Urban Emergency Department Patients Research Articles

Association of Social Needs and Housing Status Among Urban Emergency Department Patients.

People experiencing homelessness have high rates of social needs when presenting for emergency department (ED) services, but less is known about patients with housing instability who do not meet the established definitions of homelessness. We surveyed patients in an urban, safety-net ED from June-August 2018. Patients completed two social needs screening tools and responded to additional questions on housing. Housing status was determined using validated questions about housing stability. Of the 1,263 eligible patients, 758 (60.0%) completed the survey. Among respondents, 40% identified as Latinx, 39% Black, 15% White, 5% Asian, and 8% other race/ethnicities. The median age was 42 years (interquartile range [IQR]: 29-57). and 54% were male. Of the 758 patients who completed the survey, 281 (37.1%) were housed, 213 (28.1%) were unstably housed, and 264 (34.8%) were homeless. A disproportionate number of patients experiencing homelessness were male (63.3%) and Black (54.2%), P <0.001, and a disproportionate number of unstably housed patients were Latinx (56.8%) or were primarily Spanish speaking (49.3%), P <0.001. Social needs increased across the spectrum of housing from housed to unstably housed and homeless, even when controlling for demographic characteristics. Over one in three ED patients experience homelessness, and nearly one in three are unstably housed. Notable disparities exist by housing status, and there is a clear increase of social needs across the housing spectrum. Emergency departments should consider integrating social screening tools for patients with unstable housing.

A pilot study of a mixed-method approach to design an ED-based peer mHealth referral tool for HIV/HCV and opioid overdose prevention services

BackgroundThe intersecting epidemics of opioid misuse, injection drug use, and HIV/HCV have resulted in record overdose deaths and sustained high levels of HIV/HCV transmissions. Literature on social networks suggests opportunities to connect people who use drugs (PWUD) and their peers to HIV/HCV and opioid overdose prevention services. However, little evidence exists on how to design such peer referral interventions in emergency department (ED) settings. MethodsA mixed-method study was conducted to assess the feasibility of an mHealth-facilitated ‘patient to peer social network referral program’ for PWUD. In-depth interviews (IDIs) and quantitative surveys were conducted with urban ED patients (n = 15), along with 3 focus group discussions (FGDs) (n = 19). ResultsOverall, 34 participants were enrolled (71 % males, 53 % Black). 13/15 IDI participants reported a history of opioid overdose; all had witnessed overdose events; all received HIV/HCV testing. From survey responses, most would invite their peers for HIV/HCV testing and naloxone training; and anticipated peers to accept referrals (HIV: 60 %, HCV: 73 %, naloxone: 93 %). Qualitative data showed PWUD shared health-related information with each other but preferred word of mouth rather than text messages. Participants used smartphones regularly and suggested using Internet advertising for prevention services. Participants expressed enthusiasm for ED-based peer mHealth referral platform to prevention services, as well as referring their peers to proposed services, with monetary incentives. ConclusionED-based peer referral intervention to HIV/HCV testing and naloxone training was viewed favorably by PWUD. Frequent smartphone use among PWUD suggests that the medium could be a promising mode for peer referral.

Acceptability of Exercise in Urban Emergency Department Patients With Metabolic Syndrome, Including a Subset With Venous Thromboembolism

Metabolic syndrome (MetS) afflicts more than one-third of US adults. In venous thromboembolism (VTE), MetS increases the risk of recurrence and severity of the post-pulmonary embolism syndrome, disproportionately affecting persons of color in urban settings. Exercise can positively modulate components of MetS. Our objective was to survey a sample of urban emergency department (ED) patients with MetS on their exercise habits and interest in increasing activity levels and to compare ± VTE patients. This survey study consisted of: (1) International Physical Activity Questionnaire, and (2) Likert scale gauging interest in increasing activity levels. Any adult ED patient with a composite MetS profile was included. We surveyed 247 patients with an average age of 59 years and 57% reported Black race. Only 9% met recommendations for vigorous exercise and 28% for moderate activity, with no significant difference in the 18% with prior VTE. Fifty-seven percent responded positively regarding motivation in increasing activity. This survey presents novel data supporting the need and feasibility of an interventional study examining exercise as an adjuvant therapy in patients with MetS and VTE.

