Repeat Emergency Department Use Research Articles

Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients: Protocol for a Multisite Randomized Controlled Trial.

Older adults with cognitive impairment have more emergency department visits and 30-day readmissions and are more likely to die after visiting the emergency department than people without cognitive impairment. Emergency department providers frequently do not identify cognitive impairment. Use of cognitive screening tools, along with better understanding of root causes for emergency department visits, could equip health care teams with the knowledge needed to develop individually tailored care management strategies for post-emergency department care. By identifying and directly addressing patients' and informal caregivers' (or care partners') psychosocial and health care needs, such strategies could reduce the need for repeat acute care. We have used the terms "caregiver" and "care partner" interchangeably. We aimed to describe the protocol for a randomized controlled trial of a new care management intervention, the Program of Intensive Support in Emergency Departments for Care Partners of Cognitively Impaired Patients (POISED) trial, compared with usual care. We described the research design, intervention, outcome measures, data collection techniques, and analysis plans. Emergency department patients who were aged ≥75 years and screened positive for cognitive impairment via either the Mini-Cog or the proxy-reported Short Informant Questionnaire on Cognitive Decline in the Elderly, with a planned discharge to home, were recruited to participate with their identified informal (family or friend) caregiver in the 2-site POISED randomized controlled trial at New York University Langone Health and Indiana University. The intervention group received 6 months of care management from the POISED Care Team of registered nurses and specialty-trained paraprofessionals, who perform root cause analyses, administer standardized assessments, provide advice, recommend appropriate referrals, and, when applicable, implement dementia-specific comorbid condition protocols. The control group received care as recommended at emergency department discharge (usual care) and were given information about resources for further cognitive assessment. The primary outcome is repeat emergency department use; secondary outcomes include caregiver activation for patient health care management, caregiver depression, anxiety, and experience of social support as important predisposing and time-varying enabling and need characteristics. Data were collected from questionnaires and patients' electronic health records. Recruitment was conducted between March 2018 and May 2021. Study findings will be published in peer-reviewed journals and presented to peer audiences, decision makers, stakeholders, and other interested persons. The POISED intervention is a promising approach to tailoring care management based on root causes for emergency department admission of patients with cognitive impairment with the aim of reducing readmissions. This trial will provide insights for caregivers and emergency department and primary care providers on appropriate, personalized, and proactive treatment plans for older adults with cognitive impairment. The findings will be relevant to audiences concerned with quality of life for individuals with cognitive impairment and their caregivers. ClinicalTrials.gov NCT03325608; https://clinicaltrials.gov/ct2/show/NCT03325608. DERR1-10.2196/36607.

Delay to Surgery for Patients with Symptomatic Cholelithiasis: Retrospective Analysis of an Administrative California Database after Discharge from the Emergency Department.

Timely receipt of surgery should be available for all patients. Few studies have examined differences in the treatment of symptomatic cholelithiasis (SC), a common surgical problem, based on race/ethnicity or insurance status. This study aimed to identify differences in repeat emergency department (ED) use and wait time to cholecystectomy for SC. Patients discharged from the ED with SC between July 1, 2016, and December 31, 2017, were identified from California administrative databases and followed for 1 year. Repeat ED use and wait time to elective and nonelective cholecystectomy after ED discharge were examined using logistic and negative binomial regression models. The final cohort analyzed 13,596 patients who underwent cholecystectomy within 1 year from index ED visit for SC. In adjusted analysis, non-Hispanic Black patients had higher odds for repeat ED use for biliary-related conditions before elective surgery and experienced longer waits for cholecystectomy (across several measures of wait times) compared with non-Hispanic White patients. Similar findings were seen for Medicaid and self-pay compared with privately insured patients. For example, self-pay patients had more than double the odds of experiencing repeat ED use while waiting for elective cholecystectomy compared with privately insured patients (adjusted odds ratio 2.49, 95% CI 1.88-3.31). Patients with SC receiving cholecystectomy within 1 year from index ED visit were more likely to have repeat ED use and longer waits to surgery based on their race/ethnicity and insurance status, even after adjusting for other measures of access. We identify a vulnerable population at risk for differences in treatment for a common surgical pathology.

Exploring differential response to an emergency department-based care transition intervention.

