Frequency of emergency department attendances as a predictor of mortality: nine-year follow-up of a population-based cohort

Heavy users of the services of emergency departments (EDs) have in previous studies been found to have psychological, social, economic and other difficulties besides their more or less acute medical problems. In order to establish whether mortality is associated with high ED use, a nine-year follow-up study was conducted of a 10 per cent population sample (n = 17,000), selected from the catchment area of Huddinge Hospital, Sweden. ED visits were found to predict nine-year mortality in the cohort. The group of individuals who had made four or more ED visits during a period of 15 months prior to follow-up (heavy ED users) had a two-fold excess mortality (95 per cent confidence interval (CI) = 1.9-2.1), those who had made one to three ED visits (moderate ED users) had a slightly elevated mortality (standardized mortality ratio SMR = 1.1, 95 per cent CI = 1.0-1.3), while the SMR of the non-users was 0.9 (95 per cent CI = 0.8-1.0). The three predominant causes of death in the cohort were diseases in the circulatory system, tumours and violent death. Heavy ED users had elevated mortality in all diagnoses, the most important excess mortality being from violent death, comprising suicide, probable suicide and alcohol/drug abuse, with an SMR of 6.3 (95 per cent CI = 6.0-6.7). The excess mortality from these causes of the heavy ED users accounted for more than one-third of their total excess mortality.(ABSTRACT TRUNCATED AT 250 WORDS)     

Hospital care utilization in a 17,000 population sample: 5-year follow-up

The growing utilization of hospital care, especially of the services of Emergency Departments (ED), has been of great concern for many Western countries. The purpose of this study was to relate the amount of hospital care utilization to the frequency of ED visits. The study, based on a computerized medical information system, was carried out at Huddinge hospital which serves a suburban area of Stockholm, Sweden. ED visits were found to predict hospital care utilization in a 5-year follow-up of a 10% population sample. Persons who had made 2 or more ED visits during a period of 15 months before follow-up (less than 1/8 of the population sample) contributed 24% of all hospital outpatient visits, 29% of all hospital admissions and 31% of all hospital days during the 5-year follow-up period. The number of hospital outpatient visits per 100 personyears was more than 3 times higher among those who had 4 or more ED visits as compared to those who were non-visitors at the ED. Hospital admissions and days were 5 times higher. The utilization of medical specialties differed most in psychiatry, where those with 4 or more ED visits had nearly 17 times more admissions per 100 personyears than non-visitors. The difference increased gradually with increasing number of ED visits and was also evident in each age group. The mortality was also significantly increased for those with several ED visits. Higher migration in the latter group may besides indicate social instability.(ABSTRACT TRUNCATED AT 250 WORDS)     

Health care utilization after referral from a hospital emergency department

In a trial, patients who came to a hospital Emergency Department (ED) with non-urgent complaints were advised and referred to primary health care outside the hospital. The effect of this was assessed by measuring health care utilization one year before and one year after the referral, using the Stockholm County computerized medical information system and ED medical records. The proportion of the 189 referred patients who visited the ED decreased from 48% to 42%, whereas in a control group of 107 patients the proportion increased from 41% to 51%. A small proportion, 7%, of the referred patients with four or more ED visits accounted for 45% of the total number of ED visits the year before the trial. These frequent ED users did not reduce their ED utilization more than frequent ED users in the control group. The use of health care centres increased in the referred group and was practically unchanged in the control group. However, those referred patients who continued to use the ED still quite often did so for non-urgent complaints.     

Does better access to primary care reduce utilization of hospital accident and emergency departments? A time-series analysis

