Subsequent Emergency Department Visits Research Articles

Thresholds in PROMIS Scores Anchored to Subsequent Unscheduled Health Service Use Among People Diagnosed With Cancer.

To establish thresholds in the Patient-Reported Outcomes Measurement Information System (PROMIS) pain interference, physical function, fatigue, and depression scores on the basis of their association with subsequent use of the emergency department (ED) or urgent care by people diagnosed with cancer. Retrospective data from 952 people seen at Henry Ford Cancer and insured through the Health Alliance Plan were analyzed using generalized linear mixed-effects models. The log odds of ED or urgent care use during 14 or 30 days after each patient-reported outcome (PRO) assessment were related to PRO scores, while adjusting for comorbidity, sociodemographic, and tumor characteristics. Pain interference and physical function were associated with subsequent ED or urgent care visits, but fatigue and depression were not, and the results for 14- and 30-day visits were similar. Thresholds anchored in the likelihood of these visits differed according to cancer stage. For people with advanced cancer, a pain interference score of 60 or higher (odds ratio [OR] 3.75, [95% CI, 1.53 to 7.87]) and a physical function score lower than 40 (OR 2.94, [95% CI, 1.22 to 7.06]) produced the largest ORs with narrowest CIs for 30-day visits. For people with nonadvanced cancer, the thresholds of 65 for pain interference (OR 2.64, [95% CI, 1.40 to 5.01]) and 35 for physical function (OR 1.87, [95% CI, 1.01 to 3.45]) produced largest ORs with narrowest CIs for 30-day visits. These anchor-based thresholds in PROMIS scores can inform clinicians' actions with the goal of preventing ED or urgent care visits.

Changes in interpersonal violence and utilization of trauma recovery services at an urban trauma center in the United States during the COVID-19 pandemic: a retrospective, comparative study

Purpose: This study investigated changes in interpersonal violence and utilization of trauma recovery services during the COVID-19 pandemic. At an urban level I trauma center, trauma recovery services (TRS) provide education, counseling, peer support, and coordination of rehabilitation and recovery to address social and mental health needs. The COVID-19 pandemic prompted considerable changes in hospital services and increases in interpersonal victimization. Methods: A retrospective analysis was conducted between September 6, 2018 and December 20, 2020 for 1,908 victim-of-crime patients, including 574 victims of interpersonal violence. Outcomes included length of stay associated with initial TRS presentation, number of subsequent emergency department visits, number of outpatient appointments, and utilization of specific specialties within the year following the initial traumatic event. Results: Patients were primarily female (59.4%), single (80.1%), non-Hispanic (86.7%), and Black (59.2%). The mean age was 33.0 years, and 247 patients (49.2%) presented due to physical assault, 132 (26.3%) due to gunshot wounds, and 76 (15.1%) due to sexual assault. The perpetrators were primarily partners (27.9%) or strangers (23.3%). During the study period, 266 patients (mean, 14.9 patients per month) presented before the declaration of COVID-19 as a national emergency on March 13, 2020, while 236 patients (mean, 25.9 patients per month) presented afterward, representing a 74.6% increase in victim-of-crime patients treated. Interactions with TRS decreased during the COVID-19 period, with an average of 3.0 interactions per patient before COVID-19 versus 1.9 after emergency declaration (P<0.01). Similarly, reductions in length of stay were noted; the pre–COVID-19 average was 3.6 days, compared to 2.1 days post–COVID-19 (P=0.01). Conclusions: While interpersonal violence increased, TRS interactions decreased during the COVID-19 pandemic, reflecting interruption of services, COVID-19 precautions, and postponement/cancellation of elective visits. Future direction of hospital policy to enable resource and service delivery to this population, despite internal and external challenges, appears warranted.

Hospital Encounters Within 1 Year Postpartum Across Insurance Types, Oregon 2012-2017.

