Self-reported Emergency Department Research Articles

The association between patient self-reported experiences with medication discharge counselling and hospital readmissions: A cross-sectional analysis of a population-based survey

ObjectiveTo investigate the association between patient-reported experiences with new medication discharge counselling and readmission to hospital or emergency department (ED) visits within 30 days of discharge. MethodsA retrospective cross-sectional study of patient-reported experiences from 8715 patients who reported being prescribed a new medication at discharge from a public hospital. Completeness of medication counselling was assessed based on (i) explanation of medication purpose, (ii) explanation of medication side effects, (iii) patient involvement in decision to use medication, (iv) provision of contradictory information. Multilevel models were used to estimate self-reported 30-day readmission or ED visit related to care received using adjusted odds ratios (AORs). ResultsPatients who were explained medication purpose were half as likely to report a readmission (AOR 0.54, 95%CI 0.31–0.93) or ED visit (AOR 0.65, 95%CI 0.48–0.87) within 30 days of discharge. Conversely, those who reported receiving contradictory information were more likely to report a readmission (AOR 1.62, 95%CI 1.16–2.26) and ED visit (AOR 1.82, 95%CI 1.41–2.34). ConclusionPatients who reported receiving comprehensive counselling on new medications were less likely to report being readmitted or visiting an ED within 30 days of discharge.

Integrated primary and community mental health care for young adults with serious mental illness: A program evaluation.

Young adults with serious mental illness (SMI) have poor physical health and high Emergency Department (ED) and hospital utilization. Integrating primary care into community mental health care may be an important form of early intervention. Adjusted multivariable regressions assessed changes in self-reported annual primary care, ED and hospital utilization for 83 young adults with SMI enrolled in integrated care. Participants' mean annual per person utilization changed significantly as follows: primary care visits, from 1.8 to 3.6, p < .001; medical ED visits, from 1.0 to 0.6, p < .01; psychiatric ED visits from 0.6 to 0.2, p < .001; medical inpatient days, from 1.2 to 0.1, p < .001 and psychiatric inpatient days, from 6.3 to 2.6, p < .001. Young adults with SMI receiving integrated care increased primary care and reduced ED and inpatient utilization. Future controlled research is warranted to further assess integrated care for young adults with SMI.

Characteristics of emergency department visits among older adults with hearing difficultly during the COVID19 pandemic in the US

Hearing difficulty (HD) may be associated with an increased frequency of emergency department (ED) visits among older adults. The COVID-19 pandemic has adversely affected the health of older adults. However, less is known about the characteristics of ED visits by older adults with HD during the pandemic. This study examines the association between self-reported HD severity and ED visits during the pandemic. This population-based cross-sectional study used self-reported data on HD and the characteristics of respondents aged 65 years or older from three cycles of the National Health Interview Survey from 2020 to 2022. Data were analysed from February 23, 2023, to March 22, 2023. The primary outcome was self-reported ED visits in the past 12 months. This study employed generalised linear models to examine the relationship between ED visits (dependent variable) and HD in older adults, and the effect sizes were expressed as rate ratios. Key independent variables included the reasons for ED visit. Covariates such as demographic characteristics and socio-economic status were controlled for to account for potential confounding effects. During the pandemic, older adults with HD commonly visited the ED because of chronic pain (82.8%), frailty (77.9%), trouble falling/staying asleep (73.2%), hypertension (67.4%), and arthritis (60.1%), all of which were 1.5-times more likely in these adults than in those with normal hearing (chronic pain: adjusted rate ratio [ARR], 1.64 [95% CI 1.44–1.93]; frailty: ARR, 1.57 [95% CI 1.16–1.87]; trouble falling/staying asleep: ARR, 1.51 [95% CI 1.21–1.82]; hypertension: ARR, 1.01 [95% CI 0.92–1.23]; arthritis: ARR, 1.39 [95% CI 1.31–1.57]. Older adults with HD were more likely to visit the ED for chronic pain, frailty, trouble falling/staying asleep, hypertension, and arthritis than those with normal hearing during the COVID-19 pandemic. Our findings will be help for healthcare providers to be aware of these potential barriers and to implement strategies to ensure that patients with hearing difficulties can access necessary emergency care effectively.