Prevalence and Temporal Characteristics of Housing Needs in an Urban Emergency Department.

IntroductionOur objective was to determine the proportion of patients in our emergency department (ED) who are unhoused or marginally housed and when they typically present to the ED.MethodsWe surveyed patients in an urban, safety-net ED from June–August 2018, using a sampling strategy that met them at all times of day, every day of the week. Patients used two social needs screening tools with additional questions on housing during sampling shifts representing two full weeks. Housing status was determined using items validated for housing stability, including PRAPARE, the Accountable Health Communities Survey, and items from the United States Department of Health and Human Services. Propensity scores estimated differences among respondents and non-respondents.ResultsOf those surveyed, 35% (95% confidence interval [CI], 31–38) identified as homeless and 28% (95% CI, 25–31) as unstably housed. Respondents and non-respondents were similar by propensity score. The average cumulative number of homeless and unstably housed patients arriving per daily 8-hour window peaks at 7 AM, with 46% (95% CI, 29–64) of the daily aggregate of those reporting homelessness and 44% (95% CI, 24–64) with unstable housing presenting over the next eight hours.ConclusionThe ED represents a low-barrier contact point for reaching individuals experiencing housing challenges, who may interact rarely with other institutions. The current prevalence of homelessness and housing instability among urban ED patients may be substantially higher than reported in historical and national-level statistics. Housing services offered within normal business hours would reach a meaningful number of those who are unhoused or marginally housed

Frequency of Intimate Partner Violence among an Urban Emergency Department Sample: A Multilevel Analysis.

Intimate partner violence (IPV) is a pervasive public health problem. Within the U.S., urban emergency department (ED) patients have elevated prevalence of IPV, substance use, and other social problems compared to those in the general household population. Using a social-ecological framework, this cross-sectional study analyzes the extent to which individual, household, and neighborhood factors are associated with the frequency of IPV among a socially disadvantaged sample of urban ED patients. Confidential survey interviews were conducted with 1037 married/partnered study participants (46% male; 50% Hispanic; 29% African American) at a public safety-net hospital. Gender-stratified multilevel Tobit regression models were estimated for frequency of past-year physical IPV (perpetration and victimization) and frequency of severe IPV. Approximately 23% of participants reported IPV. Among men and women, impulsivity, adverse childhood experiences, substance use, and their spouse/partner’s hazardous drinking were associated with IPV frequency. Additionally, household food insufficiency, being fired or laid off from their job, perceived neighborhood disorder, and neighborhood demographic characteristics were associated with IPV frequency among women. Similar patterns were observed in models of severe IPV frequency. IPV prevention strategies implemented in urban ED settings should address the individual, household, and neighborhood risk factors that are linked with partner aggression among socially disadvantaged couples.

Adverse childhood experiences are associated with at-risk drinking, cannabis and illicit drug use in females but not males: an Emergency Department study

ABSTRACT Background Adverse childhood experiences (ACEs) are associated with adult substance use in the general population. Given pervasive health disparities among underserved populations, understanding how ACEs are associated with substance use among urban Emergency Department (ED) patients could help inform design of effective screening, brief interventions, and referral to treatment. Objectives To estimate gender differences in prevalence of separate and cumulative ACEs among a sample of urban ED patients, and assess its association with at-risk drinking (4+/5+ drinks for females/males), cannabis, and illicit drug use. We hypothesized that the association between ACEs and each outcome would be stronger among females than males. Methods Cross-sectional survey data were obtained from 1,037 married/partnered ED patients (53% female) at a public safety-net hospital. Gender-stratified logistic regression models were estimated for each substance use outcome. Results One+ ACEs were reported by 53% of males and 60% of females. Females whose mother was a victim of domestic violence had greater odds of at-risk drinking compared to females who did not report this ACE (AOR = 1.72; 95% CI 1.03, 2.88). Females’ cumulative ACEs were associated with cannabis use (OR = 2.26, 95% CI 1.06, 4.83) and illicit drug use (OR = 3.35; 95% CI 1.21, 9.30). Males’ separate and cumulative ACEs were not associated with increased likelihood for any of the outcomes. Conclusion ACEs are associated with greater odds of substance use among female than male ED patients. The prevalence of ACE exposure in this urban ED sample underscores the importance of ED staff providing trauma-informed care.

