Case finding and referral model for emergency department elders: a randomized clinical trial

STUDY OBJECTIVE: Elderly emergency department patients have complex medical needs and limited social support. A transitional model of care adapted from hospitals was tested for its effectiveness in the ED in reducing subsequent service use. METHODS: A randomized clinical trial was conducted at 2 urban, academically affiliated hospitals. Participants were 650 community-residing individuals 65 years or older who were discharged home after an ED visit. Main outcomes were service use rates, defined as repeat ED visits, hospitalizations, or nursing home admissions, and health care costs at 30 and 120 days. Intervention consisted of comprehensive geriatric assessment in the ED by an advanced practice nurse and subsequent referral to a community or social agency, primary care provider, and/or geriatric clinic for unmet health, social, and medical needs. Control group participants received usual and customary ED care. RESULTS: The intervention had no effect on overall service use rates at 30 or 120 days. However, the intervention was effective in lowering nursing home admissions at 30 days (0.7% versus 3%; odds ratio 0.21; 95% confidence interval [CI] 0.05 to 0.99) and in increasing patient satisfaction with ED discharge care (3.41 versus 3.03; mean difference 0.37; 95% CI 0.13 to 0.62). The intervention was more effective for high-risk than low-risk elders. CONCLUSION: An ED-based transitional model of care reduced subsequent nursing home admissions but did not decrease overall service use for older ED patients. Further studies are needed to determine the best models of care for this setting and for at-risk patients.     

Ambulatory health care use by patients in a public hospital emergency department

OBJECTIVE: To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use. DESIGN: Cohort observational study. SETTING: A public hospital in Atlanta, Georgia. PATIENTS: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years. MEASUREMENTS AND MAIN RESULTS: Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was 0 (mean 1.1) with only 90 (26%) of the patients having any primary care clinic visits. The 58 patients (16.6%) who had more than 10 subsequent ED visits accounted for 65.6% of all subsequent ED visits. Overall, patients received 55% of their subsequent ambulatory care in the ED, with only 7.5% in a primary care clinic. In multivariate regression, only access to a telephone (odds ratio [OR] 0.48; 95% confidence interval [CI] 0.39, 0.60), hospital admission (OR 5.90; 95% CI 4.01, 8.76), and primary care visits (OR 1.68; 95% CI 1.34, 2.12) were associated with higher ED visit rates. Regular source of care, insurance coverage, and health status were not associated with ED use. From clinical record review, 74.1% of those with high rates of use had multiple chronic medical conditions, or a chronic medical condition complicated by a psychiatric diagnosis, or substance abuse. CONCLUSIONS: All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs. This study was supported by a grant from the Emory Medical Care Foundation.     

Lack of long-term benefits of a 6-month heart failure disease management program

BackgroundHeart failure (HF) represents a major burden on the health care system, causing repeated hospitalizations and numerous emergency department (ED) visits. In a 6-month randomized study of a multidisciplinary HF clinic, we have previously shown decreased hospital readmissions and improved quality of life. Despite these encouraging results, it is unknown if these beneficial effects are sustained.Methods and ResultsTo assess long-term recurrent ED visits, readmissions, and mortality among HF patients who were discharged after a 6-month intensive HF management program (HFMP). Of the 230 subjects (New York Heart Association Class II-IV) who were initially randomized to standard follow-up care or to a HFMP for 6 months, 190 were studied retrospectively for long-term evaluation. Long-term data was obtained from the Quebec administrative health databases. We compared the intervention and control groups for the number of recurrent ED visits, hospital readmissions, and all-cause deaths. After a mean follow-up of 2.8 ± 1.7 years, there was no difference in the composite end point of all-cause death, hospital admissions, and ED visits between those patients initially in the HFMP group and the controls. After multivariable adjustment, there was no difference in the composite primary endpoint (HR 1.01, 95% CI: 0.75–1.37) or in the secondary end point of all-cause death alone (HR 1.09, 95%CI:0.69–1.72) between those initially assigned to the HF clinic and those receiving usual care.ConclusionsFor severely ill patients, the clinical and resource benefits of a 6-month HFMP are not sustained upon program cessation. Further research into the benefits of long-term HFMP is required.     