Abstract PO1-10-03: Prevalence of and Factors Associated with Food Insecurity and Other Adverse Social Determinants of Health Among Breast Oncology Patients

Abstract Background: Social determinants of health (SDOH), the non-medical factors that influence health status, have a profound impact on breast cancer (BC) outcomes and contribute to survival disparities. Food insecurity (FI), defined as a lack of consistent access to adequate food resources, is a modifiable SDOH associated with treatment disruptions, medication nonadherence, and decreased quality of life. To identify at-risk patients and inform future interventions, we implemented SDOH screening of patients seen in breast oncology clinic at our urban academic medical center. Methods: Screening was conducted through an 8-item questionnaire on the electronic patient portal. The questions covered FI, housing and transportation challenges, and emergency department (ED) visits. We conducted a retrospective analysis of SDOH data collected among patients scheduled for a breast oncology appointment between 11/1/22 and 5/25/23. Any level of food hardship or concern constituted a positive FI screen. Descriptive statistics were used to determine the prevalence of FI and other SDOH, to assess differences in FI rates by age, race/ethnicity, and clinical stage, and to compare characteristics of food-insecure vs food-secure patients. We also conducted a multivariable logistic regression analysis to estimate the odds ratio (OR) and 95% confidence interval (CI) associated with sociodemographic/clinical factors and FI. Results: A total of 2,585 patients were seen in our breast oncology practice, of which 1,189 (46.0%) were screened for SDOH, including 41.2% non-Hispanic White (NHW), 9.6% non-Hispanic Black (NHB) and 21.0% Hispanic patients. Among patients who responded to each SDOH question, 15.5% (146/940) reported some level of FI; 8.7% (84/962) were unable to pay their rent or mortgage on time; for 5.8% (57/989), lack of transportation interfered with their treatment. The FI rate differed significantly by race and ethnicity: 4.5% of NHW, 15.2% of NHB, and 41.8% of Hispanic patients reported FI (p&amp;lt; 0.001). In multivariable analysis, NHB and Hispanic patients also had significantly higher odds of FI compared to NHW patients (OR=3.68, 95% CI=1.7-7.7, p&amp;lt; 0.001 for NHB and OR=15.0, 95% CI=8.8-27.1, p&amp;lt; 0.001 for Hispanic patients). Patients with metastatic disease had higher rates of FI compared to other breast oncology patients (23.6% vs 14.8%, p=0.048), and a metastatic BC diagnosis was associated with over twice the odds of FI (OR=2.18, 95% CI=1.1-4.2, p=0.02). Among food-insecure patients, 41.1% were unable to pay their rent or mortgage on time and 22.6% reported transportation difficulties interfering with treatment (vs 2.6% and 2.4%, respectively, for food-secure patients (p&amp;lt; 0.001)). Compared to food-secure patients, those who were food-insecure had significantly higher rates of self-reported ED visits in the past 12 months: 18.8% vs. 33.6% reported at least 1 ED visit, respectively, and 5.2% vs. 16.4% reported multiple ED visits, respectively (p&amp;lt; 0.001). Conclusions: In this analysis of SDOH data among patients seen in breast oncology clinic, FI was the most common social health risk reported, with nearly a quarter of patients with metastatic BC reporting FI. Racial/ethnic minorities were also at considerably higher risk for FI. ED utilization was significantly higher among food-insecure patients. Targeted interventions to reduce FI in at-risk populations are warranted to improve clinical and healthcare utilization outcomes. Sociodemographic and Clinical Characteristics and Other Reported Social Determinants of Health Among Food-Secure vs Food-Insecure Patients Citation Format: Claire Sathe, David DeStephano, Anita Gul, Melissa Beauchemin, Justine Kahn, Melissa Accordino, Katherine Crew, Ngozika Emezienna, Dawn Hershman. Prevalence of and Factors Associated with Food Insecurity and Other Adverse Social Determinants of Health Among Breast Oncology Patients [abstract]. In: Proceedings of the 2023 San Antonio Breast Cancer Symposium; 2023 Dec 5-9; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2024;84(9 Suppl):Abstract nr PO1-10-03.

Effect of a Medical-Legal Partnership on Mental Health and Utilization: A Randomized Controlled Trial in Primary Care.