Little is known about the timing and frequency of postpartum hospital encounters and postpartum visit attendance and how they may be associated with insurance types. Research on health insurance and its association with postpartum care utilization is often limited to the first 6 weeks. To assess whether postpartum utilization (hospital encounters within 1 year postpartum and postpartum visit attendance within 12 weeks) differs by insurance type at birth (Medicaid, high deductible health plans, and other commercial plans) and whether rates of hospital encounters differ by postpartum visit attendance and insurance status. Time-to-event analysis of Oregon hospital births from 2012 to 2017 using All Payer All Claims data. We conducted weighted Cox Proportional Hazard regressions and accounted for differences in insurance type at birth using multinomial propensity scores. Among 202,167 hospital births, 24.9% of births had at least 1 hospital encounter within 1 year postpartum. Births funded by Medicaid had a higher risk of a postpartum emergency department (ED) visit (hazard ratio: 2.05, 95% CI: 1.99, 2.12) and lower postpartum visit attendance (hazard ratio: 0.71, 95% CI: 0.70, 0.72) compared with commercial plans. Among Medicaid beneficiaries, missing the postpartum visit in the first 6 weeks was associated with a lower risk of subsequent readmissions (adjusted hazard ratio 0.77, 95% CI: 0.68, 0.87) and ED visits (adjusted hazard ratio: 0.87 (0.85, 0.88). Medicaid beneficiaries received more care in the ED within 1 year postpartum compared with those enrolled in other commercial plans. This highlights potential issues in postpartum care access.

A Primary Care-Based Quality Improvement Project to Reduce Asthma Emergency Department Visits.

Asthma exacerbation is a common and often preventable cause of Emergency Department (ED) utilization. Children eligible for Medicaid are at increased risk of poor asthma control and subsequent ED visits. In 2010, we implemented a multicomponent longitudinal quality improvement project to improve pediatric asthma care for our primary care population, which was 90% Medicaid-eligible. Our goal was to reduce asthma-related ED visits by patients ages 2 to 18 years by 3% annually. The setting was a multisite large urban high-risk primary care network affiliated with a children's hospital. We implemented 5 sequential interventions within our network of pediatric primary care centers to increase: use of asthma action plans by clinicians, primary care-based Asthma Specialty Clinic visits (extended asthma visits in the main primary care site), use of a standard asthma note at all visits, documentation of the Asthma Control Test, and step-up therapy for children with poorly controlled asthma. At baseline in 2010, there were 21.7 asthma-related ED visits per 1000 patients per year. By 2019, asthma-related ED visits decreased to 14.5 per 1000 patients per year, a 33% decrease, with 2 center line shifts over time. We achieved and sustained our goal metrics for 4 of 5 key interventions. We reduced ED utilization for asthma in a large, high-risk pediatric population. The interventions implemented and used over time in this project demonstrate that sustainable outcomes can be achieved in a large network of primary care clinics.

Health care utilization and outcomes of patients seen by virtual urgent care versus in-person emergency department care.

Virtual urgent care (VUC) is intended to support diversion of patients with low-acuity complaints and reduce the need for in-person emergency department visits. We aimed to describe subsequent health care utilization and outcomes of patients who used VUC compared with similar patients who had an in-person emergency department visit. We used patient-level encounter data that were prospectively collected for patients using VUC services provided by 14 pilot programs in Ontario, Canada. We linked the data to provincial administrative databases to identify subsequent 30-day health care utilization and outcomes. We defined 2 subgroups of VUC users; those with a documented prompt referral to an emergency department by a VUC provider, and those without. We matched patients in each cohort to an equal number of patients presenting to an emergency department in person, based on encounter date, medical concern and the logit of a propensity score. For the subgroup of patients not promptly referred to an emergency department, we matched patients to those who were seen in an emergency department and then discharged home. Of the 19 595 patient VUC visits linked to administrative data, we matched 2129 patients promptly referred to the emergency department by a VUC provider to patients presenting to the emergency department in person. Index visit hospital admissions (9.4% v. 8.7%), 30-day emergency department visits (17.0% v. 17.5%), and hospital admissions (12.9% v. 11.0%) were similar between the groups. We matched 14 179 patients who were seen by a VUC provider with no documented referral to the emergency department. Patients seen by VUC were more likely to have a subsequent in-person emergency department visit within 72 hours (13.7% v. 7.0%), 7 days (16.5% v. 10.3%) and 30 days (21.9% v. 17.9%), but hospital admissions were similar within 72 hours (1.1% v. 1.3%), and higher within 30 days for patients who were discharged home from the emergency department (2.6% v. 3.4%). The impact of the provincial VUC pilot program on subsequent health care utilization was limited. There is a need to better understand the inherent limitations of virtual care and ensure future virtual providers have timely access to in-person outpatient resources, to prevent subsequent emergency department visits.