Emergency medicine and hospital medicine: a call for collaboration

BackgroundIn the United States, emergency physicians and hospitalists are increasingly responsible for managing hospitalized patients. These specialists share a common practice space and similar shift work schedules. Together they govern decisions about use of the most expensive care setting in medicine—the hospital.DiscussionUnfortunately, in most institutions there is little collaboration between emergency physicians and hospitalists, resulting in missed opportunities to improve the quality of care and reduce its cost. In this call to action, we challenge emergency physicians and hospitalists to work together to develop protocols for consistent, evidence-based, and expeditious care of patients admitted from the ED; to collaborate in the care of ED patients who can safely be discharged home; to pursue joint quality, hospital leadership, and cost-effectiveness projects; to work in partnership to assure adequate staffing of hospital-based specialists; and to cooperate in the professional, front-line assessment of clinically and fiscally driven policies aimed at assessing the appropriateness of hospital admissions and readmissions.SummaryHospital care is increasingly driven by emergency physicians and hospitalists. We envision a vital role for ongoing collaboration between them in achieving the goals of patient care, education, and quality and safety outcomes.     

Benefits of implementing a rapid access clinic in a high-volume inflammatory bowel disease center:Access,resource utilization and outcomes

BACKGROUND Emergency situations in inflammatory bowel diseases(IBD)put significant burden on both the patient and the healthcare system.AIM To prospectively measure Quality-of-Care indicators and resource utilization after the implementation of the new rapid access clinic service(RAC)at a tertiary IBD center.METHODS Patient access,resource utilization and outcome parameters were collected from consecutive patients contacting the RAC between July 2017 and March 2019 in this observational study.For comparing resource utilization and healthcare costs,emergency department(ED)visits of IBD patients with no access to RAC services were evaluated between January 2018 and January 2019.Time to appointment,diagnostic methods,change in medical therapy,unplanned ED visits,hospitalizations and surgical admissions were calculated and compared.RESULTS 488 patients(Crohn’s disease:68.4%/ulcerative colitis:31.6%)contacted the RAC with a valid medical reason.Median time to visit with an IBD specialist following the index contact was 2 d.Patients had objective clinical and laboratory assessment(C-reactive protein and fecal calprotectin in 91%and 73%).Fast-track colonoscopy/sigmoidoscopy was performed in 24.6%of the patients,while computed tomography/magnetic resonance imaging in only 8.1%.Medical therapy was changed in 54.4%.ED visits within 30 d following the RAC visit occurred in 8.8%(unplanned ED visit rate:5.9%).Diagnostic procedures and resource utilization at the ED(n=135 patients)were substantially different compared to RAC users:Abdominal computed tomography was more frequent(65.7%,P<0.001),coupled with multiple specialist consults,more frequent hospital admission(P<0.001),higher steroid initiation(P<0.001).Average medical cost estimates of diagnostic procedures and services per patient was$403 CAD vs$1885 CAD comparing all RAC and ED visits.CONCLUSION Implementation of a RAC improved patient care by facilitating easier access to IBD specific medical care,optimized resource utilization and helped avoiding ED visits and subsequent hospitalizations.     