Context: Family physicians lack resources to effectively intervene on health-harming legal needs (HHLNs), despite growing calls to address social determinants of health. One promising model is the medical-legal partnership (MLP), which embeds legal screening and referral in clinics, but more evidence is needed prior to broader implementation. Objective: To examine whether an MLP reduces stress, depression, and medical overutilization. Study design: Randomized controlled trial. Setting: Urban, primary care clinic in Houston. Population studied: Low-income individuals, aged 18 or older, who are English or Spanish speaking with positive screens for HHLNs. Intervention: Randomization to an MLP referral or 6-month waitlist. Outcome measures: The primary outcome was perceived stress at 6 months (Perceived Stress Scale (PSS); 0-40 range). Secondary outcomes were depression (Center for Epidemiologic Studies Depression Scale (CES-D); 0-60 range), anxiety (Generalized Anxiety Disorder scale (GAD-7); 0-21 range) and self-reported emergency department, urgent care, and hospital visits. Assessments occurred at 3, 6, and 9 months. Analysis: Generalized linear modeling was used to fit each outcome at 6-months as a function of MLP group, controlling for baseline. Bayesian statistical inference with weakly informative priors and a 75% posterior probability (PP) threshold was used to identify noteworthy differences. Results: One hundred sixty individuals were randomized to intervention (80) and control (80) groups. Analyses did not find meaningful group differences for emergency department visits, urgent care visits, or CES-D. Being in the intervention group was associated with lower PSS scores (18.8 vs. 19.9; PP = 75%) but higher hospitalizations (0.4 vs. 0.3; PP = 78%) and GAD-7 scores (10.3 vs. 6.7; PP=90%). Conclusion: Findings in this trial of an MLP referral were mixed. At 6 months, participants who received an MLP referral appeared to be less stressed but also reported higher anxiety and more hospitalizations.

CAREGIVER HEALTH LITERACY AS A MODIFIABLE TARGET TO PROMOTE OLDER ADULT HEALTH

Abstract Many older adults receive assistance in managing chronic conditions. Yet complicating the utility of caregiver support is whether caregivers have sufficient skills to aid in a patient’s self-care. Health literacy (HL) is as an important determinant of older adults’ health outcomes, but few studies have examined caregiver HL and patient outcomes. We interviewed 162 patient-caregiver dyads during an ongoing cognitive aging cohort study to examine associations between caregiver HL, measured using the Newest Vital Sign, and older adults’ health outcomes. Physical function and mental health symptoms were assessed using PROMIS short form assessments. Patients’ also self-reported emergency department (ED) visits and hospitalizations over the past 12 months. Chi-square and t-tests were performed, as appropriate. Patients were on average 73 years old and managing 4 comorbidities. The majority were female (70%), identified as Black (35%) or White (60%). Caregivers’ mean age was 64 years; half were female (56%) and had limited HL (48%). Limited caregiver HL was associated with poorer physical function (M=43.0 (8.5) vs. M=46.0 (9.1), p=0.05), greater comorbidities (M=4.0 (1.9) vs M=3.3 (1.8), p=0.02) and more ED visits in the past year (36.7% vs. 19.3%, p=0.01). No differences by caregiver HL were observed for patients’ mental health or hospitalization. Findings suggest that caregivers with limited HL are caring for medically complex patients, and further research should examine whether limited caregiver HL leads to poorer self-management of chronic conditions. The development of HL training for caregivers may better equip them to assist older adults and improve older adult health.

Heart Disease Self-management for African American Older Adults: Outcomes of an Adapted Evidence-Based Intervention.

Background and ObjectivesTo assess the impact of an evidence-based self-management intervention adapted through a community-engaged process for African American midlife and older adults with heart disease and/or cardiovascular risk factors.Research Design and MethodsAdults 50 years and over, living in or near Detroit, MI, with diagnosed heart disease or greater or equal to two major risk factors for heart disease, were randomized to a 7-week group-format program called Take Heart, or a usual-care control group. Take Heart included education about heart disease and support for behavioral lifestyle change, using a goal-setting process based on self-regulation theory. Outcome data were collected via telephone surveys at baseline and 1 year from baseline. Primary outcomes were self-reported emergency department visits and hospitalizations in the last year. Secondary outcomes were health-related quality of life (PROMIS-29 Adult Profile) and cardiac symptom burden.ResultsA total of 453 participants enrolled (74% female, 84% African American, mean age 65.4 years; 55% with diagnosed heart disease and 45% with risk factors only); 362 provided baseline and follow-up data. Using generalized linear and binomial regression models, at 12-month follow-up, there were no significant differences between intervention and control groups in ED visits or hospitalizations. Intervention versus control participants had greater improvements in PROMIS fatigue (p = .003) and sleep (p = .04) subscales as well as cardiac symptom burden (p = .04).Discussion and ImplicationsThe Take Heart intervention was associated with modest improvements in sleep, fatigue, and cardiac symptom burden. Take Heart was well received and has potential for dissemination by agencies serving older adults.Clinical Trial Registration Number: https://www.clinicaltrials.gov/ct2/show/NCT02950818