To identify multivariable subgroups of patients with differential responses to a nurse-delivered care transition intervention after an emergency department (ED) visit in a randomized controlled trial (RCT) using an emerging data-driven method. Secondary analysis of RCT. 512 individuals enrolled in an RCT of a nurse-delivered care transition intervention after an ED visit. All 512 participants were included in a pre-specified subgroup analysis, and 451 of these had sufficient complete case data to be included in a model-based recursive (MoB) partitioning analysis. The primary outcome was having at least one ED visit in 30 days after the index ED visit. Two analytical methods explored heterogeneity of treatment effects: data driven model-based recursive partitioning (MoB) using 37 candidate baseline variables, and a contextual point of comparison with prespecified subgroups defined by ED super-user status (≥ 3 ED visits in previous 6 months or not), sex (male/female), and age, individually examined via treatment arm by subgroup interaction terms in logistic regression models. Internal validation of the MoB analysis via bootstrap resampling with an optimism corrected c-statistic was conducted to provide a bias-corrected estimate. MoB detected treatment effect heterogeneity in a single subgroup, marital status. Unmarried patients randomized to the intervention had a repeat ED use rate of 22% compared to 34% in the usual care group; married patients randomized to the intervention had a 27% ED return rate compared to 12% in the usual care group. Internal validation demonstrated an optimism corrected c-statistic of 0.54. No treatment-by-covariate subgroup interactions were identified among the 3 prespecified subgroups. Although exploratory, the results of the MoB analysis suggest that patient factors related to social relationships such as marital status may be important contributors to differential response to a care transition intervention after an ED visit. These were characteristics that the investigators had not anticipated or planned to examine in the individual prespecified subgroup analysis. Data-driven methods can yield unexpected findings and contribute to a more complete understanding of differential treatment effects in subgroup analysis, which can inform further work on development of effective care transition interventions in the ED setting.

Discharge Information and Support for Patients Discharged from the Emergency Department: Results from a Randomized Controlled Trial.

Little research has been done on primary care-based models to improve health care use after an emergency department (ED) visit. To examine the effectiveness of a primary care-based, nurse telephone support intervention for Veterans treated and released from the ED. Randomized controlled trial with 1:1 assignment to telephone support intervention or usual care arms (ClinicalTrials.gov: NCT01717976). Department of Veterans Affairs Health Care System (VAHCS) in Durham, NC. Five hundred thirteen Veterans who were at high risk for repeat ED visits. The telephone support intervention consisted of two core calls in the week following an ED visit. Call content focused on improving the ED to primary care transition, enhancing chronic disease management, and educating Veterans and family members about VHA and community services. The primary outcome was repeat ED use within 30days. Observed rates of repeat ED use at 30days in usual care and intervention groups were 23.1% and 24.9%, respectively (OR = 1.1; 95% CI = 0.7, 1.7; P = 0.6). The intervention group had a higher rate of having at least 1 primary care visit at 30days (OR = 1.6, 95% CI = 1.1-2.3). At 180days, the intervention group had a higher rate of usage of a weight management program (OR = 3.5, 95% CI = 1.6-7.5), diabetes/nutrition (OR = 1.8, 95% CI = 1.0-3.0), and home telehealth services (OR = 1.7, 95% CI = 1.0-2.9) compared with usual care. A brief primary care-based nurse telephone support program after an ED visit did not reduce repeat ED visits within 30days, despite intervention participants' increased engagement with primary care and some chronic disease management services. ClinicalTrials.gov NCT01717976.

Low and Higher Wage Workers Report No Differences in Four Barriers to Primary Care Access.

Lower wage workers, known to seek more care in the emergency department (ED), may encounter more barriers to timely outpatient primary care. This study aimed to identify differences in self-reported delays in care related to 4 modifiable barriers (phone availability, appointment wait time, in-clinic wait time, and limited service hours) across self-reported wage and to examine the relationship between these care delays and self-reported ED use. The authors examined data from the 2011-2015 National Health Interview Surveys for 58,298 self-identified full-time workers. Multivariable logistic models with geographical region and year fixed effects were used to test the association of wage group and barriers to care. In addition, the multiplicative and additive interaction effects upon self-reported ED use were tested. No association was observed between wage level and barrier to timely care. Lower wage workers (<$25,000 vs. >$75,000/yr.; OR 1.53, 95% CI 1.20-1.94, P = 0.001) and those reporting any of the 4 barriers to care (OR 1.99, 95% CI 1.71-1.94, P < 0.001) were more likely to report 2 or more ED visits in the past year. Multiplicative effects were not statistically significant. Additive interaction effects of wage and barriers were only significant among workers with wages $35,000-$44,999 annually (vs. >$75,000: relative excess risk coef. 1.23, 95% CI 0.07-2.38, P = 0.037) for 2 or more ED visits in past year. Although these modifiable barriers may explain the differences in repeat ED use for workers earning $35,000-$44,999 annually, these barriers do not explain disparities in ED use between highest and lowest wage workers.