Hospital Readmissions After Implementation of a Discharge Care Program for Patients with COVID-19 Illness

BackgroundThe surge of coronavirus 2019 (COVID-19) hospitalizations in New York City required rapid discharges to maintain hospital capacity.ObjectiveTo determine whether lenient provisional discharge guidelines with remote monitoring after discharge resulted in safe discharges home for patients hospitalized with COVID-19 illness.DesignRetrospective case seriesSettingTertiary care medical centerPatientsConsecutive adult patients hospitalized with COVID-19 illness between March 26, 2020, and April 8, 2020, with a subset discharged homeInterventionsCOVID-19 Discharge Care Program consisting of lenient provisional inpatient discharge criteria and option for daily telephone monitoring for up to 14 days after dischargeMeasurementsFourteen-day emergency department (ED) visits and hospital readmissionsResultsAmong 812 patients with COVID-19 illness hospitalized during the study time period, 15.5% died prior to discharge, 24.1% remained hospitalized, 10.0% were discharged to another facility, and 50.4% were discharged home. Characteristics of the 409 patients discharged home were mean (SD) age 57.3 (16.6) years; 245 (59.9%) male; 27 (6.6%) with temperature ≥ 100.4 °F; and 154 (37.7%) with oxygen saturation < 95% on day of discharge. Over 14 days of follow-up, 45 patients (11.0%) returned to the ED, of whom 31 patients (7.6%) were readmitted. Compared to patients not referred, patients referred for remote monitoring had fewer ED visits (8.3% vs 14.1%; OR 0.60, 95% CI 0.31–1.15, p = 0.12) and readmissions (6.9% vs 8.3%; OR 1.15, 95% CI 0.52–2.52, p = 0.73).LimitationsSingle-center study; assignment to remote monitoring was not randomized.ConclusionsDuring the COVID-19 surge in New York City, lenient discharge criteria in conjunction with remote monitoring after discharge were associated with a rate of early readmissions after COVID-related hospitalizations that was comparable to the rate of readmissions after other reasons for hospitalization before the COVID pandemic.Supplementary InformationThe online version contains supplementary material available at 10.1007/s11606-020-06340-w.     

Closing the clinics: would it close the teaching hospital?

To improve their overall financial position, many teaching hospitals have considered decreasing the size of their clinics. To assess the effect this would have on the inpatient service, the medical ward service of The New York Hospital was studied during the 1981 to 1982 academic year. In 50 percent of hospitalizations, patients were enrolled in the clinic system before admission. In an additional 19 percent of hospitalizations, patients had either been previously seen in the emergency room or hospitalized at this institution, but never seen in a clinic. In the remaining 31 percent of hospitalizations, the patient's admission was the first contact with the institution. This group of "new" patients simply replaced the patients who died (14 percent) or were lost to the system through transfer to chronic-care facilities (11 percent) or referral to community physicians (7 percent). Twenty percent of patients discharged to a clinic were readmitted during the study year as opposed to only 3 percent of patients who were transferred to chronic-care facilities or referred to community physicians. The clinic system is the principal source of referral into the ward service and the most effective mechanism for insuring that a patient needing rehospitalization returns to the hospital. It is concluded that major reduction of clinic size will result in severe contraction of the inpatient service.     

Estimated Use of a Pediatric Emergency Department Observation Unit

Study objective: To estimate the use of a pediatric ED observation unit, including the number of anticipated admissions per 10,000 pediatric ED visits per year and the distribution of those admissions by age group, by month, and by time of day. Methods: Hospital and ED computer records on all ED patients younger than 18 years who were seen during a 2-year period were abstracted for diagnostic, demographic, and time-flow data. We retrospectively reviewed the charts of patients admitted to the hospital and discharged within 24 hours to determine whether discharge in less than 24 hours could have been anticipated and whether the patient could have been cared for in a pediatric ED observation unit. To refine the estimate, we also reviewed the ICD-9 discharge diagnoses of patients who were not admitted to the hospital but spent more than 6 hours in the pediatric ED. Results: Of 29,667 pediatric ED visits in a 2-year period, 2,940 (10%) resulted in admission. Of 626 patients discharged in less than 24 hours, only 410 met the anticipation and pediatric ED observation unit level of care criteria. Patients younger than 4 years represented 43% of potential observation unit patients; those aged 16 and 17 years represented 15%. Potential use of an observation unit varied throughout the year. Admission occurred between 3 and 11:59 pm in 60% of the patients. Only 20% of the 176 patients who were not admitted to the hospital but spent more than 6 hours in the pediatric ED were estimated to be candidates for a pediatric ED observation unit. Conclusion: On the basis of these data, approximately 150 patients per 10,000 each year who visit the University of Virginia pediatric ED would be likely to use an observation unit. Staffing and facility use would be seasonally uneven and would be required during the busiest part of the day. Furthermore, even in a pediatric ED large enough to admit 365 pediatric ED observation unit patients each year, random daily variation in demand means that a single bed would be inadequate 25% of the time and empty 37% of the time. Optimal use of even a single-bed pediatric ED observation unit would not occur until pediatric ED census exceeded 30,000 to 40,000 visits annually. Bond GR, Wiegand CB: Estimated use of a pediatric emergency department observation unit. Ann Emerg Med June 1997; 29:739-742.]     