BACKGROUND: Availability of primary care emergency facilities has been improved to help curb heavy growth in the use of Accident and Emergency Departments (A&EDs). The aim of this paper is to analyse the relationship between time series for visits to hospital A&EDs and primary care centres. METHODS: Using a co-integration time series we analyse the visits to the emergency services of the county hospital and seven healthcare primary centres in the healthcare district of Mieres, Asturias, Espa?a, during the period 1992-1999. The main outcome measured is the relationship between the time series for emergency visits to the primary care centres and the hospital A&ED, for groups aged 0-14 years, over 14 years and the total. RESULTS: A total of 506,158 visits to the emergency services of the primary care centres (62.4%) and hospital A&ED (37.6%) have been studied. Emergency visits rose by 40.9% during the period studied (50.3% in primary care centres and 26.5% in the hospital). The gross rise in visits was higher for adults (51.2%) than for 0-14 year olds (6.6%). The co-integration time-series analysis showed that in both age groups and in the total, there was a significant and positive relationship between the primary care and hospital series, indicating that the use of both services had grown simultaneously. The use of the hospital services did not decrease as a result of the increase in primary care services. CONCLUSIONS: The rise in use of primary care emergency services did not reduce use of the hospital A&ED.     

Patients seen in emergency departments who had a prior visit within the previous 72 h-National Hospital Ambulatory Medical Care Survey, 2002

OBJECTIVE: This study characterized emergency department (ED) visits of patients who had received services in an ED within the previous 72 h. METHODS: ED data from the National Hospital Ambulatory Medical Care Survey were analysed for: (a) infectious-disease-related visits; (b) infectious-disease-related return visits; and (c) return visits reported within the previous 72 h for all visits. Data were collected from a nationally representative sample of hospital EDs and were weighted to generate national estimates. RESULTS: In 2002, an estimated 20.5 million ED visits occurred in the USA for infectious diseases, for a visit rate of 73/1,000 people. A total of 3.5 million total return visits to EDs occurred within 72 h, and 67% were for follow-up visits. An estimated 625,280 return visits were for infectious diseases (18% of total ED return visits); 72% of these were for follow-up services. For total visits and infectious-disease-related visits, the majority of return visits were reported among those aged 25--44 years and among females. DISCUSSION: Approximately seven of every 10 return visits to EDs in 2002 were for follow-up services, and no difference existed in the percentage of return visits for infectious diseases compared with total visits. A health services implication exists for treating this percentage of patients in EDs when primary care practitioners should be the point of contact.     

Comparing frequent and average users of elementary school-based health centers in the Bronx,New York City

This study analyzed health care utilization at three school-based health centers (SBHCs) in the Bronx, New York City, and compared characteristics of "frequent" and "average" service users. Encounter form data for visits by 2,795 students who received services at least once between September 7, 1998, and June 30, 1999, were reviewed. Demographic comparisons between clinic users and the total school population, and between "frequent" (five or more visits/year) and "average" (one to four visits/year) users were made. The two groups also were compared after primary diagnoses were classified into five general categories. Some 96% (3,469/3,614) of students were registered in the SBHCs, of whom 81% (2,795/3,469) used clinic services at least once during the school year. Clinic users did not differ from the general school population by gender, but were younger (p < 0.01). "Frequent" users were more likely than "average" users to be older (p < 0.01), but they did not differ by gender, race/ethnicity, or insurance status. "Frequent" users comprised 28% of the clinic-using population, but accounted for 72.5% of all visits. Similarly, "average" users comprised 72.4% of the clinic-using population, but accounted for 27.5% of all visits. "Frequent" users generated most visits for mental health and chronic medical conditions, while "average" users generated most visits for preventive care, acute medical care, and injuries/emergencies (p < 0.01 for all). Important challenges for elementary SBHCs include developing new approaches that meet children's needs while protecting clinic resources, like scheduling group interventions for those with on-going health care needs who require frequent use of school health services.     

Intimate partner violence injuries--Oklahoma, 2002

Intimate partner violence (IPV) is a serious public health problem in the United States and a common cause of injury. Prevalence rates of IPV vary by the surveillance methods and definitions used. National data from the 1995 National Violence Against Women Survey indicate that 22.1% of women and 7.4% of men experience IPV during their lifetimes and that 1.3% of women and 0.9% of men experience IPV annually. IPV results in an estimated 4.1 billion dollars each year in direct medical and mental health-care costs, including 159 million dollars in emergency department (ED) treatments for IPV physical assaults. IPV might constitute as much as 17% of all violence-related injuries treated in EDs. To determine the magnitude of the IPV problem in Oklahoma, including IPV-related injuries and medical service utilization, researchers analyzed injury surveillance data from ED medical records and data from the Oklahoma Women's Health Survey (OWHS). This report summarizes the findings, which indicated that, during 2002 in Oklahoma, approximately 16% of all ED visits for assaults were for IPV injuries, including 35% of assault visits among females and 3% of assault visits among males. In addition, results of the OWHS for 2001-2003 indicated that 5.9% of surveyed Oklahoma women aged 18-44 years sustained an IPV injury during the preceding year. Overall, IPV resulted in a substantial number of injuries, particularly to women, many of whom required treatment in EDs. Medical recognition and documentation of IPV are important for identification of persons in need of services.     