Homeless Shelter Entry in the Year After an Emergency Department Visit: Results From a Linked Data Analysis

Housing instability is prevalent among emergency department (ED) patients and is known to adversely affect health. We aim to determine the incidence and timing of homeless shelter entry after an ED visit among patients who are not currently homeless. We conducted a random-sample survey of ED patients at an urban public hospital from November 2016 to September 2017. Patients provided identifying information and gave informed consent for us to link their survey data with the New York City Department of Homeless Services shelter database. Shelter use was followed prospectively for 12 months after the baseline ED visit. We examined timing of shelter entry in the 12 months after the ED visit, excluding patients who were homeless at baseline. Of 1,929 unique study participants who were not currently homeless, 96 (5.0%) entered a shelter within 12 months of their baseline ED visit. Much of the shelter entry occurred in the first month after the ED visit, with continued yet slower rates of entry in subsequent months. Patients in our sample who entered a shelter were predominantly men and non-Hispanic black, and commonly had past shelter and frequent ED use. In this single-center study, 5.0% of urban ED patients who were not currently homeless entered a homeless shelter within the year after their ED visit. Particularly if replicated elsewhere, this finding suggests that ED patients may benefit from efforts to identify housing instability and direct them to homelessness prevention programs.

Risk Factors for Bed Bugs Among Urban Emergency Department Patients.

Bed bugs are a significant and under-studied public health nuisance. We surveyed 706 emergency department patients and found bed bug infestations were more likely (p < 0.05) among subjects having persons 19-64years of age in the house, living in a group home, a previous history with bed bugs, and knowing someone who currently has bed bugs. Sleeping in a hotel, recent homelessness, obtaining used clothing or furniture and using a laundromat were not associated with increased risk (p > 0.05) for infestation. Individuals with less education and income were more likely (p < 0.05) to have bed bugs and express concern about getting bed bugs. Younger persons were more likely to correctly identify a picture of a bed bug compared to those over the age of 60years (p < 0.001).

83 Can Pharmacists Effectively Manage Blood Pressure for Discharged Urban Emergency Department Patients With Uncontrolled Hypertension?

Uncontrolled hypertension (HTN) leads to severe cardiovascular morbidity, and is commonly encountered in emergency department (ED) practice. Linkage to primary care is elusive for many ED patients, specifically in underserved communities, and thus alternative modalities are needed. Pharmacist-led HTN medication management has proven effective for patients with uncontrolled BP. However, no studies to date have addressed the ability of pharmacists to manage HTN in ED patients post-discharge. The objective of this study is to assess the effectiveness of a pharmacist-led HTN management clinic in the ED population. This a prospective, single arm trial of an innovative healthcare delivery system, a pharmacist-led HTN clinic. We recruited 89 patients with uncontrolled HTN, and lack of access to primary care from our urban ED from May 24, 2017 to May 18, 2018. Per protocol, 5 follow-up visits were planned in an outpatient pharmacy clinic, where antihypertensive medications were initiated and titrated by a pharmacist, under a collaborative agreement with emergency physicians. Information regarding the patient demographics and medical history were collected. Descriptive statistics were applied with graphic display of blood pressure change. These data represent an ad hoc, interim analysis of an ongoing study. The mean age was 42.5 years old (SD=9.9); 51% were males; 94% were African American; 81% had 12th grade or more education; 53% reported full-time employment and 18% had no health insurance. The mean BMI was 34.5 and 51.2% were current smokers. The median BP at ED admission was 160/102 mmHg. Of 89 patients recruited, only 32 (35%) actually attended the first visit. Both systolic and diastolic BP declined throughout the follow-up pharmacy clinic visits with the most impact on systolic BP (Figure), which showed a mean decrease of 48 mmHg (95% confidence interval 20-77). The pharmacist made 47 medication interventions (initiation or titration) during 95 follow-up visits, for a rate of 0.49 interventions/visit. At protocol completion the mean number of antihypertensive medications per patient was 3. Preliminary results show pharmacist-led HTN management provided to ED patients post-discharge is effective at lowering BP in a clinically meaningful manner. The pharmacist was proactive in medication titration, and patients received evidence based care. Linkage between recruitment in the ED, and actual study participation was suboptimal. These data are encouraging, and provide the rationale for future larger scale studies. To better understand the potential for clinical implementation, an exploration of factors influencing the effectiveness of treatment and a comparison with usual care are needed, with special attention paid to improving ED to pharmacy transition.