Emergency department visits after pancreatoduodenectomy: examining a novel quality metric

BackgroundPostoperative emergency department (ED) visits represent fragmented care, are costly, and often evolve into readmission. Readmission rates after pancreatoduodenectomy (PD) are defined, while ED visits following PD are not. We examined the pattern of 30-day post-discharge ED visits for PD patients.MethodsA quaternary institutional database analysis of adult patients who underwent PD between 2010–2017 was reviewed for ED utilization within 30 days from discharge.ResultsOf the 1,004 patients who underwent PD, 12% (N = 117) patients sought care in the ED within 30 days from postoperative discharge. The median time to ED presentation was 5 days post-discharge (IQR 3–9). Half of ED visits occurred during nights and weekends (N = 59, 50%). Of ED-utilizing patients, 64% (N = 76) were admitted to the hospital and 29% (N = 34) were discharged from the ED. ED visits were associated with a Clavien-Dindo Classification of 0 in 10.2% (N = 13) of patients, I-II in 62.4% (N = 73), and III-V in 26.5% (N = 31).DiscussionPost-discharge ED utilization is a novel quality metric and represents a potential target population for reducing hospital readmissions. Over two-thirds (72%) of ED visits were associated with low acuity complications, and promoting institutional strategies addressing postoperative ED visits may improve patient care and efficient utilization of healthcare resources.     

SALAD‐BAAR: A numerical risk score for hospital admission or emergency department presentation in ambulatory patients with cardiovascular disease

BackgroundWhile many interventions to reduce hospital admissions and emergency department (ED) visits for patients with cardiovascular disease have been developed, identifying ambulatory cardiac patients at high risk for admission can be challenging.HypothesisA computational model based on readily accessible clinical data can identify patients at risk for admission.MethodsElectronic health record (EHR) data from a tertiary referral center were used to generate decision tree and logistic regression models. International Classification of Disease (ICD) codes, labs, admissions, medications, vital signs, and socioenvironmental variables were used to model risk for ED presentation or hospital admission within 90 days following a cardiology clinic visit. Model training and testing were performed with a 70:30 data split. The final model was then prospectively validated.ResultsA total of 9326 patients and 46 465 clinic visits were analyzed. A decision tree model using 75 patient characteristics achieved an area under the curve (AUC) of 0.75 and a logistic regression model achieved an AUC of 0.73. A simplified 9‐feature model based on logistic regression odds ratios achieved an AUC of 0.72. A further simplified numerical score assigning 1 or 2 points to each variable achieved an AUC of 0.66, specificity of 0.75, and sensitivity of 0.58. Prospectively, this final model maintained its predictive performance (AUC 0.63–0.60).ConclusionNine patient characteristics from routine EHR data can be used to inform a highly specific model for hospital admission or ED presentation in cardiac patients. This model can be simplified to a risk score that is easily calculated and retains predictive performance.     

Health care disparities in the acute management of venous thromboembolism based on insurance status in the U.S.