Understanding Frequent Emergency Department Use Among Primary Care Patients.

Patients with high emergency department (ED) utilization are an important focus in population health management. This retrospective cohort study analyzed patterns of frequent ED use for 4087 patients enrolled at an academically-affiliated primary care clinic. For all ED visits (n = 4776), the chief complaints, admission rates, number of complaints per patient, and median time between return visits were assessed. Chart reviews were conducted for the 10 highest utilizers from each of the 3 leading complaints to help explain repeated ED use for the same complaints. Results showed that chief complaints for high utilizers were statistically similar to other patients. Nearly half (49.8%) of all ED visits among high utilizers were repeat visits for the same complaint. However, most high utilizers (85%) had 4 or more separate complaints. Their visits clustered temporally, with 55% occurring less than 30 days apart. Visits for psychiatric symptoms demonstrated the shortest time to repeat visit (median 17.5 days, interquartile range: 39.5). Abdominal pain, chest pain, and shortness of breath were the leading complaints and the leading sources of hospital admissions and repeat visits. Chart review revealed that these 3 chief complaints often were associated with a wide range of ongoing chronic conditions, confounded by substance abuse, anxiety, and treatment nonadherence. This study demonstrates an integrative method for examining patterns of ED use among high utilizers. It also highlights the complex nature of high utilization and the inherent difficulty in predicting and addressing the needs of high-utilizer patients.

Discharge information and support for veterans Receiving Outpatient Care in the Emergency Department: Study design and methods

BackgroundAn explicit goal of Patient Aligned Care Teams (PACTs) within the Veterans Health Administration is to promote continuity of care in primary care clinics and thereby reduce Emergency Department (ED) utilization; however, there has been little research to guide PACTs on how to accomplish this. ObjectivesThe overall goal of this study is to examine the impact of a primary care-based nurse telephone support program [DISPO ED] on Veterans treated and released from the ED who are at high risk for repeat visits. MethodsThis study is a two group randomized, controlled trial to evaluate DISPO ED for Veterans treated and released from the ED who are at high risk for repeat visits. We define high risk as those who have had an ED visit or hospitalization during the 6month period before the index ED visit and have ≥2 chronic conditions. Veterans are randomized to nurse telephone support or usual care. The primary outcome is repeat ED use within 30days; secondary outcomes are patient satisfaction with care and total costs. DiscussionThe results of this randomized, controlled trial with an Effectiveness–Implementation Type I Hybrid design will be directly relevant to the care of more than 500,000 high risk patients seen in Veterans' Affairs Medical Center (VAMC) EDs annually. Results will also be informative to health systems outside VA aiming to reduce ED use through accountable care organizations.

Non-urgent pediatric emergency department utilization - A case review

Parents who repetitively use the emergency department (ED) for non-urgent care create potential risk for their children. This phenomenon is influenced by inconvenient primary care office hours, insurance issues, and guaranteed same day services in the ED. Essentially, parents are using the ED as a primary care office, rather than a place for the care of urgent illness. This is a serious health concern as children do not receive continuity of care nor do they receive a focus on preventative healthcare when their primary place of obtaining care is solely in the ED. This case study presents an example of inappropriate, repeated ED use and offers potential solutions that enhance parental, ED provider, and primary care provider (PCP) accountability; enhancing the ability to provide appropriate care to a vulnerable population.

Geriatric Syndromes Predict Postdischarge Outcomes Among Older Emergency Department Patients: Findings From the interRAI Multinational Emergency Department Study