Substance use and homelessness among emergency department patients

BackgroundHomelessness and substance use often coexist, resulting in high morbidity. Emergency department (ED) patients have disproportionate rates of both homelessness and substance use, yet little research has examined the overlap of these issues in the ED setting. We aimed to characterize alcohol and drug use in a sample of homeless vs. non-homeless ED patients. MethodsA random sample of urban hospital ED patients were invited to complete an interview regarding housing, substance use, and other health and social factors. We compared substance use characteristics among patients who did vs. did not report current literal (streets/shelter) homelessness. Additional analyses were performed using a broader definition of homelessness in the past 12-months. ResultsPatients who were currently homeless (n = 316, 13.7%) versus non-homeless (n = 1,993, 86.3%) had higher rates of past year unhealthy alcohol use (44.4% vs. 30.5%, p < .0001), any drug use (40.8% vs. 18.8%, p < .0001), heroin use (16.7% vs. 3.8%, p < .0001), prescription opioid use (12.5% vs. 4.4%, p < .0001), and lifetime opioid overdose (15.8% vs. 3.7%, p < .0001). In multivariable analyses, current homelessness remained significantly associated with unhealthy alcohol use, AUDIT scores among unhealthy alcohol users, any drug use, heroin use, and opioid overdose; past 12-month homelessness was additionally associated with DAST-10 scores among drug users and prescription opioid use. ConclusionsPatients experiencing homelessness have higher rates and greater severity of alcohol and drug use than other ED patients across a range of measures. These findings have implications for planning services for patients with concurrent substance use and housing problems.

270 Patients Have Poor Recall for Prior CT Exposure: A Multicenter Study of Urban Emergency Department Patients

Regulators and the scientific community are increasingly focused on patient risk from radiation exposure related to medical imaging. As a central/national database is currently lacking, emergency physicians are often reliant on patient recall of prior CT history to assess the risk/benefits of emergent imaging vs. the risk of recurrent radiation exposure. The objective of our study was to assess the proportion of patients in our population who would underestimate the prior number of CT scans that they had received previously. This was a prospective, cross-sectional study. We enrolled a convenience sample of adult, hemodynamically stable, oriented, consenting patients at an academic inner-city ED. Each patient completed a written survey providing demographic, chief complaint information, and questions regarding their imaging history. Patients’ estimates of prior CT imaging exposure were then compared with electronic records from a 6-hospital system database that includes over 80% of all ED visits within a 12-county region (2005-present). Categorical data presented as frequency of occurrence and analyzed by chi-square. Continuous data presented as means+/-SD and analyzed by t-tests. There were 298 patients enrolled; mean age 41+/-16 years, 49% female, 67% Hispanic, 35% income < $20,000, 34% < or = high school education, 14% private insurance, 43% presented for painful conditions. 39.9% (119/298) of patients underestimated their total number of prior CTs by at least one (difference = patient reported CTs - in system CTs in electronic records). The following patient characteristics were not associated with underestimation: age (p=0.08), female sex (p=0.38), less than high school education (p= 0.15), Hispanic race (p=0.47), income < $20,000/year (p=0.91). 12.4% of patients underestimated their total number of chest CTs, while 24.2% underestimated their total number of abdominal CTs. 66.1% (197/298) patients reported that they had not had any imaging outside of our hospital system. For patients with no reported outside system CTs, 35.0% (69/197) underestimated their prior CT exposure by at least one. Within the overall study group, 25.6% overestimated their total CTs by at least one. For our predominantly Hispanic, urban poor study group, emergency department patient recall for prior CT imaging history was poor. There were a significant proportion of patients who either underestimated or overestimated respectively their prior exposure.