Acute venous thromboembolism (VTE) is common, costly, and potentially lethal. Therapeutic anticoagulation requires timely, closely monitored medical follow-up. If ineffective, clinical outcomes worsen and resource utilization increases. This risk may be magnified in uninsured patients. This study examined VTE care in hospital patients and investigated differences based on insurance status. We performed a retrospective chart review on medical VTE patients at an academic teaching hospital between December 1, 2007 and April 30, 2009. We reviewed medical records for demographics, insurance, admission status, length of stay (LOS), and 30-day Emergency Department (ED) recidivism and hospital readmission. Measured outcomes were analyzed based on payer source. We identified 234 medical VTE patients; 67 patients were uninsured (28.6%). 106 patients (45.3%) presented with deep vein thrombosis only. Most VTE patients were admitted to the hospital (171; 73.1%), including all 128 pulmonary embolism patients. Admitted uninsured patients averaged a LOS of 5.5 versus 3.7 days for insured (P = 0.03), with ED recidivism rates of 26.1 versus 11.3%, respectively (P = 0.02). Average cost for all VTE care in uninsured patients was 12,297 versus12,297 versus 7,758 for insured patients (P = 0.04). This study identified disparities in medical care and resource utilization for medical VTE patients based on insurance. Uninsured VTE patients were hospitalized nearly two additional days and were more than two times as likely to return to the ED within 30 days compared to insured patients. Additional research is needed to explain these disparities, and to explore system improvements for the uninsured VTE patient.     

Surgical and nonsurgical hospitalization rates and charges for patients with ulcerative colitis in Italy: a 10-year cohort study

BackgroundToday we are observing an increasing incidence of ulcerative colitis associated with an improved survival of patients.AimTo analyse current rates, outcomes, and costs of inpatient care for ulcerative colitis patients of central Italy.MethodsThe cohort included 644 ulcerative colitis patients, living in the Lazio region, with diagnosis made or confirmed by the staff of a single tertiary referral centre in Rome (1997–2006). Follow-up data on hospitalization rates, costs, and colectomy rates were collected from the Regional Hospital Information System.ResultsOverall hospitalization rates were 3 times higher than those of the region's general population, reflecting excess admissions for digestive or infectious diseases (standardized hospitalizations rates for digestive-tract: 15.9; for infectious diseases: 3.5). The overall cumulative risk for colectomy was 7.5%. On the average, hospitalizations for ulcerative colitis lasted 10 days. The mean reimbursement for a ulcerative colitis-related hospitalization was EUR 5120 (€4609 for nonsurgical admissions, €8655 for surgical hospitalizations).ConclusionUlcerative colitis patients are 3 times more likely to be hospitalized than the general population. Colectomy rates in Italian ulcerative colitis patients resemble those of northern Europe, but most hospital admissions are for diagnostic procedures or medical therapy. Hospitalizations are almost twice as long as those reported in the United States although their mean cost is considerably lower.     

Healthcare resource utilization and costs in stable patients with rheumatoid arthritis: Comparing nurse-led and rheumatologist-led models of care delivery

ObjectivesHaving previously shown similar clinical outcomes, this study compared the healthcare resource utilization and direct costs in stable patients with RA followed in the nurse-led care (NLC) and rheumatologist-led care (RLC) models.MethodsPreviously collected clinical data were linked to data on practitioner claims, ambulatory care, and hospital discharges. Assessed resources included physician visits; emergency department (ED) visits; hospital admissions, and disease-modifying anti-rheumatic drugs (DMARDs). The mean per-patient resource utilization and cost (2020 Canadian dollars) over 1 year were compared between the groups using Wilcoxon rank-sum test. The mean per-patient cost of health services and total cost were also estimated using Generalized Linear Models (GLMs) accounting for the baseline differences between the groups.ResultsOverall, 244 patients were included. No differences in the number of visits to the ED or to general practice and internal medicine physicians and orthopedic surgeons were found. The NLC group had fewer hospitalizations than the RLC group (p-value=0.03). The mean cost of health services was not statistically different in NLC and RLC groups ($2275 vs. $3772, p-value=0.30). The RLC group included more patients on biologic DMARDs, contributing to a higher mean total cost than the NLC group ($9191 vs. $3056, p-value<0.01). The mean cost estimates with GLMs were consistent with the observed costs.ConclusionsA nurse-led model of care delivery for stable patients with RA was not associated with increases in healthcare resource utilization or cost as compared to RLC. NLC is one approach to meeting patient needs and better managing scarce healthcare resources.     