Language Barriers among Patients in Boston Emergency Departments: Use of Medical Interpreters After Passage of Interpreter Legislation

Background Since 2001, Massachusetts state law dictates that emergency department (ED) patients with limited English proficiency have the right to a professional interpreter. Methods one year later, for two 24-h periods, we interviewed adult patients presenting to four Boston EDs. We assessed language barriers and compared this need with the observed use and type of interpreter during the ED visit. Results We interviewed 530 patients (70% of eligible) and estimated that an interpreter was needed for 60 (11%; 95% confidence interval, 7–12%) patients. The primary interpreter for these clinical encounters was a physician (30%), friend or family member age ≥18 years (22%), hospital interpreter services (15%), younger family member (11%), or other hospital staff (17%). Conclusions We found that 11% of ED patients had significant language barriers, but use of professional medical interpreters remained low. One year after passage of legislation mandating access, use of professional medical interpreters remained inadequate.     

Factors related to frequent usage of the primary healthcare services in old age: findings from The Swedish National Study on Aging and Care

People aged 60 or more are the most frequent users of healthcare services. In this age range, however, both frequent and infrequent users can be found. Frequent users have high rates of illnesses. Previous research has found that the frequency may be influenced also by psychological and social factors. The aim of this study was to investigate to what degree such factors add to the explanation of differences in number of visits to a physician. A cross-sectional study was conducted with a random sample consisting of 1017 individuals, aged 60 to 78 years, from the Blekinge part of the Swedish National Study on Aging and Care database. The data were collected during 2001 to 2003. Hierarchical logistic regression analyses were used with frequent (three visits or more during a year) and infrequent use as a dichotomous dependent variable. The final statistical analyses included 643 individuals (63% of the sample). Independent variables were sense of coherence (SOC), internal locus of control, education level and social anchorage. Control variables were age, gender, functional ability and comorbidity. The results showed that comorbidity was most strongly related to frequent use [adjusted odds ratio (OR) = 8.17, 95% confidence interval (CI) 5.54–12.04]. In addition, SOC and internal locus of control had small, but significant effects on the odds of being a frequent user (adjusted OR = 1.03, 95% CI 1.00–1.06 and adjusted OR = 1.14, 95% CI 1.02–1.27, respectively). The lower the SOC and the internal locus of control were, the higher were the odds of frequent use. Education level and social anchorage were unrelated to frequency of use. The results indicate that frequent healthcare services users are more ill than infrequent users. Psychological factors influence the use only marginally, and social factors as well as age and gender are not by themselves reason for frequent healthcare services use.     

Characterizing behavioral health-related emergency department utilization among children with Medicaid: Comparing high and low frequency utilizers

While the frequency of children’s behavioral health (BH)-related visits to the emergency department (ED) is rising nationwide, few studies have examined predictors of high rates of ED use. This study examines Florida Medicaid claims (2011–2012) for children age 0–18 who were seen in an emergency department (ED) for behavioral health (BH) conditions. A logistic regression model was used to explore factors associated with frequent ED use and patterns of psychotropic medication utilization. The majority (95%) of patients with at least one BH-related ED visit had three or fewer of these visits, but 5% had four or more. Seventy-four percent of ED visits were not associated with psychotropic medication, including over half (54%) of visits for attention deficit hyperactivity disorder (ADHD). Frequent ED use was higher among older children and those with substance use disorders. The implementation of interventions that reduce non-emergent ED visits through the provision of care coordination, social work services, and/or the use of community health workers as care navigators may address these findings.     

