record (EHR), billing, and administrative scheduling data from five primary care practices in Midwest United States. Adult patients seen for acute Evaluation & Management visits between 10/1/2015 and 9/30/2017 were included. Patients scheduled for 15-min appointments were propensity score matched to those scheduled for ≥ 30-min. Multivariate regression models examined the effects of appointment length on repeat primary care visits, emergency department (ED) visits, hospitalizations, and diagnostic services within 7 days following the visit. Models were adjusted for baseline patient, visit, and provider characteristics. A non-inferiority approach was employed.ResultsWe identified 173,758 total index visits (6.5% 15-min, 93.5% ≥ 30-min). 11,222 15-min appointments were matched to a comparable ≥ 30-min visit. Longer appointments were more frequent among trainee physicians, patients with limited English proficiency, and patients with more comorbidities. There was no significant effect of scheduled appointment length on the incidence of repeat primary care visits (OR = 0.983, CI: 0.873, 1.106) or ED visits (OR = 0.856, CI: 0.700, 1.047). Shorter appointments were associated with lower rates of subsequent hospitalizations (OR = 0.689, CI: 0.504, 0.941), laboratory services (OR = 0.682, CI: 0.643, 0.724), and diagnostic imaging services (OR = 0.499, CI: 0.466, 0.534). None of the non-inferiority thresholds were exceeded.ConclusionsFor select indications and select low risk patients, shorter duration appointments may be a non-inferior option for scheduling of patient care that will not result in greater downstream healthcare utilization. These findings can help inform healthcare delivery models and triage processes as health systems and payers re-examine how to best deliver care to growing patient populations.

Reasons for repeated emergency department visits among community-dwelling older adults with dementia in Ontario, Canada.

Community-dwelling older adults living with dementia visit the emergency department (ED) more frequently than other older adults, but research on the reasons for repeated visits is lacking. We examined the rate of repeated ED visits and reasons for visits in a cohort of individuals with dementia. We conducted a population-based retrospective cohort study of community-dwelling older adults (≥66 years) living with dementia in Ontario, Canada, who visited the ED and were discharged home between April 1, 2010, and March 31, 2019. We calculated the proportion of the population with one, two, and three or more repeat ED visits within 1 year of the baseline visit and the categorized the reason for the visits. Our cohort contained 175,863 individuals with dementia who visited the ED at least once. Overall, 66.1% returned at least once to the ED within 1year, 39.4% returned twice, and 23.5% returned 3 or more times. Visit reasons were heterogenous and were most frequently related to general signs and symptoms (25.3%) while being infrequently due to cognitive or behavioral reasons (5.9%). Individuals typically visited for different reasons across successive visits. Community-dwelling older adults with dementia who visited an ED were very likely to return to the ED within a year, with a substantial proportion visiting multiple times. The high frequency of repeated visits for different reasons highlights the complexity of caring for this population and indicates greater need for comprehensive community and primary care as well as timely communication between the ED and the community.

Manual Uterine Aspiration in the Emergency Department as a First-Line Therapy for Early Pregnancy Loss: A Single-Centre Retrospective Study

ObjectivesManual uterine aspiration (MUA) is a currently underused management option for early pregnancy loss (EPL) in the emergency department (ED). This study addresses the safety and efficiency of MUA in the ED. MethodsWe performed a single-site retrospective observational chart review of pregnant women presenting to the ED with vaginal bleeding and ED pathology submissions for products of conception (POC) between 2012 and 2016. Patients were excluded for gestational age >14 weeks, no evidence of pregnancy loss, uterine cavity anomaly, hemodynamic instability, or hemoglobin <80 g/L. We compared the frequencies of complications (need for blood transfusion, repeat ED visit, failed initial management, admission to hospital) and ED utilization time between 4 management options: expectant, misoprostol, MUA, and electric vacuum aspiration (EVA) outside the ED, as well as time to procedure between MUA and EVA. ResultsA total of 162 patients were included with 123 (76%) having a pathology report positive for POC. The mean patient and gestational ages were 30 ± 7 years and 66 ± 17 days, respectively. One hundred nine patients were managed expectantly, 9 were given misoprostol, 23 underwent MUA, and 21 underwent EVA. Composite complication rates were 40%, 33%, 9%, and 10% (P = 0.001), and mean ED times were 5.4, 4.9, 7.3, and 6.0 hours (P = 0.01), for expectant, misoprostol, MUA, and EVA, respectively. The mean time to procedure was 5.1 hours for MUA and 23.1 hours for EVA (p=0.002). ConclusionsIntegrating MUA in the ED has the potential to reduce health care resource utilization while improving patient care.