Clinical and financial outcome impacts of comprehensive geriatric assessment in a level 1 geriatric emergency department

Background

The aging population has led to an increase in emergency department (ED) visits by older adults who have complex medical conditions and high social needs. The purpose of this study was to assess if comprehensive geriatric evaluation and management impacted service utilization and cost by older adults admitted to the ED.

Methods

This is a retrospective matched case–control study at a level 1 geriatric ED (GED) from January 1, 2018–March 31, 2020. Geriatric nurse specialists (GENIEs) provided comprehensive evaluations and management for GED patients. Propensity score matching was used to match patients receiving GENIE consultations to ED patients who did not receive a GENIE consult. Regression was used to assess the impact of the GENIE services on inpatient admissions, ED revisits and cost of inpatient and ED care from the payor perspective.

Results

GENIE consults were associated with a 13.0% reduction in absolute risk of admission through the ED at index (95% confidence interval [CI] −17.0%, −9.0%, p < 0.001) and a reduction in risk for total admissions at 30 and 90-days post discharge (−11.3%, 95% CI −15.6%, −7.1%, p-value < 0.001; and −10.0, 95% CI −13.8%, −6.0%; p < 0.001 respectively), both driven by reduced risk of admission at the index visit. GENIE consults were associated with a 4% increase in absolute risk of revisits to the ED within 30 days (95% CI 0.6%, 7.3%; p = 0.001). GENIE consults were associated with a decrease in cost of inpatient and ED care, with savings of $2344 within 30 days (95% CI $2247, $2441, p < 0.001) and savings of $2004 USD within 90 days (95% CI $1895, $2114, p < 0.001), driven by reduced costs at the index visit.

Conclusions

GENIE consults were associated with decreased inpatient admissions through the ED, modestly increased ED revisits, and decreased cost of inpatient and ED care. The results of this study can be useful for EDs considering approaches to better serve older adults. They can also be of interest to payers as an area of potential cost savings.     

Health care resource utilization associated with a diabetes center and a general medicine clinic

OBJECTIVE: Studies have proposed that the features of diabetes clinics may decrease hospital utilization and costs by reducing complications and providing more efficient outpatient care. We compared the health care utilization associated with a diabetes center (DC) and a general medicine clinic (GMC). DESIGN: Retrospective cohort study. SETTING: An urban academic medical center. PATIENTS/PARTICIPANTS: Type 2 diabetes patients (N = 601) under care in a DC and GMC before March 1996. MEASUREMENTS AND MAIN RESULTS: We compared baseline patient characteristics and outpatient care for the period of March 1996 to August 1997. Using administrative data from March 1996 to October 2000, we compared the probability of a hospitalization, length of stay, costs of hospitalizations, the probability of an emergency room visit, and costs of emergency room visits. Diabetes center patients had a longer mean duration of diabetes (12 years vs 6 years, P <.01), more baseline microvascular disease (65% vs 44%, P <.01), and higher baseline glucose levels (hemoglobin A1c 8.6% vs 7.9%, P <.01) than GMC patients. Diabetes center patients received more intensive outpatient care directed toward glucose monitoring and control. In all crude and adjusted analyses of hospitalizations and emergency room visits, we found no statistically significant differences for inpatient utilization or cost outcomes comparing clinic populations. CONCLUSIONS: Diabetes center attendance did not have a definitive positive or negative impact on inpatient resource utilization over a 4-year period. However, DC patients had more severe diabetes but no greater hospital utilization compared with GMC patients. Clear demonstration of the clinical and financial benefits of features of diabetes centers will require long-term controlled trials of interventions that promote comprehensive diabetes care, including cardiovascular prevention.     

