Randomized controlled trial to improve primary care follow-up among emergency department patients

Study objectivePrimary care (PC) follow-up for discharged emergency department (ED) patients provides patients with further medical attention. We conducted a pilot randomized controlled trial to determine whether using a freely-available physician appointment-booking website results in higher self-reported PC follow-up.MethodsWe randomized discharged patients whom treating physicians determined PC follow-up was important and who possessed health insurance but had no PC provider to one of three groups: (1) a PC appointment booked through the booking website prior to ED discharge; (2) written information on how to use the booking website; or (3) usual care (i.e. standard follow-up instructions). We phoned subjects two weeks after the ED visit to determine whether they had completed a PC follow-up visit. We also asked subjects about their satisfaction with obtaining a PC appointment, satisfaction with the ED visit, symptom resolution and subsequent ED visits. The self-reported PCP follow-up rate was compared among the study groups by estimating the risk difference (RD) and 95% CI between usual care and each intervention group.Results272 subjects were enrolled and randomized and 68% completed the two-week telephone follow-up interview. The self-reported PCP follow-up rate was higher (52%) among subjects whose appointment was booked on the website before ED discharge (RD = 16%; 95% CI -1%, 34%) and lower (25%) for subjects who received booking website information (RD = 13%; 95% CI -32%, 7%) compared to subjects (36%) in the usual care group. A higher percentage of subjects in the booking group were more likely to report being extremely or very satisfied with obtaining a PC appointment (78%) compared to those who received booking website information (54%) or usual care (40%).ConclusionAmong ED patients that providers judged PC follow-up is important, using a booking website to schedule an appointment before ED discharge resulted in a higher but not statistically significant self-reported PC follow-up rate. This intervention warrants further investigation in a study with a larger sample size and objective follow-up visit data.     

Smoking Habits of Emergency Department Patients: An Opportunity for Disease Prevention

Objective: To determine smoking habits, levels of addiction, readiness to quit, and access to primary care among ED patients.
Methods: A questionnaire was administered prospectively to all non-critical adult patients who presented to one university hospital ED during 23 randomly selected four-hour time blocks; 336 (89%) of 376 eligible patients responded. Self-reported smoking was validated by carbon monoxide breath testing in a pilot sample of 49 patients.
Results: The study patients were mostly young (mean age = 35 ± 15 years), female (59%), white (62%), and high school-educated (73%). Of the 336 ED patients, 41% were current smokers (95% CI = 0.36–0.46); 42% of these were "moderately" to "very highly" dependent on nicotine (Fagerstrom Test for Nicotine Dependence > 4). Of those who smoked, 68% stated they wanted to quit, and 49% wanted to quit within the month. Fifty-six percent of all those who smoked stated that they had never been told to quit smoking by any physician. Thirty-five percent of the ED sample (118 patients) relied upon EDs for most or all of their routine, primary health care; 55% (95% CI = 0.46–0.64) of these patients were current smokers.
Conclusions: The prevalence rates of smoking and nicotine addiction among ED patients are high. Almost half of ED smokers are ready to quit, but most state they have never been told by a physician to do so. Finally, a large proportion of ED smokers receive their primary care in EDs. Therefore, the ED may be an underused setting for smoking cessation intervention.     

Dating Aggression and Risk Behaviors Among Teenage Girls Seeking Gynecologic Care