High Incidence of Hepatitis C Virus (HCV) Infection among an Urban Emergency Department (ED) Patients. 2003–2016.

Background CDC estimated 30,500 new HCV infections in the US in 2014 [or 0.096 per 1,000 person-years (PYs)] and HCV incidence of high-risk groups ranged from 2 to 400 per 1000 PYs. High seroprevalence of HCV antibody, evidence of HCV infection ever, is common among urban emergency department (ED) patients. Little is known regarding incidence of HCV infection in ED patients in recent years.Methods We conducted a retrospective cohort study to determine HCV incidence among ED adult patients. The study ED rolled out an ED-based HCV screening program since November 2015. A secondary data analysis was performed from a seroprevalence study on all adult patients who visited the study ED during December 10, 2015 and January 21, 2016. Patients who had at least two HCV antibody testings from two separate visits at the study hospital from 2003 to 2016 were included for this secondary data analysis. Patients who had reactive HCV antibody result at the first time point were excluded. Follow-up time (PYs) was calculated for each patient by the interval of between two HCV antibody tests. Time of HCV seroconversion was defined as the midpoint between the negative and positive HCV antibody test. Incidence rate ratio (IRR) and corresponding 95% CI was used to present the relative incidence between groups by mid-p exact test.ResultsA total of 302 ED patients were identified. The majority of them were female (60%), African American (79%), aged 35 years and older (60%). Sixty-eight percent of patients were born after 1965 (68%) and 25% born between 1945 and 1965 (birth cohort). Fifty-six percent of patients had commercial insurance payor and 36% had Medicaid or Medicare. Thirty-four (11%) patients had HIV infection and 7 (2%) were injection drug users (IDU). Overall, 6 (2%) had HCV seroconversion during 971.1 PYs, resulting in an HCV incidence of 6.2 per 1,000 PYs (95% CI: 2.5, 12.9 per 1,000 PYs). The incidence was significantly different by race [white: 30.9/1,000 PYs, African American: 2.9/1,000 PYs; RR: 12.3 (2.2, 95.8)] and IDU [IDU: 192.3/1,000 PYs, non-IDU: 4.2/1,000 PYs; RR: 46.2 (5.9, 260.3)] but not by birth cohort or HIV status.Conclusion The HCV incidence in urban ED patients was over 60 times higher than the general US population and even higher in some high-risk groups, indicating ED is a critical venue for identifying high-risk individuals for HCV prevention and detecting HCV-infected Americans for treatment.Disclosures All authors: No reported disclosures.

Utility of Framingham risk score in urban emergency department patients with asymptomatic hypertension.