Use of emergency departments by elderly patients: projections from a multicenter data base.

STUDY OBJECTIVES: To assess the use of emergency medical care by the elderly in the United States, including emergency department visits, level of ED care required, ambulance services, and hospital admission rate. SETTING AND PARTICIPANTS: A multicenter computerized data base of 70 hospitals in 25 states. DESIGN: A retrospective review of elderly patients seeking ED care and comparison of elderly and nonelderly patients. The data were then used to estimate the use of emergency medical services nationally. MEASUREMENTS AND MAIN RESULTS: Fifteen percent of the 1,193,743 ED visits were made by patients 65 years or older. Thirty-two percent of elderly patients seen in EDs were admitted to the hospital, compared with 7.5% of nonelderly patients. Seven percent of elderly patients were admitted to ICUs, compared with 1% of nonelderly patients. Thirty percent of elderly patients seeking emergency care used ambulance transports compared with 8% of nonelderly. It is estimated that 13,693,400 elderly patients were seen in EDs in 1990, with more than 4 million patients admitted to hospitals. Compared with the nonelderly, the elderly are 4.4 times more likely to use ambulance transport, 5.6 times more likely to be admitted to the hospital, 5.5 times more likely to be admitted to an intensive care bed, and 6.1 times more likely to be classified as a comprehensive ED level of service. In our sample, 36% of all patients arriving by ambulance to the ED, 43% of all ED admissions, and 48% of all intensive care admissions were geriatric patients. CONCLUSION: With the rapid growth of the size of the elderly population, it is important that we assess the emergency medical resources needed to care for the geriatric population.     

Palliative care referral in ST-segment elevation myocardial infarction complicated with cardiogenic shock in the United States

BackgroundST-segment elevation myocardial infarction complicated with cardiogenic shock (STEMI-CS) is associated with high mortality but the trends of utilization and predictors of palliative care (PC) referral in this population have not been well described.ObjectivesTo investigate the utilization trends and predictors of PC referral in STEMI-CS.MethodsNationwide inpatient sample from 2005–2014 was queried to identify patients with STEMI-CS of age ≥18. PC referral was identified International Classification of Diseases, Ninth Edition Clinical Modification, V66.7.ResultsA total of 33,294 admissions were identified and 1,878 (5.6%) had PC encounter. PC referral group were older and had higher comorbidities. PC consultation increased approximately 10 times over the study period in those who died (from 2.3% to 27.4%) and in those who survived (from 0.21% to 2.83%). In multivariable analysis, age, higher Exlixhauser score, no revascularization, teaching hospital, large bed hospital, mechanical circulatory support use, and lower income status were associated with increased PC referral whereas coronary artery bypass graft was associated with lower PC referral rates. Patients under PC group were more often discharged to an extended care facility and less likely discharged home.ConclusionPC utilization increased substantially during the 10-years study period in the United States in STEMI-CS. Several baseline, procedural, hospital, and socioeconomic factors were associated with PC referral in the setting STEMI-CS.     

Evaluation of a program aimed at increasing referrals for asthma education of patients consulting at the emergency department for acute asthma