Identifying older emergency department (ED) patients with clinical features associated with adverse postdischarge outcomes may lead to improved clinical reasoning and better targeting for preventative interventions. Previous studies have used single-country samples to identify limited sets of determinants for a limited number of proxy outcomes. The objective of this study was to identify and compare geriatric syndromes that influence the probability of postdischarge outcomes among older ED patients from a multinational context. A multinational prospective cohort study of ED patients aged 75 years or older was conducted. A total of 13 ED sites from Australia, Belgium, Canada, Germany, Iceland, India, and Sweden participated. Patients who were expected to die within 24 hours or did not speak the native language were excluded. Of the 2,475 patients approached for inclusion, 2,282 (92.2%) were enrolled. Patients were assessed at ED admission with the interRAI ED Contact Assessment, a geriatric ED assessment. Outcomes were examined for patients admitted to a hospital ward (62.9%, n=1,436) or discharged to a community setting (34.0%, n=775) after an ED visit. Overall, 3% of patients were lost to follow-up. Hospital length of stay (LOS) and discharge to higher level of care was recorded for patients admitted to a hospital ward. Any ED or hospital use within 28 days of discharge was recorded for patients discharged to a community setting. Unadjusted and adjusted odds ratios (ORs) were used to describe determinants using standard and multilevel logistic regression. A multi-country model including living alone (OR=1.78, p≤0.01), informal caregiver distress (OR=1.69, p=0.02), deficits in ambulation (OR=1.94, p≤0.01), poor self-report (OR = 1.84, p≤0.01), and traumatic injury (OR=2.18, p≤0.01) best described older patients at risk of longer hospital lengths of stay. A model including recent ED visits (OR=2.10, p≤0.01), baseline functional impairment (OR=1.68, p≤0.01), and anhedonia (OR=1.73, p≤0.01) best described older patients at risk of proximate repeat hospital use. A sufficiently accurate and generalizable model to describe the risk of discharge to higher levels of care among admitted patients was not achieved. Despite markedly different health care systems, the probability of long hospital lengths of stay and repeat hospital use among older ED patients is detectable at the multinational level with moderate accuracy. This study demonstrates the potential utility of incorporating common geriatric clinical features in routine clinical examination and disposition planning for older patients in EDs.

Depression is associated with repeat emergency department visits in patients with non-specific abdominal pain.

Introduction: Patients with abdominal pain often return multiple times despite no definitive diagnosis. Our objective was to determine if repeat emergency department (ED) use among patients with non-specific abdominal pain might be associated with a diagnosis of moderate to severe depressive disorder.Methods: We screened 987 ED patients for major depression during weekday daytime hours from June 2011 through November 2011 using a validated depression screening tool, the PHQ-9. Each subject was classified as either no depression, mild depression or moderate/severe depression based on the screening tool. Within this group, we identified 83 patients with non-specific abdominal pain by either primary or secondary diagnosis. Comparing depressed patients versus non-depressed patients, we analyzed demographic characteristics and number of prior ED visits in the past year.Results: In patients with non-specific abdominal pain, 61.9% of patients with moderate or severe depression (PHQ9≥10) had at least one visit to our ED for the same complaint within a 365-day period, as compared to 29.2% of patients with no depression (PHQ9<5), (p=0.013).Conclusion: Repeat ED use among patients with non-specific abdominal pain is associated with moderate to severe depressive disorder. Patients with multiple visits for abdominal pain may benefit from targeted ED screening for depression. [West J Emerg Med. 2014;15(3):325–328.]

Evaluating early repeat emergency department use in patients with atrial fibrillation: A population-based analysis

Emergency department (ED) use by patients with atrial fibrillation is high and will accelerate with the aging of the population. In patients with atrial fibrillation who are discharged from the ED, we aimed to describe their subsequent outpatient care, return ED visits, and management strategies associated with early return. We conducted a retrospective cohort analysis of patients 65 years or older with a primary ED diagnosis of atrial fibrillation who were discharged home from an ED in the province of Ontario, Canada, between April 2007 and March 2010. We describe subsequent outpatient care and repeat ED visits within 14 days of the index visit. We assessed factors associated with a repeat visit, overall, as well as by repeat visit outcome (discharged or admitted). Among 12,772 index ED visits, the mean (SD) age was 77 (7.4) years, and 14-day mortality was 0.7% (95% CI 0.5%-0.8%). Within 14 days, 67.8% had no follow-up care, 19.4% saw solely a family physician, and 12.8% saw a specialist (internist or cardiologist). There were 1,310 (10.3%) repeat ED visits made by 1,146 (9.0%) patients. Management strategies associated with a lower hazard of a repeat visit included follow-up care with a specialist (hazard ratio 0.61; P = .003) and a digoxin prescription (vs a β-blocker; hazard ratio 0.69, P = .001). Among older patients with atrial fibrillation discharged from an ED in the province of Ontario, 9% make 1 or more repeat visits within 14 days. Reductions in repeat emergency visits by low-risk patients are associated with timely specialist follow-up care.