Hypertension (HTN) is the primary population-attributable risk for the development of heart failure (HF); a disease with devastating consequences particularly in urban centers where morbidity and mortality are more pronounced. The Framingham Risk Profile (FRP) is widely used to quantify risk for cardiovascular disease (CVD), but its applicability in an urban population who utilize the emergency department (ED) for primary care is unknown. The objective of this study is to evaluate FRP scores in ED patients with asymptomatic HTN and subclinical hypertensive heart disease (SHHD). This is a substudy of a prospective randomized clinical trial designed to evaluate optimal blood pressure (BP) targets. Eligible patients were screened with echocardiography for the presence of SHHD and FRP scores were calculated. One hundred forty-nine patients enrolled in the study, 133 (89.2%) of whom had detectable SHHD. Mean [SD] calculated FRP scores were statistically similar for patients with SHHD versus those without (general CVD: 20.2 [8.5] vs. 15.6 [8.7]; P = 0.13 and HF calibrated: 2.4 [1.0] vs. 1.8 [1.0]; P = 0.12) corresponding to a calculated risk of 15%-30% for subsequent development of CVD. The HF-specific risk score for patients with SHHD was 2.4, which equates to a 2.5% risk of HF development in 10 years. The FRP correctly identified those with SHHD as high-risk for general CVD but appeared to underestimate the likelihood of HF. Recalibration of the HF adjustment factor and inclusion of additional data elements such as echocardiography is needed to enhance applicability of the FRP in this setting.

HCV and HBV testing acceptability and knowledge among urban emergency department patients and pharmacy clients

ObjectiveHepatitis C and hepatitis B are public health problems in the United States and remain largely undiagnosed. In response to the availability of rapid, point of care hepatitis tests, we assessed hepatitis knowledge and acceptability of hepatitis testing during an emergency department (ED) or pharmacy visit. MethodsFrom June 2010 to May 2011, an anonymous prospective survey was administered to a convenience sample of New York City ED patients and pharmacy clients. ResultsThe study population (N=2078) was 54% female, 36% Hispanic and 41% black. Mean age was 39, SD±15years. The majority (72%;1480/2,2060) of the participants responded that they would get tested if free testing were offered, and 67% (1272/1912) of those responded that they would test for hepatitis B/C in conjunction with HIV. Participants who had previously tested for hepatitis had higher mean knowledge scores than those who had never tested. Pharmacy clients, those of black race, and those with higher mean knowledge scores would be more willing to accept hepatitis B/C testing if offered. ConclusionsUrban ED patients and pharmacy clients were receptive to hepatitis testing. Most individuals would elect to be tested for hepatitis with HIV, which raises the possibility of integrated testing.

Family Support Mediates the Association Between Substance Use Severity and Suicidal Ideation in Early Adult Emergency Department Patients

Suicidality and its etiology in non-treatment-seeking substance abusers is understudied. We address this gap by examining data collected in 2009–2010 on suicidal ideation (SI) in early adult, urban emergency department patients (N = 505) . Prevalence of past year SI was 15 %. A positive, indirect effect of cocaine use severity, but not alcohol or marijuana use severity, on likelihood of SI mediated through family support was found. Implications and future directions for ED practices and suicide risk etiology among this population are discussed, as well as study limitations. Funding provided by the Substance and Mental Health Services Administration (SAMHSA).

Synergy to Reduce Emergency Department Visits for Uncontrolled Hyperglycemia

The purpose of this pilot study was to evaluate the safety and preliminary efficacy of a treatment algorithm and education intervention for the management of patients with type 2 diabetes and hyperglycemia presenting to the emergency department (ED) and stable enough to be discharged home. Urban hospital ED patients (n = 86) with BG ≥ 200 mg/dL were enrolled in a 4-week prospective, nonrandomized pilot intervention with historic self-controls. Follow-up visits occurred at 12 to 72 hours, 2 and 4 weeks, and 6 months. T2DM medications were initiated or adjusted at each visit using a guideline-based diabetes medication management algorithm. Survival skills diabetes self-management education and navigation to outpatient services were provided. Participants were 51.8% male and 92% black, and 87.3% had private or public insurance. The top reasons for presenting to the ED were no provider appointment available (41.7%) and no primary care provider (14.6%). No hypoglycemia occurred in the first 24 hours following ED T2DM medication initiation or titration and overall hypoglycemia rates were low. BG was reduced from 356 ± 110 mg/dL at baseline to 183 ± 103 mg/dL at 4 weeks (P < .001). Diabetes medication management and survival skills education for uncontrolled diabetes may be safely initiated in the ED, as demonstrated by the multidisciplinary STEP-DC intervention, which effectively enabled glycemic control in this pilot study.