Factors Associated With Repeat Emergency Department Visits for Low Back Pain.

BackgroundLow back pain represents 2-3% of Emergency Department (ED) visits. In this study, we aimed to identify patient and treatment-related variables that contributed to repeat visits to the ED for low back pain within a 12-month period.MethodologyWe conducted a retrospective review of adult patients presenting to the ED of one hospital over a two-year period with the primary diagnosis of low back pain. The primary outcome included return to the ED within 12 months with the same complaint, and the secondary outcome included return to the ED within 30 days or six months.ResultsA total of 793 patients met the inclusion criteria. The rate of return to the ED with the same complaint within 30 days, six months, and 12 months of the first visit was 7%, 11%, and 14%, respectively. Patients who received opioids at discharge were more likely to return within 12 months (68% vs. 55%; p = 0.0075) and six months (68% vs. 56%; p = 0.0184) compared to those who did not receive opioids at discharge. Undergoing an X-ray decreased the odds of a 30-day return visit by 70% (p = 0.0067), and by 59% within 12 months (p = 0.0032). Receiving opioids at discharge also doubled the odds of return within 12 months (odds ratio = 2.030, p = 0.0183), while receiving nonsteroidal anti-inflammatory drugs (NSAIDs) reduced the odds by 60% (p = 0.0028).ConclusionsPatients who received opioids at discharge were more likely to have a return visit for low back pain within six and 12 months. Patients who underwent X-rays at the index visit and were prescribed NSAIDs at discharge were less likely to return to the ED for low back pain.

Care transitions intervention reduces ED revisits in cognitively impaired patients.

IntroductionAbout half of older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We tested the effect of an adapted Care Transitions Intervention (CTI) at reducing ED revisits in this vulnerable population.MethodsWe conducted a pre‐planned subgroup analysis of community‐dwelling, cognitively impaired older (age ≥60 years) participants from a randomized controlled trial testing the effectiveness of the CTI adapted for ED‐to‐home transitions. The parent study recruited ED patients from three university‐affiliated hospitals from 2016 to 2019. Subjects eligible for this sub‐analysis had to: (1) have a primary care provider within these health systems; (2) be discharged to a community residence; (3) not receive care management or hospice services; and (4) be cognitively impaired in the ED, as determined by a score >10 on the Blessed Orientation Memory Concentration Test. The primary outcome, ED revisits within 30 days of discharge, was abstracted from medical records and evaluated using logistic regression.ResultsOf our sub‐sample (N = 81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (odds ratio [OR] 0.25, 95% confidence interval [CI] 0.07 to 0.90) but not 14 days (OR 1.01, 95% CI 0.26 to 3.93). Multivariate analysis of outpatient follow‐up found no significant effects.DiscussionCommunity‐dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.