The Relationship of Secondary and Chronic Health Conditions With Emergency Department Visits and Related Hospitalizations Among People With Traumatic Spinal Cord Injury

ObjectiveIdentify the relationship of health conditions with self-reported emergency department (ED) visits and ED-related hospitalizations among people with traumatic spinal cord injury (SCI), while controlling for demographic, injury, and socioeconomic factors. DesignCross-sectional. SettingA regional SCI model system in the Southeastern United States. ParticipantsParticipants (N=648) were adults with chronic traumatic SCI at least 1 year postinjury who were identified through their Form II annual follow-up within the SCI Model Systems. InterventionsN/A. Main Outcome MeasuresSelf-reported ED visits and ED-related hospitalizations within the 12 months prior to the study. ResultsSeveral types of factors were significantly related to ED visits, with fewer related to ED hospitalizations. Men (odds ratio [OR]=1.58); those divorced, widowed, or separated (OR=1.57); and those with more severe SCI (C1-C4, or American Spinal Injury Association Impairment Scale A/B) had greater odds of having at least 1 ED visit; education and employment factors were not significant. Of health conditions, acute secondary health conditions including falls (OR=1.45), urinary tract infections (UTIs; OR=2.40), and pressure injuries (OR=1.58) were all associated with a greater odds of ED visits, whereas chronic health conditions were not. Being unemployed was associated with greater odds of an ED hospitalization (OR=1.79), as was having at least 1 UTI (OR=2.24) and at least 1 pressure injury (OR=2.37). ConclusionsThe current findings suggest acute secondary health conditions, particularly UTIs and pressure injuries, were much more highly related to ED visits and related hospitalizations compared to chronic health conditions (eg, diabetes, hypertension). Greater attention needs to be paid to fall, UTI, and pressure injury prevention to reduce the ED burden related to SCI.

Suboptimal nonmedical qualities of primary care linked with care avoidance among people who use drugs in a Canadian setting amid an integrated health care reform

BackgroundPeople who use unregulated drugs (PWUD) often face significant barriers to—and thereby avoid seeking—health care. In Vancouver, Canada, a neighborhood-wide health care system reform began in 2016 to improve health care delivery and quality. In the wake of this reform, we sought to determine the prevalence of health care avoidance and its association with emergency department use among PWUD in this setting and examine patient-reported nonmedical qualities of health care (“responsiveness”). MethodsThe study derived data from two prospective cohort studies of community-recruited PWUD in Vancouver in 2017–18. Responsiveness was ascertained by the World Health Organizations' standardized measurements and we evaluated seven domains of responsiveness (dignity, autonomy, communication, confidentiality, prompt attention, choice of provider, and quality of basic amenities). The study used Pearson chi-squared test to examine differences in responsiveness between those who did and did not avoid care. The study team used multivariable logistic regression to determine the relationship between care avoidance due to past mistreatment and emergency department use, adjusting for potential confounders. ResultsAmong 889 participants, 520 (58.5%) were male, 204 (22.9%) reported avoiding health care, most commonly for chronic pain (47.4%). Overall, 6.6% to 36.2% reported suboptimal levels (i.e., not always meeting the expected quality) across all seven measured domain of responsiveness. Proportions reporting suboptimal qualities were significantly higher among those who avoided care than those who did not across all domains, including care as soon as wanted (51.0% vs. 31.8%), listened to carefully (44.1% vs. 20.4%), and involved in health care decision-making (27.9% vs. 12.7%) (all p < 0.05). In multivariable analyses, avoidance of health care was independently associated with self-reported emergency department use (adjusted odds ratio = 1.49; 95% confidence interval:1.01–2.19). ConclusionWe found that almost a quarter of our sample of PWUD avoided seeking health care due to past mistreatment, and all seven measured domains of responsiveness were suboptimal and linked with avoidance. Individuals who reported avoidance of health care were significantly more likely to report emergency department use. Multi-level interventions are needed to remedy the suboptimal qualities of health care and thereby reduce care avoidance.

Validity of Wait Time Complaints and Effect of Trainee Presence in an Ophthalmic Emergency Department.