Youth alcohol use and dating abuse victimization and perpetration: a test of the relationships at the daily level in a sample of pediatric emergency department patients who use alcohol.

This study retrospectively examined the daily-level associations between youth alcohol use and dating abuse (DA) victimization and perpetration for a 6-month period. Timeline Followback (TLFB) interview data were collected from 397 urban emergency department patients, ages 17 to 21 years. Patients were eligible if they reported past month alcohol use and past year dating. Generalized estimating equation (GEE) analyses estimated the likelihood of DA on a given day as a function of alcohol use or heavy use (≥4 drinks per day for women, ≥5 drinks per day for men), as compared with nonuse. Approximately 52% of men and 61% of women participants reported experiencing DA victimization ≥1 times during the past 6 months, and 45% of men and 55% of women reported perpetrating DA ≥1 times. For both men and women, DA perpetration was more likely on a drinking day as opposed to a nondrinking day (ORs = 1.70 and ORs = 1.69, respectively). DA victimization was also more likely on a drinking day as opposed to a nondrinking day for both men and women (ORs = 1.23 and ORs = 1.34, respectively). DA perpetration and DA victimization were both more likely on heavy drinking days as opposed to nondrinking days (2.04 and 2.03 for men's and women's perpetration, respectively, and 1.41 and 1.43 for men's and women's victimization, respectively). This study found that alcohol use was associated with increased risk for same day DA perpetration and victimization, for both male and female youth. We conclude that for youth who use alcohol, alcohol use is a potential risk factor for DA victimization and perpetration.

Emergency Department Patients' Preferences for Technology-Based Behavioral Interventions

To assess emergency department (ED) patients' preferences for technology-based behavioral interventions, and the demographic factors associated with these preferences. A cross-sectional survey of a random sample of urban ED patients (≥13 years) from a representative sample of shifts, with oversampling of adolescents/young adults (aged 13 to 24 years). Participants self-administered the survey about baseline technology use, concerns about technology-based interventions, and preferred intervention format for 7 behavioral health topics. We performed descriptive statistics and multivariate logistic regression (controlling for demographics and then additionally for baseline technology use) to identify factors differentially associated with technology preference for each behavioral topic. Of patients presenting during research assistant shifts, 1,429 (≈59%) were screened and 664 (68.2% of eligible) consented to participate. Mean age was 31 years (SD 0.69); 54.5% were female, 64.1% were white, 23.2% were Hispanic, and 46.6% reported low income. Baseline use of computers (91.2%), Internet (70.7%), social networking (66.9%), mobile phones (95.0%), and text messaging (73.8%) was high. Participants reported interest in receiving interventions on each behavioral topic. Ninety percent preferred a technology-based intervention for at least 1 topic. Patients expressed greatest concerns about Internet (51.5%) and social networking (57.6%), particularly about confidentiality. Adjusting for sex, race, ethnicity, and income, younger age associated with preference for technology-based interventions for unintentional injuries (odds ratio 0.63 for technology preference if adult versus youth; 95% confidence interval 0.45 to 0.89) and peer violence (odds ratio 0.63 if adult; 95% confidence interval 0.43 to 0.92). Additionally adjusting for baseline technology usage, only baseline usage was associated with preference for technology-based interventions. ED patients reported high baseline technology use, high interest in behavioral health interventions, and varying preferences for technology-based interventions. Future studies should address actual feasibility and acceptability of technology-based interventions in a more generalized population and ways to alleviate concerns about these interventions.