Social Navigation for Adolescent Emergency Department Patients: A Randomized Clinical Trial

PurposeAdolescent emergency department (ED) patients have unmet social needs that contribute to ED use. This study aimed to evaluate the effect of social needs navigation for adolescents on subsequent ED visits and community resource use and to identify characteristics associated with elevated social risk. MethodsBetween July 2017 and August 2019, we used a random date generator to establish intervention and control group enrollment dates. All adolescents completed a social needs survey. Adolescents enrolled on intervention dates received in-person, risk-tailored social needs navigation. Those enrolled on control dates received a preprinted resource guide. We used chart review and follow-up calls to assess 12-month ED revisits and community resource use. Logistic regression was used to compare these outcomes between groups. We measured the association between ≥3 reported unmet needs and characteristics hypothesized a priori to be associated with elevated social risk (nonurgent visits, obesity, or any of nine “socially sensitive” chief complaints) using logistic regression. ResultsA total of 399 adolescents were randomized. There was no difference between groups in the number of ED revisits. There was increased community resource use in the intervention group (adjusted odds ratio [aOR]: 3.5 [95% confidence interval {CI}: 1.5, 8.2]). Adolescents with a socially sensitive chief complaint had increased odds of ≥3 unmet needs (aOR: 2.2 [95% CI: 1.3, 3.6]), as did those with food insecurity in a post hoc analysis (aOR: 9.9 [95% CI: 4.0, 24.6]). DiscussionSocial needs navigation increased community resource use but not subsequent ED visits. Adolescents with socially sensitive chief complaints or food insecurity reported increased unmet needs.

A descriptive study of screening and navigation on health-related social needs in a safety-net hospital emergency department

BackgroundHealth-related social needs (HRSN) have been associated with worse clinical outcomes, increased Emergency Department (ED) utilization and higher healthcare costs. The ED is uniquely positioned to bring HRSN screening to the bedside and develop effective interventions. We evaluated whether navigation services for high-risk patients led to the resolution of HRSN. MethodsNavigators screened a convenience sample of patients for HRSN with the Accountable Health Communities Screening Tool from October 2019 to January 2022. Patients with HRSN were considered high-risk if they had at least two ED visits in the previous 12 months. Patients who were high-risk were eligible for navigation including community referrals and one-on-one close follow-up. The HRSN status (resolved, in-progress, unable to resolve) was queried from the Centers for Medicare and Medicaid database. The state hospital association provided data on ED visits and inpatient hospitalizations within 6 months of the screening visit. ResultsOf 185,470 ED visits, HRSN screening occurred in 4050 (2%). HRSN were self-reported in 48% (1944) of patient visits, with 71% of these (1379) considered high-risk. 15% of high-risk patients with HRSN opted out of navigation. Food insecurity was the most identified HRSN (35%) followed by housing instability (26%), transportation needs (24%) and utility assistance (15%). Food insecurity was the most resolved HRSN (39%, in-progress 32%) followed by utility assistance (37%, in-progress 26%), transportation needs (35%, in-progress 35%) and housing instability (28%, in-progress 36%). High-risk visits in which the patient or guardian accepted navigation were less likely to be associated with an ED visit within 6 months of the screening visit (51%) compared to high-risk patients in which the patient or guardian opted out of navigation (61%, p < 0.001), but there was no difference in inpatient hospitalizations (p = 0.427). ConclusionsDuring the study period, one-third of HRSN were successfully resolved with another one-third in-progress. Navigation in high-risk patients was associated with fewer subsequent ED visits.

A Previously Healthy Infant with Lemierre Syndrome in the Emergency Department: Case Report.