PurposePress Ganey (PG) surveys can provide a more comprehensive evaluation of specific patient complaints through input of comments. In this paper, we evaluate the validity of wait time complaints submitted via PG surveys in an ophthalmic emergency department (ED) and determine the effect of trainee presence on total time spent in the ED and negative PG comments.Materials and MethodsThis was a retrospective study evaluating PG reports for ED demographic, diagnostic, visit time and trainee involvement trends.ResultsFemales made up 48.0% (4465) of overall ED patients yet submitted 62.8% (98) of the negative comments on PG surveys. More than a quarter (27.7%) of the negative comments pertained to wait time. Patient-reported times spent in the ED were significantly longer than actual total ED times (p < 0.001). Both reported and actual total ED times were significantly longer for patients who submitted wait time negative comments than those with other complaints (p < 0.001 vs p = 0.039, respectively). Patients seen by residents spent a significantly longer time in the ED than those seen by non-resident providers (p = 0.015), although self-reported total ED times did not differ significantly in these patients (p = 0.467).ConclusionPatients submitting complaints about wait time and those seen by treatment teams including residents spent a significantly longer time in the ED. Although PG survey respondents are not representative of the overall ED patient population, this highlights the need for academic institutions to seek methods to maximize efficiency in patient care without compromising trainee education.

Examining the association between loneliness and emergency department visits using Canadian Longitudinal Study of Aging (CLSA) data: a retrospective cross-sectional study

BackgroundLoneliness is a public health concern and its influence on morbidity and mortality are well documented. The association between loneliness and emergency department visits is less clear. Further, while sex and gender-related factors are known to be associated with loneliness and health services use, little research looks at the relationship by gender. Our study aimed to estimate the association between loneliness and emergency department use in the previous 12 months. We aimed to determine if this association differed based on gender identity and gender-related characteristics.MethodsWe used a retrospective cohort study design to analyze population-based survey data from the Canadian Longitudinal Study on Aging (CLSA). We analysed data from the baseline and follow-up 1 survey respondents (2015-2018) from both the tracking (telephone interviews) and comprehensive (in-home data collection) cohorts (n=44816). Loneliness was assessed using a dichotomous measure (lonely/not lonely) from a validated scale. Emergency department visits were dichotomous (yes/no) by self-reported emergency department use in the 12 months prior to the survey date. Multivariable logistic regression analyses using analytic weights examined the association between loneliness and emergency department visit, controlling for other demographic, social, and health related factors.ResultsWe identified 44,413 respondents to the baseline and follow-up 1 survey. The prevalence of loneliness in our sample was 23.1% (n=10263). Of those who had been to the emergency department in the previous year, 27.2% (n=2793) were lonely. Lonely respondents had higher odds of an emergency department visit (aOR: 1.13, 95% CI: 1.05-1.21), adjusted for various demographic and health factors. Loneliness was associated with emergency department visits more so in women (aOR: 1.15, 95% CI: 1.05-1.25) than in men (aOR: 1.10, 95% CI: 0.99-1.22).ConclusionsIn our study, loneliness was associated with emergency department visits in the previous 12 months. When our analysis was disaggregated by gender, we found differences in the odds of emergency department visit for men, women, and gender-diverse respondents. The odds of ED visit were higher in women than men. These findings highlight the general importance of identifying loneliness in both primary care and hospital. Care providers in ED need resources to refer patients who present in this setting with health issues complicated by social conditions such as loneliness.

Effect of cohabiting partners on the development of posttraumatic stress symptoms after emergency department visits for stroke and transient ischemic attack

ObjectivePartners can be beneficial for patients experiencing stressful health events such as a stroke/transient ischemic attack (TIA). During such events, however, partners may exacerbate early distress. The present study tested whether having a cohabiting partner modified the association between patients’ early perceptions of threat (e.g., feeling vulnerable, helpless) and longer-term posttraumatic stress symptoms (PTSS). MethodsParticipants (N = 328) were drawn from an observational cohort study of patients evaluated for stroke/TIA at an urban academic hospital between 2016 and 2019. Participants self-reported emergency department (ED) threat perceptions and PTSS secondary to the stroke/TIA at three days and one month post-event. ResultsCohabiting partner status modified the association of ED threat with early PTSS. Patients with a cohabiting partner exhibited a positive association between ED threat and early PTSS, B = 0.12, p < .001; those without a cohabiting partner did not, B = 0.04, p = .067. A cohabiting partner was protective only for patients who initially reported low levels of ED threat, as patients with a cohabiting partner who reported low levels of ED threat also had lower early PTSS, B = −0.15, p = .016; at high levels of ED threat, a cohabiting partner was not protective, B = −0.02, p = .68. ED threat was associated with PTSS at one month, B = 0.42, p < .001, but cohabiting partner status did not modify the association. ConclusionsED threat perceptions were positively associated with early PTSS only for patients with a cohabiting partner. For patients who do not initially experience a stroke/TIA event as threatening, cohabiting partners may help patients maintain psychological equanimity.