A study of the relationship between social network, perceived ill health and utilization of emergency care. A case-control study

Several studies have shown that persons who repeatedly turn to somatic emergency departments, besides having ailments also often have social and psychological problems. It has also been shown that this group of patients differs from the general population and can be considered a psycho-socially exposed group. In the present study a group of recurrent users (4 + yearly visits) was compared to a group of first-time visitors to the general emergency department of a middlesized metropolitan hospital. Both patient groups were asked to complete a questionnaire that contained 45 items, covering socio-demographic and social network variables, social and personal problems, perceived state of health and contacts with other care-giving institutions. The results showed that the first-time visitors were significantly younger than the recurrent users, and more often actively employed. Only 2 percent of the first-time visitors developed a behaviour of recurrent use of the ED. The recurrent users were well-known at the hospital, not only in the emergency department but also at the out-patient clinics and the social work department. The multiple Odds ratio showed that alcohol abuse, lack of close friend, general health problems and deteriorating health were important risk factors for recurrent ED use. It is suggested that an individual treatment plan including medical, social and societal measures could be one alternative in an attempt to more efficiently treat these patients.     

Reducing the Use of Emergency Medical Resources Among Head Start Families: A Pilot Study

The objective of this study was to determine whether self-care training with Head Start parents can improve their ability to manage the healthcare needs of their children measured by utilization of emergency department (ED) and physician services. Four hundred and six families in Head Start agencies were included in the study. Parents were given a low-literate self-help book entitled What To Do When Your Child Gets Sick. The study design included using multiple-choice, pre-and post-intervention survey data. In a six month follow-up, parents who received the book reported a 48% reduction in ED visits and a 37.5% reduction in clinic visits. More research is needed to determine if this self-care tool and additional training can have a significant impact on inappropriate use of medical resources.     

Relapse following emergency treatment for acute asthma: Can it be predicted or prevented?

We prospectively followed 314 children discharged from a children's hospital emergency department (ED) following an asthma attack, to identify risk, factors for relapse, i.e. a second ED visit for asthma within the next 10 days. Parents were surveyed concerning their child's past medical history, drugs received prior to the index visit, triggering factors, physician availability, parental anxiety, and sociodemographic variables. Data on severity of the attack, emergency treatment, response to treatment and drugs prescribed on discharge were extracted from the medical record. Ninety-six of the 314 children (31%) relapsed, most (68%) within 24 hours. Using multiple logistic regression, a predictive model was developed on 211 patients (“test sample”). The best model contained two variables: (1) the number of ED visits for acute asthma in the previous year (odds ratio [OR] = 2.4 for 4 or more vs fewer visits, 95% CI = 1.3–4.4) and (2) the intake of an oral short-acting theophylline preparation during the course of the acute treatment (OR = 0.4, 95% CI = 0.2-0.7). The sensitivity, specificity and positive predictive values of this model for predicting relapse were 73, 53, and 40%, respectively. When applied to a second randomly selected “validation sample” of 103 children, sensitivity was 73%, specificity 50%, and PPV 41%, thus indicating the stability of the model. The model identifies the number of ED visits in the previous year as an important risk factor for relapse. It also suggests that oral short-acting theophylline may still have a role in the treatment of patients in whom the contribution of inflammation to airway obstruction is minimal.     

Novel Emergency Department High Utilizer Surveillance In New Hampshire

Objective

To develop a manageable surveillance methodology to detect Emergency Department (ED) patients with the highest healthcare utilization, and monitor their targeted treatment improvement and medical health cost reductions over time for overall improvements in statewide health.

Introduction

Researchers have demonstrated benefits to identifying and developing interventions for patients that frequently seek healthcare services in the ED. The New Yorker Magazine, recently published an article titled The Hot Spotters, summarizing work being done in the United States to lower medical costs by giving the neediest patients better healthcare (1). In Camden, NJ, Physician Jeffrey Brenner closed his regular practice to focus on Hot Spotter patients (directing resources and brainpower to help their improvement) and measured a 40% reduction in hospital inpatient and ED visits and a 56% medical cost reduction for the first 36 Hot Spotters. A 2008 NH Office of Medicaid Business and Policy (OMBP) outpatient Medicaid ED frequency visit study was conducted, which cited that frequent ED users were more likely to have higher costs and rates of illness or disease than all Medicaid members (2). It was noted that increased prevention and wellness could reduce frequent ED use and increase cost savings (5% of the NH Medicaid population contributed to approximately 38% of ED costs). The NH Division of Public Health Services initiated a pilot project to examine NH Emergency Department (ED) surveillance data to identify high utilizer patients and realize improved health benefits and medical cost reductions.