Community paramedic‐delivered care transitions intervention reduces emergency department revisits among cognitively impaired patients

AbstractBackgroundUp to half of community‐dwelling older adults with impaired cognition who are discharged home from the emergency department (ED) return for further care within 30 days. We examined the effects of delivering the Care Transitions Intervention (CTI) to older adult patients with impaired cognition discharged home from the ED, hypothesizing that the CTI would decrease ED revisits in the following 30 days.MethodWe conducted a pre‐planned sub‐analysis of community‐dwelling older adults (age≥60 years) with impaired cognition participating in a single‐blind, randomized controlled trial testing the effectiveness of the CTI adapted for use following ED discharge. The parent study recruited ED patients from three university‐affiliated hospitals from 2016–2019. Subjects eligible for this analysis had to: 1) have a primary care provider within these health systems; 2) be discharged to a community residence; 3) not receive care management or hospice services; and 4) be cognitively impaired in the ED, as determined by a score&gt;10 on the Blessed Orientation Memory Concentration Test. Intervention group subjects received a home visit from a trained paramedic coach within 72 hours of discharge, and up to three follow‐up phone calls during the following month. Our primary outcome was occurrence of any ED revisit within 30 days of discharge. Secondary outcomes included any ED revisit within 14 days and outpatient clinic follow‐up. We evaluated intervention effects using multivariate logistic regression.ResultOf our sub‐sample (N=81, 36 control, 45 treatment), 57% were female and the mean age was 78 years. Bivariate comparison of primary and secondary outcomes found no significant differences. Multivariate analysis, adjusted for the presence of moderate to severe depression and inadequate health literacy, found that the CTI significantly reduced the odds of a repeat ED visit within 30 days (OR 0.25, 95%CI 0.07‐0.90) but not 14 days (OR 1.01, 95%CI 0.26‐3.93). Multivariate analysis of outpatient follow‐up found no significant effects.ConclusionCommunity‐dwelling older adults with cognitive impairment receiving the CTI following ED discharge experienced fewer ED revisits within 30 days compared to usual care. Further studies must confirm and expand upon this finding, identifying features with greatest benefit to patients and caregivers.

Strategies to Optimize Nephrolithiasis Emergency Care (STONE): Prospective Evaluation of an Emergency Department Clinical Pathway

To convene a multi-disciplinary panel to develop a pathway for Emergency Department (ED) patients with suspected nephrolithiasis and then prospectively evaluate its effect on patient care. The STONE Pathway was developed and linked to order sets within our Electronic Health Record in April 2019. Records were prospectively reviewed for ED patients who underwent ultrasound or Computerized Tomography (CT) to evaluate suspected nephrolithiasis between January 2019 and August 2019 within our institution. The primary outcome measure was the proportion of patients whose ED CT was low dose (<4 mSv). Secondary outcome measures included receipt of pathway-concordant pain medications and urine strainers. Order set utilization was evaluated as a process measure. Balance measures assessed included repeat ED visits, imaging, hospitalizations, and a urologic clinic visit or surgery within 30 days of discharge. 441 patients underwent ED imaging, of whom 261 (59%) were evaluated for suspected nephrolithiasis. The STONE Pathway was used in 50 (30%) eligible patients. Patients treated with the Pathway were more likely to undergo low-dose CTs (49% vs 23%, P <.001), and receive guideline-concordant pain medications such as NSAIDs (90% vs 62%, P <.001), and were less likely to return to the ED within 30 days (13% vs 2%, P = .01). These measures demonstrated special cause variation following Pathway release. Clinical pathways increase compliance with evidence-based practices for pain control and imaging in nephrolithiasis emergency care and may improve the delivery of value-based care.

Depression and anxiety screening in emergency department patients with recurrent abdominal pain: An evidence synthesis for a clinical practice guideline.