Lemierre syndrome (LS) is a rare condition with a high mortality risk. It is well described in older children and young adults involving bacteremia, thrombophlebitis, and metastatic abscess commonly due to Fusobacterium infections. Young, pre-verbal children are also susceptible to LS; thus, careful attention must be given to their pattern of symptoms and history to identify this condition in the emergency department (ED). A 12-month-old previously healthy boy with a recent diagnosis of acute otitis media and viral illness presented to the ED with a complaint of fever. Additional symptoms developed at the head and neck and were noted on subsequent ED visits. Advanced imaging revealed significant lymphadenopathy and deep space inflammation extending to the mediastinum. Subsequent imaging confirmed extensive sinus and deep vein thromboses, consistent with LS. Methicillin-resistant Staphylococcus aureus (MRSA) was the only organism identified. After surgical debridement, appropriate intravenous antibiotics, and heparin anticoagulation therapy, the patient experienced full recovery after prolonged hospitalization. A febrile infant with multiple acute care visits and development of lymphadenopathy, decreased oral intake, decreased cervical range of motion, and sepsis should raise suspicion for Lemierre syndrome. The medical evaluation of deep neck spaces and deep veins should be similar to that of older children and adults with LS, including advanced imaging of the head and neck. However, medical management should particularly target MRSA due to its emerging prevalence among infantile LS cases. Further research is necessary to determine the optimal management strategies of LS for this age group.

Emergency Care Utilization for Mental and Sexual Health Concerns Among Adolescents Following Sexual Assault: A Retrospective Cohort Study

PurposeThis study aimed to explore the health outcomes of adolescent survivors of sexual assault, as measured by subsequent emergency department (ED) utilization for mental and sexual health concerns. MethodsThis retrospective cohort study used the Pediatric Health Information System (PHIS) database. We included patients aged 11–18 years seen at a PHIS hospital with a primary diagnosis of sexual assault. The control group included age- and sex-matched patients seen for an injury. Participants were followed in PHIS for 3–10 years; subsequent ED visits for suicidality, sexually transmitted infection, pelvic inflammatory disease (PID), or pregnancy were identified, and likelihoods of each were compared using Cox proportional hazards models. ResultsThe study population included 19,706 patients. ED return visit rates in the sexual assault and control groups were 7.9% versus 4.1% for suicidality, 1.8% versus 1.4% for sexually transmitted infection, 2.2% versus 0.8% for PID, and 1.7% versus 1.0% for pregnancy, respectively. Compared to controls, sexual assault patients were significantly more likely to return to the ED for suicidality throughout the follow-up period, with the highest hazard ratio of 6.31 (95% confidence interval 4.46–8.94) during the first 4 months. Sexual assault patients also had higher likelihood of returning for PID (hazard ratio 3.80, 95% confidence interval 3.07–4.71) throughout the follow-up period. DiscussionAdolescents seen in the ED for sexual assault were significantly more likely to return to the ED for suicidality and sexual health concerns, highlighting the need for increased allocation of research and clinical resources to improve their care.

Alpha Blocker Medical Expulsive Therapy for Ureteral Stones—Usage of Health Care Resources

Abstract Objective: To study the effects of alpha blocker prescription for ureteral stones on health care resources. Methods: In this retrospective study, patients with a new ureteral stone diagnosis were selected from a commercial claims database between 2011 and 2016. We examined data from patients who were and were not prescribed an alpha blocker for ureteral stone diagnosis. Comparative analyses were performed between these groups at 30 and 90 days postdiagnosis. We evaluated the need for surgical intervention, repeat imaging, emergency department (ED) visits, adverse events, and total medical claims cost. Results: Of 70,599 patients with ureteral stones, alpha blockers were prescribed to 51.1% for a median duration of ten days. At 30 and 90 days after index diagnosis, alpha blocker treated patients were more likely to undergo surgical intervention (P &lt; .01, 1.06 HR), have additional imaging studies (P &lt; .01, 1.37 HR), and visit the emergency department (P &lt; .01, 1.19 HR). Total medical costs at 30 and 90 days were increased by 11.3% and 10.1%, respectively, for patients treated with an alpha blocker (P &lt; .01). Conclusions: Patients who were prescribed an alpha blocker for a diagnosis of ureteral stone had increased surgical interventions, subsequent ED visits, additional imaging studies, and overall total cost to the health care system compared with patients not on alpha blockers. In addition to uncertain and disputed efficacy, the negative impact on health care resources should also be considered in the decision for the use of alpha blockers for ureteral stones.