Methods

This pilot focused first on identifying 2010 ED high utilizers in one hospital. A high utilizer was defined as a patient with 9 or more ED visits (top 10%) and were identified using Medical Record Number followed by sorting number of visits in descending order. Visit diagnosis codes were identified for the top 10% of high utilizers, along with the date of admission, resident town, age, and gender. Finally, the top 10% over utilizers were mapped, identifying the total number of utilzers in each town. We overlaid this information on a map of NH’s social vulnerability index to provide comparative data. Plans for future expansion include: Creating a GIS system that trends data over 10 years; Identifying ED high utilizers by location (visits by town, number of diagnosis codes per visit, date of visits, and summative data); and Creating hospital and total state-wide breakdown of highest utilizers, most common state-wide diagnosis for ED high utilizers, and specific data from each hospital in relation to state-wide social vulnerability index data.

Results

Over 56,000 ED visits at one pilot hospital were analyzed targeting 2,005 high utilizer visits for 158 patients. Identification by location, age, gender and ICD-9-CM diagnosis coding was determined for each ED over utilizer. Mapping of the high utilizers showed that 142 of the 158 patients resided in the city where the hospital was located. The most frequent diagnosis codes for the top 10% ED high utilizers included mental health, substance abuse, and chronic disease conditions (such as diabetes mellitus).

Conclusions

This pilot project provides a manageable approach for identifying ED high utilizers for both health improvement and cost reduction surveillance efficiencies, and is a model for other surveillance management monitoring applications. Potentially, 2.1 million dollars per year could be saved, if each over utilizer used the ED one less time (2).     

Scattering of primary care: Doctor switching and utilization of health care by children on fee-for-service medicaid

Objective To determine whether children on fee-for-service Medicaid who switch primary care doctors use less health care and are less up to date with preventive care visits than children who do not switch primary care doctors. Design Retrospective cohort study using Medicaid claims data. Setting 51,027 children enrolled on Medicaid in Monroe County, New York. Patients 14,187 children enrolled continuously on fee-for-service Medicaid between January 1992 and December 1994. Main Outcome Measures Utilization of primary care, emergency department (ED) services, and specialty care and proportion up to date with preventive care visits according to American Academy of Pediatrics guidelines. Results During the 2-year study period, 22% of children switched primary care doctors. Compared with children who did not switch primary care doctors, those who switched had more primary care visits (4.7 vs. 3.2 visits/year,P<.01), age-adjusted preventive care visits (1.2 vs. 1.0 visits/year), ED visits (0.72 vs. 0.47 visits/year,P<.01), and specialist visits (0.99 vs. 0.31,P<.01). On multivariate analysis, doctor switching was associated with increased odds of being up to date with preventive care visits (odds ratio [OR]=1.7; 95% confidence interval [CI] 1.3 to 2.1). However, on multivariate analysis stratified by age, the association was significant only for older children (ages 11 to 14). Altogether, 68% of all children and 44% of infants less than 1 year old made the recommended number of preventive care visits during the study period. Conclusions All groups of children received less preventive care than recommended by the American Academy of Pediatrics. Children who switched primary care doctors had higher utilization of health care, including primary care, ED, and specialty care. Contrary to expectations, they were more likely to be up to date with preventive care visits. The heavy utilization of health services by doctor switchers indicates that this subgroup of children on Medicaid may not be at risk for poor access to health care, but additional research is needed to determine whether the quality of care is related to doctor switching. Presented in part at the Pediatric Academic Societies 1996 Annual Meeting, Washington, DC, May 8, 1996. This work was supported in part by a Frank Disney Scholarship through the Strong Children's Research Center, University of Rochester School of Medicine and Dentistry, and by National Research Service Award 1F32 HS00089-01 from the Agency for Health Care Policy and Research.     