Recurrent abdominal pain in the emergency department (ED) might represent an opportunity for screening of depression and/or anxiety. We systematically searched five databases for studies evaluating the effect of screening for depression and/or anxiety in ED patients with recurrent and undifferentiated abdominal pain. Given paucity of direct evidence, we also searched for indirect evidence including studies that assessed prevalence of depression and/or anxiety in EDs (not necessarily recurrent abdominal pain), diagnostic accuracy of screening tools, effectiveness of screening in other settings, and outcomes such as repeat ED visits of patients with abdominal pain who were screened in the ED. Two methodologists evaluated certainty in the evidence using the GRADE approach. A total of 4,337 citations were reviewed, and zero studies were found on the effect of screening in patients with recurrent and undifferentiated abdominal pain in the ED. A total of 35studies were included as relevant indirect evidence. In studies of ED patients with abdominal pain, depression ranged from 10% to 29%, while anxiety ranged from 18% to 50%. False positives appear to be an issue given relatively low specificity of screening tools. One randomized trial including ED patients with vague symptoms evaluated the effect of depression screening on a composite outcome of depression recognition, psychiatric consultation, or referral by the emergency physician (risk ratio=1.49, 95% confidence interval [CI]=0.49 to 4.53, very low certainty). One study reported that patients with undifferentiated abdominal pain who screened positive for depression have had increased ED recidivism (odds ratio=3.17, 95% CI=1.14 to 8.85, very low certainty). We were unable to identify any evidence that confirms that depression or anxiety screening in ED patients with recurrent and undifferentiated abdominal pain improves outcomes or changes management downstream.

Suicide and Self-Harm Outcomes Among Psychiatric Emergency Service Patients Diagnosed As Malingering.

Malingering is a common and challenging clinical presentation in emergency departments (EDs). This study describes characteristics and outcomes among patients diagnosed as malingering in a psychiatric emergency service. Index psychiatric ED encounters were identified for all adult patients seen during a 27-month period. Mortality data were obtained for patients from the state public health authority, and repeat ED visits for self-harm were obtained from the state hospital association. Patients with a diagnosis of malingering were compared with those without a malingering diagnosis using correlative statistics and multivariable analyses. Of 4710 encounters analyzed, 236 (5%) had a malingering diagnosis. No patients diagnosed as malingering died of suicide within 365 days of discharge, compared with 16 (0.4%) nonmalingering patients. Self-harm outcomes were available for 2689 encounters; 129 (5%) had a malingering diagnosis. Malingering was significantly associated with a repeat ED visit for self-harm within 365 days in multivariable analyses (adjusted odds ratio 2.52; 95% confidence interval 1.35-4.70); p < 0.01). No psychiatric emergency service patients diagnosed as malingering died by suicide after discharge. New clinical approaches must balance malingering patients' apparent low suicide risk with their other substantial comorbidities and risk for self-harm.