Seizure first aid training for people with epilepsy attending emergency departments and their significant others: the SAFE intervention and feasibility RCT

Background No seizure first aid training intervention exists for people with epilepsy who regularly attend emergency departments and their significant others, despite such an intervention’s potential to reduce clinically unnecessary and costly visits. Objectives The objectives were to (1) develop Seizure first Aid training For Epilepsy (SAFE) by adapting a broader intervention and (2) determine the feasibility and optimal design of a definitive randomised controlled trial to test SAFE’s efficacy. Design The study involved (1) the development of an intervention informed by a co-design approach with qualitative feedback and (2) a pilot randomised controlled trial with follow-ups at 3, 6 and 12 months and assessments of treatment fidelity and the cost of SAFE’s delivery. Setting The setting was (1) third-sector patient support groups and professional health-care organisations and (2) three NHS emergency departments in England. Participants Participants were (1) people with epilepsy who had visited emergency departments in the prior 2 years, their significant others and emergency department, paramedic, general practice, commissioning, neurology and nursing representatives and (2) people with epilepsy aged ≥ 16 years who had been diagnosed for ≥ 1 year and who had made two or more emergency department visits in the prior 12 months, and one of their significant others. Emergency departments identified ostensibly eligible people with epilepsy from attendance records and patients confirmed their eligibility. Interventions Participants in the pilot randomised controlled trial were randomly allocated 1 : 1 to SAFE plus treatment as usual or to treatment as usual only. Main outcome measures Consent rate and availability of routine data on emergency department use at 12 months were the main outcome measures. Other measures of interest included eligibility rate, ease with which people with epilepsy could be identified and routine data secured, availability of self-reported emergency department data, self-reported emergency department data’s comparability with routine data, SAFE’s effect on emergency department use, and emergency department use in the treatment as usual arm, which could be used in sample size calculations. Results (1) Nine health-care professionals and 23 service users provided feedback that generated an intervention considered to be NHS feasible and well positioned to achieve its purpose. (2) The consent rate was 12.5%, with 53 people with epilepsy and 38 significant others recruited. The eligibility rate was 10.6%. Identifying people with epilepsy from attendance records was resource intensive for emergency department staff. Those recruited felt more stigmatised because of epilepsy than the wider epilepsy population. Routine data on emergency department use at 12 months were secured for 94.1% of people with epilepsy, but the application process took 8.5 months. Self-reported emergency department data were available for 66.7% of people with epilepsy, and people with epilepsy self-reported more emergency department visits than were captured in routine data. Most participants (76.9%) randomised to SAFE received the intervention. The intervention was delivered with high fidelity. No related serious adverse events occurred. Emergency department use at 12 months was lower in the SAFE plus treatment as usual arm than in the treatment as usual only arm, but not significantly so. Calculations indicated that a definitive trial would need ≈ 674 people with epilepsy and ≈ 39 emergency department sites. Limitations Contrary to patient statements on recruitment, routine data secured at the pilot trial’s end indicated that ≈ 40% may not have satisfied the inclusion criterion of two or more emergency department visits. Conclusions An intervention was successfully developed, a pilot randomised controlled trial conducted and outcome data secured for most participants. The consent rate did not satisfy a predetermined ‘stop/go’ level of ≥ 20%. The time that emergency department staff needed to identify eligible people with epilepsy is unlikely to be replicable. A definitive trial is currently not feasible. Future work Research to more easily identify and recruit people from the target population is required. Trial registration Current Controlled Trials ISRCTN13871327. Funding This project was funded by the National Institute for Health Research (NIHR) Health Services and Delivery Research programme and will be published in full in Health Services and Delivery Research; Vol. 8, No. 39. See the NIHR Journals Library website for further project information.

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.

Senior PharmAssist: Less Hospital Use with Enrollment in an Innovative Community-Based Program.