Association of chronic opioid therapy with emergency department visits and hospitalizations among super-utilizers

Abstract Objectives Patients with complex medical needs and high inpatient utilization frequently use opioids for non-malignant chronic pain. We examine the association between chronic opioid therapy and healthcare utilization among high-need, high-cost patients insured by Medicare. Methods This study is a retrospective cohort study of Medicare beneficiaries in a medically underserved metropolitan area. Patients were included in the study if they had ≥2 hospitalizations or ≥1 hospitalization and ≥2 emergency department (ED) visits in a 6-month-period preceding an index hospitalization between July 2011 and June 2014. Exclusion criteria included substance abuse, psychosis and malignancy. Multivariable negative binomial regression models assessed associations between baseline opioid medication use and subsequent ED and hospital visits for the study population and two subgroups: (1) those with chronic pain and (2) those with both chronic pain and a primary care provider. Key findings The majority of high-need, high-cost patients filled opioid prescriptions of ≥7-day supply (51%). Yet only 2.7% of patients with chronic pain received an opioid prescription of ≥7-day supply from an ED provider in the baseline period. Overall (n = 677), receipt of a ≥7-day opioid supply was positively associated with subsequent ED utilization but not subsequent hospitalization. Among those with chronic pain and ≥1 primary care practice visit (N = 481), opioid use was associated with inpatient utilization but not ED utilization. Receipt of adjuvant pain prescriptions was not protective of hospitalizations or ED visits. Conclusions Chronic pain and opioid therapy are common among high-need, high-cost patients and they are independently associated with higher ED and hospital utilization. Novel patient-centred outpatient pain management strategies have potential to reduce inpatient care in this population.

Implementation of a compulsory clinical pharmacist-led medication deprescribing intervention in high-risk seniors in the emergency department.

The objective of this study was to assess the impact of an emergency department (ED) deprescribing intervention for geriatric adults. We hypothesized that pharmacist-led medication reconciliation for at-risk aging patients would increase the 60-day case rate of primary care provider (PCP) deprescribing of potentially inappropriate medications (PIMs). This was a retrospective, before-and-after intervention pilot study conducted at an urban Veterans Affairs ED. In November 2020, a protocol utilizing pharmacists to perform medication reconciliations for patients 75 years or older who screened positive using an Identification of Seniors at Risk tool at triage was implemented. Reconciliations focused on identifying PIMs and providing deprescribing recommendations to patients' PCPs. A preintervention group was collected between October 2019 and October 2020, and a postintervention group was collected between February 2021 to February 2022. The primary outcome compared case rates of PIM deprescribing in the preintervention group to the postintervention group. Secondary outcomes include per-medication PIM deprescribing rate, 30-day PCP follow-up visits, 7- and 30-day ED visits, 7- and 30-day hospitalizations, and 60-day mortality. A total of 149 patients were analyzed in each group. Both groups were similar in age and sex, with an average age of 82 years and 98% male. The case rate of PIM deprescribing at 60 days was 11.1% preintervention compared to 57.1% postintervention (p< 0.001). Preintervention, 91% of PIMs remained unchanged at 60 days compared to 49% (p< 0.05) postintervention. Regardless of PIM identification, the 30-day primary care follow-up rate increased postintervention: 31.5% and 55.7% (p< 0.0001), respectively. There was no improvement in 7- or 30-day subsequent ED visits, hospitalization, or mortality. Pharmacist-led medication reconciliation in high-risk geriatric patients was associated with an increase both in the rate of PIM deprescribing and in post-ED primary care engagement.

Ambulatory follow-up among publicly insured children discharged from the emergency department.