PD03-01 RACIAL AND ETHNIC DISPARITIES IN EMERGENCY CARE AMONG PATIENTS WITH URINARY STONE DISEASE

You have accessJournal of UrologyHealth Services Research: Practice Patterns, Quality of Life and Shared Decision Making I (PD03)1 Sep 2021PD03-01 RACIAL AND ETHNIC DISPARITIES IN EMERGENCY CARE AMONG PATIENTS WITH URINARY STONE DISEASE Joshua Hayden, Hui-Jie Lee, and Charles Scales Joshua HaydenJoshua Hayden More articles by this author , Hui-Jie LeeHui-Jie Lee More articles by this author , and Charles ScalesCharles Scales More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000001967.01AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Symptomatic urinary stone disease is a common cause for emergency department (ED) visits; for some patients, ED revisits often occur before cessation of a stone episode. Little is known regarding how non-clinical factors such as patient race, ethnicity, or insurance status contribute to ED revisit for stone disease. We sought to identify associations between ED revisit and patient race/ethnicity. METHODS: This was a retrospective cohort study of patients in Florida, Georgia, and Maryland who had initial ED treat-and-release visits for urinary stone disease utilizing the state-specific Healthcare Cost and Utilization Project (HCUP) databases between 2016-2017. A repeat ED visit for urinary stones within 30 days of an initial ED encounter was the primary outcome. A generalized estimating equation with a logit link that accounted for hospital-level clustering was employed, using race/ethnicity as the primary predictor and adjusting for other covariates such as age, sex, and primary payer. Race and ethnicity were reported as a single variable by HCUP, with ethnicity taking precedence over race in the assignment; categories were White, Hispanic, Black, and Other/Unknown. RESULTS: Of the 209,309 patients who had an initial treat-and-release ED visit for symptomatic urinary stones, 14,853 (7.1%) had at least one additional ED encounter for symptomatic stones within 30 days of their initial ED visit. Revisit percentages differed among racial/ethnic groups (White 7.5%, Hispanic 6.8%, Black 5.7%, p < 0.001). Black (adjusted odds ratio (aOR) 0.72, 95% confidence interval (CI) 0.67 to 0.76) and Hispanic (aOR 0.88, 95% CI 0.82 to 0.94) individuals were less likely to revisit than White individuals. Primary insurance coverage with Medicaid compared to private insurance (aOR 1.49, 95% CI 1.41 to 1.57), and rural residence compared to large metropolitan (aOR 1.13, 95% CI 1.02 to 1.25) were associated with increased odds of revisit. CONCLUSIONS: In this cohort, repeat emergency care for symptomatic urinary stones affects 7.1% of patients after initial stone management in the ED setting. Race/ethnicity was associated with stone-related ED revisit. To understand the revisit discrepancies, further investigation into potential explanations of observed race/ethnicity-associated care patterns following initial ED encounters for urinary stones is warranted. Source of Funding: N/A © 2021 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 206Issue Supplement 3September 2021Page: e43-e43 Advertisement Copyright & Permissions© 2021 by American Urological Association Education and Research, Inc.MetricsAuthor Information Joshua Hayden More articles by this author Hui-Jie Lee More articles by this author Charles Scales More articles by this author Expand All Advertisement Loading ...

Management of Toddler's Fracture: A Systematic Review With Meta-Analysis.

In studies that included children diagnosed with toddler's fractures (TFs), we determined the fracture-related adverse outcomes in those treated with immobilization versus no immobilization. Furthermore, we compared health services utilization between these 2 immobilization strategies. A search was done on Ovid MEDLINE(R), Embase Classic + Embase, and Cochrane Central Register of Controlled Trials along with reference lists as conference proceedings and abstracts. No language or publication status or location restrictions were used. All study steps, including the methodological quality assessment, were conducted independently and in duplicate by 2 authors. Of the 490 references identified, 4 retrospective studies of low quality met inclusion criteria and collectively included 355 study participants. With respect to fracture-related adverse outcomes, there was no risk difference [0; 95% confidence interval (CI), -0.09 to 0.09] between the immobilization and no immobilization treatment strategies. Furthermore, in the immobilization versus no immobilization groups, there was a higher mean difference in the number of radiographs (0.69; 95% CI, 0.15-1.23) and scheduled outpatient orthopedic visits (0.96; 95% CI, 0.24-1.68), but a decreased relative risk (0.41; 95% CI, 0.05-3.19) of repeat emergency department visits. No data were reported on patient pain or caregiver satisfaction. In children with TF, this study suggests that no immobilization may be a safe alternative to immobilization for this minor fracture; however, high-quality evidence is needed to optimally inform clinical decision making. Future work should include validated measures of patient recovery, pain, and caregiver perspectives when comparing treatment strategies for this injury.

Racial Disparities in Preventable Adverse Events Attributed to Poor Care Coordination Reported in a National Study of Older US Adults.

Previous work found that Black patients experience worse care coordination than White patients. The aim was to determine if there are racial disparities in self-reported adverse events that could have been prevented with better communication. We used data from a cross-sectional survey that was administered to participants in the Reasons for Geographic and Racial Differences in Stroke (REGARDS) study in 2017-2018. REGARDS participants aged 65+ years of age who reported >1 ambulatory visits and >1 provider in the prior 12 months (thus at risk for gaps in care coordination). Our primary outcome was any repeat test, drug-drug interaction, or emergency department visit or hospitalization that respondents thought could have been prevented with better communication. We used Poisson models with robust standard error to determine if there were differences in preventable events by race. Among 7568 REGARDS respondents, the mean age was 77 years (SD: 6.7), 55.4% were female, and 33.6% were Black. Black participants were significantly more likely to report any preventable adverse events compared with Whites [adjusted risk ratio (aRR): 1.64; 95% confidence interval (CI): 1.42-1.89]. Specifically, Blacks were more likely than Whites to report a repeat test (aRR: 1.77; 95% CI: 1.38-2.29), a drug-drug interaction (aRR: 1.76; 95% CI: 1.46-2.12), and an emergency department visit or hospitalization (aRR: 1.45; 95% CI: 1.01-2.08). Black participants were significantly more likely to report a preventable adverse event attributable to poor care coordination than White participants, independent of demographic and clinical characteristics.