To evaluate changes in acute health services use of Senior PharmAssist participants. Retrospective analysis. Community-based, nonprofit program in Durham County, North Carolina. Adults aged 60 and older with income of 200% of the federal poverty level or less who enrolled in the Senior PharmAssist program (N = 191) between August 1, 2011, and March 15, 2017. Medication therapy management (MTM), customized community referrals, Medicare insurance counseling, and medication copayment assistance provided by Senior PharmAssist. Primary outcomes were self-reported emergency department (ED) visits and hospital admissions in the previous year, assessed at baseline and every 6 months for up to 2 years. Mean number of ED visits declined over time (0.83 visits per year at baseline to 0.53 visits per year at 24 months, P = .002), as did the percentage of participants reporting an ED visit in the past year (49% at baseline to 31% at 24 months, P = .003). Mean hospital admissions also decreased (0.56 admissions per year at baseline to 0.4 admissions per year at 24 months, P = .02). There was no significant change in percentage of participants reporting a hospital admission in the past year (33% at baseline to 25% at 24 months, P = .23). Older adults who enrolled in a community-based program that helps them manage medications, connect with community resources, and overcome barriers to medication access experienced reductions in acute health services use. J Am Geriatr Soc 66:2394-2400, 2018.

Six-Month Emergency Department Use among Older Adults Following Jail Incarceration.

Although the number of older adults who are arrested and subject to incarceration in jail is rising dramatically, little is known about their emergency department (ED) use or the factors associated with that use. This lack of knowledge impairs the ability to design evidence-based approaches to care that would meet the needs of this population. This 6-month longitudinal study aimed to determine the frequency of 6-month ED use among 101 adults aged 55 or older enrolled while in jail and to identify factors associated with that use. The primary outcome was self-reported emergency department use within 6months from baseline. Additional measures included baseline socio-demographics, physical and mental health conditions, geriatric factors (e.g., recent falls, incontinence, functional impairment, concern about post-release safety), symptoms (pain and other symptoms), and behavioral and social health risk factors (e.g., substance use disorders, recent homelessness). Chi-square tests were used to identify baseline factors associated with ED use over 6months. Participants (average age 60) reported high rates of multimorbidity (61%), functional impairment (57%), pain (52%), serious mental illness (44%), recent homelessness (54%), and/or substance use disorders (69%). At 6months, 46% had visited the ED at least once; 21% visited multiple times. Factors associated with ED use included multimorbidity (p=0.01), functional impairment (p=0.02), hepatitis C infection (p=0.01), a recent fall (p=0.03), pain (p<0.001), loneliness (p=0.04), and safety concerns (p=0.01). In this population of older adults in a county jail, geriatric conditions and distressing symptoms were common and associated with 6-month community ED use. Jail is an important setting to develop geriatric care paradigms aimed at addressing comorbid medical, functional, and behavioral health needs and symptomatology in an effort to improve care and decrease ED use in the growing population of criminal justice-involved older adults.

How Multidimensional Health Locus of Control predicts utilization of emergency and inpatient hospital services.

Health locus of control may be an important predictor of health care utilization. We analyzed associations between health locus of control and frequency of emergency department visits and hospital admissions, and investigated self-rated health as a potential mediator. Overall, 863 patients in an urban emergency department completed the Multidimensional Health Locus of Control instrument, and self-reported emergency department use and hospital admissions in the last year. We found small but significant associations between Multidimensional Health Locus of Control and utilization, all of which were mediated by self-rated health. We conclude that interventions to shift health locus of control may change patients' perceptions of their own health, thereby impacting utilization.

Racial-Ethnic Differences in Health Service Use in a Large Sample of Homeless Adults With Mental Illness From Five Canadian Cities.

This study examined factors associated with health care use in an ethnically diverse Canadian sample of homeless adults with mental illness, a particularly disadvantaged group. Baseline survey data were available from five sites across Canada for 2,195 At Home/Chez Soi demonstration project participants. Negative binomial regression models examined the relationship between racial-ethnic or cultural group membership (white, N=1,085; Aboriginal, N=476; black, N=244; and other ethnoracial minority groups, N=390) and self-reported emergency department (ED) visits and hospitalizations in the past six months and past-month visits to a medical, other clinical, or social service provider. Adjusted models included other predisposing, enabling, and need factors, based on Andersen's behavioral model for vulnerable populations. Compared with white participants, black participants had a lower rate of ED visits (adjusted rate ratio [ARR]=.54, 95% confidence interval [CI]=.43-.69) and Aboriginal participants had a lower rate of medical visits (ARR=.84, CI=.71-.99) and a higher rate of visits to social service providers (ARR=1.54, CI=1.18-2.01). Participants in other ethnoracial minority groups had a higher rate of social service provider visits than white participants (ARR=1.44, CI=1.10-1.89). Access to a family physician, having at least high school education, and high needs for mental health services were associated with greater use of ED and medical visits and hospitalizations. Rates of ED and medical visits were lower with increased age and better physical health. In a system of universal health insurance that prioritizes access to and quality of care, the presence of racial-ethnic disparities experienced by this vulnerable population merits further attention.