While children discharged from the emergency department (ED) are frequently advised to follow up with ambulatory care providers, the extent to which this occurs is unknown. We sought to characterize the proportion of publicly insured children who have an ambulatory visit following ED discharge, identify factors associated with ambulatory follow-up, and evaluate the association of ambulatory follow-up with subsequent hospital-based health care utilization. We performed a cross-sectional study of pediatric (<18 years) encounters during 2019 included in the IBM Watson Medicaid MarketScan claims database from seven U.S. states. Our primary outcome was an ambulatory follow-up visit within 7 days of ED discharge. Secondary outcomes were 7-day ED return visits and hospitalizations. Logistic regression and Cox proportional hazards were used for multivariable modeling. We included 1,408,406 index ED encounters (median age 5 years, IQR 2-10 years), for which a 7-day ambulatory visit occurred in 280,602 (19.9%). Conditions with the highest proportion of 7-day ambulatory follow-up included seizures (36.4%); allergic, immunologic, and rheumatologic diseases (24.6%); other gastrointestinal diseases (24.5%); and fever (24.1%). Ambulatory follow-up was associated with younger age, Hispanic ethnicity, weekend ED discharge, ambulatory encounters prior to the ED visit, and diagnostic testing performed during the ED encounter. Ambulatory follow-up was inversely associated with Black race and ambulatory care-sensitive or complex chronic conditions. In Cox models, ambulatory follow-up was associated with a higher hazard ratio (HR) of subsequent ED return (HR range 1.32-1.65) visit and hospitalization (HR range 3.10-4.03). One-fifth of children discharged from the ED have an ambulatory visit within 7 days, which varied by patient characteristics and diagnoses. Children with ambulatory follow-up have a greater subsequent health care utilization, including subsequent ED visit and/or hospitalization. These findings identify the need to further research the role and costs associated with routine post-ED visit follow-up.

Mobile Integrated Health Interventions for Older Adults: A Systematic Review.

Mobile integrated health (MIH) interventions have not been well described in older adult populations. The objective of this systematic review was to evaluate the characteristics and effectiveness of MIH programs on health-related outcomes among older adults. We searched Ovid MEDLINE, Ovid EMBASE, CINAHL, AgeLine, Social Work Abstracts, and The Cochrane Library through June 2021 for randomized controlled trials or cohort studies evaluating MIH among adults aged 65 and older in the general community. Studies were screened for eligibility against predefined inclusion/exclusion criteria. Using at least 2 independent reviewers, quality was appraised using the Downs and Black checklist and study characteristics and findings were synthesized and evaluated for potential bias. Screening of 2,160 records identified 15 studies. The mean age of participants was 67 years. The MIH interventions varied in their focus, community paramedic training, types of assessments and interventions delivered, physician oversight, use of telemedicine, and post-visit follow-up. Studies reported significant reductions in emergency call volume (5 studies) and immediate emergency department (ED) transports (3 studies). The 3 studies examining subsequent ED visits and 4 studies examining readmission rates reported mixed results. Studies reported low adverse event rates (5 studies), high patient and provider satisfaction (5 studies), and costs equivalent to or less than usual paramedic care (3 studies). There is wide variability in MIH provider training, program coordination, and quality-based metrics, creating heterogeneity that make definitive conclusions challenging. Nonetheless, studies suggest MIH reduces emergency call volume and ED transport rates while improving patient experience and reducing overall health care costs.

Violent Injury as a Predictor of Subsequent Assault-Related Emergency Department Visits Among Adolescents

PurposeTo measure the risk of a subsequent assault-related emergency department (ED) visit in assault injured adolescents as compared to those who initially presented for non-assault related injuries. MethodsThis was a historical cohort study of youth (ages 10–18 years) seen at two pediatric EDs between 2016 and 2019. Participants were included if their visit had an International Classification of Diseases-10 code for assaultive injury or accidental injury (motor vehicle collisions (MVC) and sports injuries). We calculated the rate of a subsequent ED visit for an assault-related injury, and then used survival analysis to compare time to subsequent ED visit with an assault-related injury between study and comparison groups. ResultsA total of 6125 adolescents met inclusion criteria (Assault: n = 2782, 45.4%; MVC: n = 1834, 29.9%; Sports n = 1509, 24.6%). The overall rate per 100 person years of a subsequent assault-related ED visit was 5.6 (n = 344). Patients who initially presented with an assault-related injury had an increased adjusted relative risk (aRR) of return for a subsequent ED visit for an assault-related injury when compared to MVC patients (aRR 17.6 [95% CI: 9.6, 32.2]). Kaplan-Meier time to event analysis found that patients in the assault injury group have a higher probability of a subsequent ED visit for an assault-related injury compared to patients in the MVC injury group (adjusted hazard ratio (aHR): 17.7 [95% CI: 9.67, 32.42]). DiscussionAdolescents injured by assault are more likely to return to the ED for a subsequent assault-related injury compared to adolescents who initially present with non-assault-related injuries.