Determining Variable Costs in the Acute Urolithiasis Cycle of Care Through Time-Driven Activity-Based Costing

ObjectiveTo characterize full cycle of care costs for managing an acute ureteral stone using time-driven activity-based costing. MethodsWe defined all phases of care for patients presenting with an acute ureteral stone and built an overarching process map. Maps for sub-processes were constructed through interviews with providers and direct observation of clinical spaces. This facilitated calculation of cost per minute for all aspects of care delivery, which were multiplied by associated process times. These were added to consumable costs to determine cost for each specific step and later aggregated to determine total cost for each sub-process. We compared costs of eight common clinical pathways for acute stone management, defining total cycle of care cost as the sum of all sub-processes that comprised each pathway. ResultsCost per sub-process included $920 for emergency department (ED) care, $1665 for operative stent placement, $2368 for percutaneous nephrostomy tube placement, $106 for urology clinic consultation, $238 for preoperative center visit, $4057 for ureteroscopy with laser lithotripsy (URS), $2923 for extracorporeal shock wave lithotripsy, $169 for clinic stent removal, $197 for abdominal x-ray, and $166 for ultrasound. The lowest cost pathway ($1388) was for medical expulsive therapy, whereas the most expensive pathway ($8002) entailed a repeat ED visit prompting temporizing stent placement and interval URS. ConclusionWe found a high degree of cost variation between care pathways common to management of acute ureteral stone episodes. Reliable cost accounting data and an understanding of variability in clinical pathway costs can inform value-based care redesign as payors move away from pure fee-for-service reimbursement.

B-PO05-198 IMPLEMENTATION OF AN ATRIAL FIBRILLATION TREATMENT PATHWAY IN THE EMERGENCY DEPARTMENT REDUCES ATRIAL FIBRILLATION HOSPITALIZATIONS

Hospitalization rates for atrial fibrillation (AF) patients have steadily risen over two decades. An AF treatment pathway in the Emergency Department (ED) with early follow-up of appropriate patients in an AF specialty clinic may reduce unnecessary hospitalizations and repeat ED visits. To evaluate the impact of an ED AF treatment pathway based on hemodynamic stability and symptom severity on AF discharge rate, repeat ED visits, and cardiovascular mortality at the University of North Carolina Medical Center (UNCMC), compared to usual care at Pardee Hospital (PRDH), another hospital of comparable size within the University of North Carolina network of hospitals. An AF treatment pathway was developed and implemented through education and electronic medical record system integration. Between 2016 and 2020, 4,487 patients presented to the ED of two hospitals with a diagnosis of AF. Rates of admission, discharge, 30-day repeat hospitalizations, and cardiovascular mortality were tallied and compared between the two hospitals (Wilcoxon Rank Sum). Utilization of an ED AF treatment pathway was associated with a significantly increased discharge rate in comparison with usual care (67.1% vs. 55.4%, p<0.001; Figure). There was no significant difference in 30-day repeat ED visits (2.2% vs. 2.7%; p=0.739) or overall cardiovascular mortality (2.3% vs. 1.9%; p=0.226) between the two hospitals. Implementation of an AF treatment pathway can significantly decrease admission rate in the ED without affecting 30-day repeat ED presentation or cardiovascular mortality rate.