Linking HIV-positive Jail Inmates to Treatment,Care, and Social Services After Release: Results from a Qualitative Assessment of the COMPASS Program

Approximately 17% of individuals living with HIV/AIDS pass through the correctional system each year. Jails provide a unique opportunity to diagnose and treat HIV infection among high-risk, transient populations with limited access to medical services. In 2007, the US Health Resources and Services Administration funded a multi-site demonstration project entitled Enhancing Linkages to HIV Primary Care in Jail Settings that aims to improve diagnosis and treatment services for HIV-positive jail detainees and link them to community-based medical care and social services upon release. We performed an evaluation of the Rhode Island demonstration site entitled Community Partnerships and Supportive Services for HIV-Infected People Leaving Jail (COMPASS). Through in-depth qualitative interviews among 20 HIV-positive COMPASS participants in Rhode Island, we assessed how COMPASS impacted access to health care and social services utilization. Most individuals were receiving HIV treatment and care services upon enrollment, but COMPASS enhanced linkage to medical care and follow-up visits for HIV and other co-morbidities for most participants. Several participants were successfully linked to new medical services as a result of COMPASS, including one individual newly diagnosed with HIV and another who had been living with HIV for many years and was able to commence highly active antiretroviral therapy (HAART). While many individuals reported that COMPASS support prevented substance abuse relapse, ongoing substance abuse nevertheless remained a challenge for several participants. Most participants enrolled in one or more new social services as a result of COMPASS, including Medicaid, Supplemental Security Income, food assistance, and housing programs. The primary unmet needs of COMPASS participants were access to mental health services and stable housing. Intensive case management of HIV-positive jail detainees enhances access to medical and social support services and helps prevent relapse to substance abuse. Expanding intensive case management programs, public housing, and mental health services for recently released HIV-positive detainees should be public health priorities.     

Care Coordination for Community Transitions for Individuals Post-stroke Returning to Low-Resource Rural Communities

High rates of hospital readmissions have been shown within 12 months post-discharge from inpatient rehabilitation following stroke. Multiple studies coupled with our previous work indicate a need for care support for stroke survivors’ transitions to the community. The Kentucky Care Coordination for Community Transitions (KC³T) program was developed to provide access to medical, social, and environmental services to support community transitions for individuals with neurological conditions and their caregivers living in Kentucky. This program assessment was conducted to determine the effectiveness of using a specially trained community health worker to support community transitions. Thirty acute stroke survivors were enrolled in this program between July 2015 and May 2016. Data collection included: incidence of comorbidities; access to healthcare, insurance, medical equipment (DME), and medications; type of follow-up education provided; and number of 30-day rehospitalizations and Emergency Department (ED) visits. Participants required navigation in their home and community transition with support in: patient-provider communication; insurance support; accessing follow-up care; education on managing chronic health conditions, the stroke process, transfers and mobility; and accessing DME and essential medications. There were no 30-day ED visits for the KC3T participants and only one 30-day hospital readmission, which was not stroke-related. Individuals returning to rural communities following a stroke require, but often don’t receive, follow-up education on chronic disease management, support in navigating the healthcare system and accessing essential resources. KC3T’s navigator program appears to be effective in supporting the community transitions of individuals poststroke.     

Characteristics of women associated with continuing instruction in the Creighton Model Fertility Care System

Effective use of natural family planning is strongly dependent upon adequate instruction. The Creighton Model Fertility Care System (CrMS) has a standardized protocol for instruction of new users that includes individual follow-up visits in the first year of use. This study evaluated the number of follow-up visits completed by new CrMS users from eight CrMS centers in the United States. Four follow-up visits were completed by 75.7% of women. Women who continued instruction were more likely to be educated, Catholic, and white, and to have a more challenging reproductive status (discontinuing oral contraceptives, or breastfeeding). These results suggest that the number of follow-up visits needed varies among new CrMS users. Future research should address the optimal length of instruction for adequate use of the CrMS by women with different characteristics and needs.