Stroke Symptoms as a Predictor of Future Hospitalization

Stroke symptoms in the general adult population are common and associated with stroke risk factors, lower physical and mental functioning, impaired cognitive status, and future stroke. Our objective was to determine the association of stroke symptoms with self-reported hospitalization or emergency department (ED) visit. Lifetime history of stroke symptoms (sudden weakness, numbness, unilateral or general loss of vision, loss of ability to communicate or understand) was assessed at baseline in a national, population-based, longitudinal cohort study of 30,239 blacks and whites younger than 45 years, enrolled from 2003 to 2007. Self-reported hospitalization or ED visit and reason were collected during follow-up through March 2013. The symptom-hospitalization association was assessed by proportional hazards analysis in persons who were stroke/transient ischemic attack-free at baseline (27,126) with adjustment for sociodemographics and further adjustment for risk factors. One or more stroke symptoms were reported by 4758 (17.5%). After adjustment for sociodemographics, stroke symptoms were most strongly associated with greater risk of hospitalization/ED for cardiovascular disease (CVD) (hazard ratio [HR] = 1.87, 95% confidence interval [CI]: 1.78-1.96), stroke (HR = 1.69, 95% CI: 1.55-1.85), and any reason (HR = 1.39, 95% CI: 1.34-1.44). These associations remained significant and only modestly reduced after risk factor adjustment. Stroke symptoms are a marker for future hospitalization and ED visit not only for stroke but also for CVD in general. Findings suggest a role for stroke symptom assessment as a novel and simple approach for identifying individuals at high risk for CVD including stroke in whom preventive strategies could be implemented.

188 Prevalence of Social Resource and Legal Assistance Needs in the Emergency Department and the Relationship to Emergency Department Utilization

Social inequities, particularly the lack of social resources, negatively impact health and are barriers to health care access and the effective delivery of care. We investigated the prevalence of social resource and legal assistance needs in an emergency department (ED) population; identified high-risk groups; and assessed the relationship between these needs and ED utilization. We conducted a prospective, cross-sectional study of a convenience sample of adult and pediatric patients presenting to a suburban academic emergency department with over 59,000 visits in 2013, seated in a county with household median income of $87,750 (165% of the national median). Trained undergraduate research assistants approached patients over a seven-week period and administered a scripted survey. We collected demographic information, including ethnicity, primary language, and household income. We screened for four categories of social resource need: health care-related (eg, lack of health insurance, lack of primary care physician), food insecurity-related, housing-related (eg, eviction, homelessness), and public benefits-related (government funded food assistance and income supplementation programs). Finally, we screened for legal assistance needs, defined as social resource needs that could require a lawyer to remedy, such as wrongful eviction. Chi-square analysis was performed to determine significance of categorical variables and their association with self-reported ED utilization. Of the 296 patients approached, 79% (234) completed screening, 59% (141) of those patients screened positive for at least one social resource need, and 32% (76) patients had at least two social resource needs. Further, 28% of patients had at least one social resource need that potentially required legal assistance. Health care-related needs were most prevalent, affecting 50% of patients. Food insecurity affected 26% of patients, while another 26% patients had housing-related needs. Eight percent of patients had difficulty obtaining public benefits. High-risk groups included patients living below 250% of the federal poverty level (FPL) and patients who were primarily Spanish-speaking. Patients living below 250% of the FPL were significantly more likely than those living above to have a social resource need (P<.001). Spanish-speaking patients were significantly more likely than English-speaking patients to have a social resource need (P<.001). Notably, having any social resource need was significantly correlated with having at least one self-reported ED visit in the prior month (P=.012) or year (P=.042). However, lack of health insurance and/or a primary care physician was not significantly correlated with ED utilization in the past month (P=.28 and P=.61, respectively). A significant proportion of ED patients have at least one social resource need and may require legal assistance to meet this need. These patients are significantly more likely to have used the ED in the last year and even in the last month, For these patients, EDs are not only their medical safety net but also may be their social safety net. We should explore innovative strategies, including medical-legal partnerships, for screening and addressing social resource needs in the ED in order to confront the needs that underlie patients’ ED utilization.