BACKGROUND: Emergency department (ED) visits for asthma may reflect poor asthma control, often due to insufficient asthma education and medical follow-up. However, few patients consulting an ED for asthma are referred for education.Aims: To describe a model for automatic referral to educational interventions targeting patients consulting at the ED for acute asthma, to demonstrate how this model can be integrated into current care, and to increase referrals for asthma education. METHODS: The program combines a short ED-based educational intervention with the goal of motivating patients and their families to pursue an educational program with an automatic referral to an asthma education center (AEC) after agreement with ED physicians. The program was implemented in nine acute care centers with a high number of ED visits for asthma. The main study parameter was the number of patients referred to an AEC after 4 months of program implementation, as compared with 4 months before. In addition, we assessed potential barriers to successfully establishing the program. RESULTS: In the first 4 months of the program, 1,104 patients were referred to an AEC, compared with 110 for the same period the year before; 106 patients (15%) patients could not be contacted, 114 patients (16.1%) refused the intervention, 488 patients (68.9%) made appointments, and 346 patients (48.9%, or 72.8% of scheduled patients) honored their appointments. CONCLUSION: We describe a model of educational intervention for asthmatic patients consulting at the ED. We found that ED professionals can motivate patients to attend an asthma education program and that an automatic referral process is well accepted by ED staff. Such intervention can help to reduce asthma-related morbidity, but local barriers to implementation of such program should be addressed.     

Effectiveness of a group outpatient visit model for chronically ill older health maintenance organization members: a 2-year randomized trial of the cooperative health care clinic

OBJECTIVES: To compare the effectiveness of Cooperative Health Care Clinic ((CHCC) group outpatient model for chronically ill, older health maintenance organization (HMO) patients) with usual care. DESIGN: Two-year, randomized, controlled trial conducted with recruitment from February 1995 through July of 1996. SETTING: Nonprofit group model HMO. PARTICIPANTS: Two hundred ninety-four adults (145 intervention and 149 usual care), aged 60 and older (mean age 74.1) with 11 or more outpatient visits in the prior 18 months, one or more self-reported chronic conditions, and expressed interest in participating in a group clinic. INTERVENTION: Monthly group meetings held by patients' primary care physicians. MEASUREMENT: Differences in clinic visits, inpatient admissions, emergency room visits, hospital outpatient services, professional services, home health, and skilled nursing facility admissions; measures of patient satisfaction, quality of life, self-efficacy, and activities of daily living (ADLs). RESULTS: Outpatient, pharmacy services, home health, and skilled nursing facility use did not differ between groups, but CHCC patients had fewer hospital admissions (P=.012), emergency visits (P=.008), and professional services (P=.005). CHCC patients' costs were $41.80 per member per month less than those of control patients. CHCC patients reported higher satisfaction with their primary care physician (P=.022), better quality of life (P=.002), and greater self-efficacy (P=.03). Health status and ADLs did not differ between groups. CONCLUSION: The CHCC model resulted in fewer hospitalizations and emergency visits, increased patient satisfaction, and self-efficacy, but no effect on outpatient use, health, or functional status.     

Frequent use of the hospital emergency department is indicative of high use of other health care services

STUDY OBJECTIVE: We sought to determine the proportion of emergency department patients who frequently use the ED and to compare their frequency of use of other health care services at non-ED sites. METHODS: A computerized patient database covering all ambulatory visits and hospital admissions at all care facilities in the county of Stockholm, Sweden, was used. Frequent ED patients were defined as those making 4 or more visits in a 12-month period. RESULTS: Frequent users comprised 4% of total ED patients, accounting for 18% of the ED visits. The ED was the only source of ambulatory care for 13% of frequent versus 27% of rare ED users (1 ED visit). Primary care visits were made by 72% of frequent ED users versus 57% by rare ED visitors. The corresponding figures for hospital admission were 80% and 36%, respectively. Frequent ED visitors were also more likely to use other care facilities repeatedly: their odds ratio (adjusted for age and sex) was 3.43 (95% confidence interval [CI] 3.10 to 3.78) for 5 or more primary care visits and 29.98 (95% CI 26.33 to 34.15) for 5 or more hospital admissions. In addition, heavy users had an elevated mortality (standardized mortality ratio 1.55; 95% CI 1.26 to 1.90). CONCLUSION: High ED use patients are also high users of other health care services, presumably because they are sicker than average. A further indication of serious ill health is their higher than expected mortality. This knowledge might be helpful for care providers in their endeavors to find appropriate ways of meeting the needs of this vulnerable patient category.