Long‐term Follow‐up After Voluntary Human Immunodeficiency Virus/Sexually Transmitted Infection Counseling, Point‐of‐service Testing, and Referral to Substance Abuse Treatment From the Emergency Department

Public health initiatives have lowered human immunodeficiency virus (HIV) transmission risk associated with injection drug use in the United States, making sexual risk behaviors a greater source of transmission. Strategies are therefore needed to reduce these risk behaviors among all emergency department (ED) patients who use drugs, regardless of route of administration. Although recent articles have focused on the opportunity for early HIV detection and treatment through an array of ED screening and testing strategies, the effect of voluntary HIV testing and brief counseling (VT/C) on the sexual behaviors of out-of-treatment drug users over time has not yet been reported. From November 2004 to May 2008, the study screened 46,208 urban ED patients aged 18 to 54 years; 2,148 (4.6%) reported cocaine or heroin use within 30 days, 1,538 met eligibility criteria (Drug Abuse Severity Test [DAST] scores ≥3 and were either English- or Spanish-speaking), and 1,030 were enrolled. These data were obtained in the course of a randomized, controlled trial (Project SAFE) of a brief motivational intervention focused on reducing risky sexual behaviors. Although the intervention itself did not demonstrate any differential effect on the number or percentage of unprotected sexual acts, both control and intervention group participants received baseline VT/C and referral for drug treatment as part of the study protocol. This study is a report of a secondary analysis of cohort data to describe changes in sexual behaviors over time among drug users after the VT/C and referral. The mean (±SD) age of enrollees was 35.8 (±8.4) years; 67% were male, 39% were non-Hispanic black or African American, 41% were white non-Hispanic, and 19% were Hispanic. Half injected drugs, and 53% met criteria for posttraumatic stress disorder (PTSD). At baseline testing, 8.8% were HIV-positive on enzyme-linked immunosorbent assay. Follow-ups were conducted at 6 and 12 months, with an attrition rate of 22%. Known HIV-positive patients accounted for 84 of 1,030 cases (8.1%), and 13 new cases were discovered: 7 of 946 at were discovered at the baseline contact (0.74%), 2 of 655 were discovered at 6 months (0.3%), and 4 of 706 (0.57%) were discovered at the 12-month contact. Twelve of the 13 returned for confirmatory testing and were actively enrolled in our infectious disease clinic. For all partners, there was a reduction in the percentage of unprotected sex acts over time (p < 0.0001), with decreases at 6 months versus baseline (odds ratio [OR] = 0.70, 95% confidence interval [CI] = 0.60 to 0.83), sustained at 12 months versus baseline (OR = 0.69, 95% CI = 0.58 to 0.82). For the outcome of percentage of sex acts while high, there was also a significant reduction over time (p < 0.0001), with a drop-off at 6 months versus baseline (OR = 0.31, 95% CI = 0.25 to 0.37) that was sustained at 12 months (OR vs. baseline 0.25, 95% CI = 0.20 to 0.30). In an adjusted model, male sex, older age, and HIV positivity predicted significant declines over time in the likelihood of unprotected sexual acts. Older age and higher baseline drug severity predicted significant decreases over time in the likelihood of sex acts while high. Voluntary testing and counseling for HIV or sexually transmitted infections, accompanied by referral to drug treatment, for this population of ED cocaine and heroin users was associated with reduction in unprotected sex acts and fewer sex acts while high.

Correlates of Violence History Among Injured Patients in an Urban Emergency Department

This study surveyed consecutive injured patients (n = 320) in an urban emergency department (ED) regarding past year violence, substance use, and depression. Victimization and aggression variables (none = N, partner only = P, non-partner only = NP, and generalized/both partner and non-partner = G) were compared on gender, depression, and substance use/consequences. Findings were similar for victimization and aggression variables. Depression was significantly related to violence for women but not for men; women in the P group reported the most depression. Substance variables were significantly related to violence by gender groups. Men in r NP and G groups reported the most binge drinking; men in the G group reported the most consequences and drug use. Women in P and G groups reported the most binge drinking and consequences; women in the P group reported the most drug use. Screening urban ED patients for violence is warranted, with interventions addressing both partner and non-partner violence.