Effect of drug and medical treatment on wide geographic variations in repeated emergency department use by HIV-infected drug users

Repeated ( > or = two visits) emergency department (ED) visits by HIV-infected (HIV+) drug users in New York State (NYS) vary widely by region and may reflect regional inequities in receipt of needed drug treatment and medical services. The study's objective was to evaluate receipt of drug treatment and medical care by HIV+ drug users by region and its effect on ED use. For NYS Medicaid-enrolled HIV+ drug users (N = 11,556) in 1996 and 1997, we identified receipt of long-term (> or = six months) drug treatment, HIV care, and a usual source of medical care from claims files. Regions were classified as New York City, downstate suburban, upstate urban, and rural/small city. We examined adjusted associations of these services with > or = two ED visits in the entire cohort and separately among patients who do and do not receive these three types of services. Repeated ED visits were greatest in rural/small cities (40.7 percent) and least in New York City (24.1 percent; p < 0.001), and receipt of drug treatment was also poorest (p < 0.001) in rural/small cities, whereas receipt of HIV care and usual source of medical care varied less by region. Adjusted odds of > or = two ED visits was increased for patients in rural/small cities (1.89 [confidence interval, 1.44 to 2.50]) vs. New York City and reduced for patients with long-term drug treatment (0.76 [confidence interval 0.69 to 0.84]). Among persons receiving long-term drug treatment, observed regional differences in ED use largely disappeared. Regional variations in receipt of long-term drug treatment by HIV+ drug users in one state appear to contribute to large differences in ED utilization.

Availability of Medical Care Services in Drug Treatment Clinics Associated With Lower Repeated Emergency Department Use

Drug users rely heavily on emergency departments (EDs) for care. Medical and other services in outpatient drug treatment clinics may reduce demand for ED care. The objective of this study was to examine the association of services in drug treatment clinics with repeated ED use by clinic patients. This study consisted of telephone interviews of directors of a stratified random sample of 125 New York state outpatient drug treatment clinics linked to Medicaid claims for patients with long-term (>or=6 months) treatment at these clinics. This study comprised a total of 8397 Medicare enrollees in surveyed clinics in 1996 to 1997. The surveys addressed drug treatment; general medical, HIV, alcohol, and social support services; location of selected services; primary care, HIV specialty, and mental health provider staffing levels; accessibility; and academic affiliation. From Medicaid claims, we defined patient demographic, clinical, and healthcare variables. Logistic regression models examined associations of availability of onsite medical services with repeated (2 or more) ED visits in 1997, adjusted for patient characteristics and patient clustering in clinics. Repeated ED visits occurred in 15% of the cohort and were less likely when medical services were all onsite versus more distant (12.9% vs 16.8%, P<0.001). An interaction showed that onsite medical care was associated with less ED use only in low-volume (<or=1350 visits/wk, adjusted odds ratio [AOR] 0.64 [0.47-0.88]) and moderate volume (1351-2500 visits/wk, AOR 0.79 [0.64-0.97]) clinics. The availability of preventive services and HIV specialists onsite appear to mediate the beneficial effect of onsite medical care. Greater onsite medical care in low- and moderate-volume drug treatment clinics was associated with less repeated ED use.

Repeated emergency department use by HIV-infected persons: effect of clinic accessibility and expertise in HIV care.

Repeated emergency department (ED) visits by HIV-infected persons may signify poor access to care or treatment from inexperienced ambulatory providers. We examined features of 157 clinics following 6820 HIV-infected patients and associations with repeated (> or =2) ED visits by these patients in the year before their first AIDS diagnosis. Patient clinical and health care data came from 1987-1992 New York State (NYS) Medicaid files and clinic data came from interviews of clinic directors. The HIV/AIDS experience of each study patient's clinic was measured as the annual number of Medicaid enrollees newly diagnosed with AIDS who were contemporaneously followed by the patient's clinic. Repeated ED use was observed for 24%. The adjusted odds ratio (AOR) of repeated ED visits was reduced for patients in clinics with a physician on-call (0.77; 95% confidence interval [CI] = 0.65, 0.92), evening or weekend clinic hours (0.77; 95% CI = 0.64, 0.93), or >50 AIDS patients/year in 1987-1988 (0.56; 95% CI = 0.44, 0.71) versus fewer patients in those years. Patients in clinics with more than one feature promoting accessibility or HIV expertise had a greater reduction in their AOR of repeated ED use. HIV-infected patients in clinics with greater accessibility and HIV expertise rely less on the ED for care.