Characteristics and outcomes associated with two asthma quality of care measures

Objective We investigated asthma quality measures to understand patient characteristics associated with non-attainment of quality care and measure the association with asthma-related emergency department (ED) visits or inpatient hospitalizations (IPs). Methods Using administrative data from ALL Kids, Alabama’s Children’s Health Insurance Program, from 2013 to 2019 we calculated non-attainment of the Medication Management for Asthma (MMA) and Asthma Medication Ratio (AMR) quality measures. Patient characteristics and asthma-related ED visits and IPs associated with non-attainment of the MMA and AMR measures were assessed using logit regression models and Marginal effects at the mean. Results Among 2528 children with asthma, 53.2% failed to attain the MMA measure and 8.5% the AMR measure. Prior asthma-related ED visits or IP stays increased likelihood of non-attainment by 14.8 percentage points (95% CI 8.6–20.9) for MMA and 7.3 percentage points (95% CI 2.8–11.8) for AMR. Among 868 children (34.3%) with three years of continuous enrollment, AMR non-attainment was associated with a 6.1 percentage point increase in ED or IP utilization (95% CI 1.3–10.9), however MMA non-attainment was not associated with either outcome. Prior ED visit/IP stay was associated with a 17.2 percentage point (95% CI 8.3–26.1) increase in the likelihood of a subsequent ED visit/IP stay among those with non-attainment MMA and a 15.5 percentage point increase (95% CI 6.9–24.2) for non-attainment AMR. Conclusions Patient characteristics associated with non-attainment of asthma quality measures presents actionable evidence to guide improvement efforts as non-attainment AMR increases the risk of subsequent ED visits and IP stays.

Do children evaluated for maltreatment have higher subsequent emergency department and inpatient care utilization compared to a general pediatric sample?

BackgroundChild maltreatment leads to substantial adverse health outcomes, but little is known about acute health care utilization patterns after children are evaluated for a concern of maltreatment at a child abuse and neglect medical evaluation clinic. ObjectiveTo quantify the association of having a child maltreatment evaluation with subsequent acute health care utilization among children from birth to age three. Participants and settingChildren who received a maltreatment evaluation (N = 367) at a child abuse and neglect subspecialty clinic in an academic health system in the United States and the general pediatric population (N = 21,231). MethodsWe conducted a retrospective cohort study that compared acute health care utilization over 18 months between the two samples using data from electronic health records. Outcomes were time to first emergency department (ED) visit or inpatient hospitalization, maltreatment-related ED use or inpatient hospitalization, and ED use or inpatient hospitalization for ambulatory care sensitive conditions (ACSCs). Multilevel survival analyses were performed. ResultsChildren who received a maltreatment evaluation had an increased hazard for a subsequent ED visit or inpatient hospitalization (hazard ratio [HR]: 1.3, 95 % confidence interval [CI]: 1.1, 1.5) and a maltreatment-related visit (HR: 4.4, 95 % CI: 2.3, 8.2) relative to the general pediatric population. A maltreatment evaluation was not associated with a higher hazard of health care use for ACSCs (HR: 1.0, 95 % CI: 0.7, 1.3). ConclusionThis work can inform targeted anticipatory guidance to aid high-risk families in preventing future harm or minimizing complications from previous maltreatment.

The Ratio of Urine N-Terminal Pro B-Type Natriuretic Peptide to Cyclic Guanosine Monophosphate Predicts Emergency Department Visits for Heart Failure

Introduction: Emergency department (ED) visits for decompensated heart failure (HF) are frequent and associated with poor long-term outcomes. Plasma N-terminal pro B-type natriuretic peptide (NT-proBNP) and cyclic guanosine monophosphate (cGMP) are used in diagnosis and prognosis of HF patients, while clinical values of urine NT-proBNP/cGMP ratio have been rarely explored. This study aims to compare the predictive values of urine NT-proBNP/cGMP ratio versus plasma NT-proBNP for ED visits for decompensated HF. Methods: This prospective study included 126 HF patients with reduced left ventricular ejection fraction (<50%) and without chronic kidney disease. Baseline data included demographics, co-morbidities, and co-medications. Medical records were used to determine the incidence of ED visits for decompensated HF during the 3 months following the last visit. Results: Patients with subsequent ED visits had significantly higher levels of plasma and urine NT-proBNP and urine cGMP in than those without. Multivariate Cox regression analysis disclosed that Lg₁₀urine NT-proBNP/cGMP was an independent risk factor for subsequent ED visits (OR = 3.267; 95% CI: 1.105–9.663; p = 0.032). ROC analysis revealed an Lg₁₀urine NT-proBNP/cGMP ratio optimal cut-off value of 0.1706 (AUC, 0.700; 95% CI: 0.543–0.857; p = 0.036) for predicting subsequent HF-related ED visits. Conclusion: A single measurement of urinary NT-proBNP/cGMP ratio is predictive of subsequent ED visits for decompensated HF. This noninvasive and easy measurement may be a clinically useful tool for identifying a subset of patients at higher risk of ED visits.

Effects of psychiatric comorbidities in persons with epilepsy on recurrent emergency department visits

BackgroundCoexisting mental health disorders in persons with epilepsy present as substantial burdens to patients and healthcare systems. Study design and methodsIn this retrospective study, we reviewed 160 patients presenting to a safety net hospital Emergency Department (ED) with seizures to investigate whether differences in clinical workup, follow-ups, and ED visit recurrence existed between epilepsy patients with epilepsy with and without a coexisting psychiatric disorder. ResultsPatients with epilepsy with a psychiatric comorbidity had more subsequent ED visits (45 % vs 26 %, p = 0.01) and fewer outpatient follow-up opportunities (74 % vs 87 %, p = 0.042) compared to patients with epilepsy without psychiatric comorbidities, highlighting a healthcare gap that needs to be addressed. InterpretationOur findings suggest a need for ED providers to shift their clinical practice in favor of offering more outpatient follow-up opportunities, to ensure long-term management of seizures in patients with epilepsy with comorbid psychiatric disorders.

The Treatment of COVID-19 With Monoclonal Antibody Therapy: Patient-Reported Outcomes.

ObjectiveThere have been many efforts to research and produce treatment modalities for COVID-19. Monoclonal antibodies have been one of the effective treatments since their approval by the US Food and Drug Administration (FDA) under emergency use authorization (EUA) in 2020. This study surveyed COVID-19 patients about their disease course and experience with monoclonal antibody treatment.MethodsPatients who received monoclonal antibody treatment between February 12, 2021, and June 2, 2021, at a South Florida community hospital were enrolled in the study. This included patients over 18 years of age with a confirmed positive COVID-19 test result, with mild to moderate symptoms within 10 days of onset and identified as high risk for progression to severe disease. There were no exclusion criteria. After 30 days, patients were followed up via a structured telephone survey regarding subsequent emergency department (ED) visits for worsening COVID-19 symptoms, need for oxygenation, intubation, and death. Secondary outcomes were adverse effects and patient perceptions.ResultsAmong the 119 patients who received monoclonal antibodies during the established time frame, 93 (78.1%) consented to participate in the telephone survey. Of these, 11.8% had a subsequent visit to the ED for worsening COVID-19 symptoms, 6.5% required oxygen, and 2.2% were admitted to the intensive care unit (ICU). There were no reported intubations or deaths. The vast majority (91.4%) would recommend monoclonal antibody treatment to others.ConclusionPatients who received monoclonal antibody therapy had low rates of subsequent ED visits and rarely required oxygen or ICU admission. The majority of patients would recommend treatment with monoclonal antibodies to others.