Objectives: The objective was to describe rates of dating aggression and related high-risk behavior among teens presenting to the emergency department (ED) seeking gynecologic care, compared to those seeking care for other reasons. Methods: Female patients ages 14–18 years presenting to the ED during the afternoon/evening shift of a large urban teaching hospital over a 19-month period were approached to participate and completed a self-administered computerized survey regarding sexual risk behaviors, past-year alcohol use, dating aggression, and peer aggression. Logistic regression analysis was used to identify factors associated with the evaluation of gynecologic complaint as noted by completion of a pelvic exam. Results: A total of 949 teens were enrolled (87% response rate), with 148 receiving gynecologic evaluation. Among girls undergoing a gynecologic evaluation, 49% reported past-year dating aggression, compared to 34% of those who did not undergo gynecologic evaluation (odds ratio [OR] = 1.81, 95% confidence interval [CI] = 1.30 to 2.62). Logistic regression analysis predicting gynecologic evaluation found statistically significant variables to be older age (OR = 1.95, 95% CI = 1.24 to 3.06), African American race (OR = 1.58, 95% CI = 1.04 to 2.40), parental public assistance (OR = 1.64, 95% CI = 1.10 to 2.45), alcohol use (OR = 2.31, 95% CI = 1.57 to 3.38), and dating aggression (OR = 1.51, 95% CI = 1.03 to 2.21). Conclusions: Of the teens undergoing gynecologic evaluation in this urban ED, 49% reported dating aggression. These teens also reported higher rates of other sexual risk behaviors compared to their peers. Care providers in urban EDs treating all female teens and particularly those seeking gynecologic care should be aware of this high rate of dating aggression and screen for aggression in dating relationships in this high-risk group.     

An Emergency Department–Based Nurse Discharge Coordinator for Elder Patients: Does It Make a Difference?

OBJECTIVES: To evaluate the impact of an emergency department (ED)-based nurse discharge plan coordinator (NDPC) on unscheduled return visits within 14 days of discharge, satisfaction with discharge recommendations, adherence with discharge instructions, and perception of well-being of elder patients discharged from the ED. METHODS: Patients aged 75 years and older discharged from the ED of the Sir Mortimer B. Davis-Jewish General Hospital were recruited in a pre/post study. During the pre (control) phase, study patients (n = 905) received standard discharge care. Patients in the post (intervention) phase (n = 819) received the intervention of an ED-based NDPC. The intervention included patient education, coordination of appointments, patient education, telephone follow-up, and access to the NDPC for up to seven days following discharge. RESULTS: Patients in the two groups were similar with respect to gender and age. However, the patients managed by the ED NDPC appeared to be, at baseline, less autonomous, frailer, and sicker. The unadjusted relative risk for unscheduled return visits within 14 days of discharge was 0.79 (95% confidence interval [95% CI] = 0.62 to 1.02). A relative risk reduction of 27% (95% CI = 0% to 44%) for unscheduled return visits was observed for up to eight days postdischarge, and a relative risk reduction of 19% (95% CI = -2% to 36%) for unscheduled return visits was observed for up to 14 days postdischarge. Significant increases in satisfaction with the clarity of discharge information and perceived well-being were also noted. CONCLUSIONS: An ED-based NDPC, dedicated specifically to the discharge planning care of elder patients, reduces the proportion of unscheduled ED return visits and facilitates the transition from ED back home and into the community health care network.     

Implementation of an Emergency Department–based Transient Ischemic Attack Clinical Pathway: A Pilot Study in Knowledge Translation

Objectives To assess the feasibility of implementing an emergency department (ED)—based transient ischemic attack (TIA) clinical pathway that uses computer-based clinical support, and to evaluate measures of quality, safety, and efficiency.
Methods This was a prospective cohort study of adult patients presenting to a community ED with symptoms consistent with acute TIA. Adherence to the clinical pathway served as a test of feasibility. Compliance with guideline recommendations for antithrombotic therapy and vascular imaging were used as process measures of quality. The 90-day risk of recurrent TIA, stroke, or death provided estimates of safety. Efficiency was assessed by measuring the rate of uneventful hospitalization, defined as a hospital admission that did not result in any major medical event or vascular intervention such as endarterectomy or stent placement.
Results Of the 75 subjects enrolled, physician adherence to the clinical pathway was 85.3%, and 35 patients (46.7%) were discharged home from the ED. Antithrombotic agents were prescribed to 68 (90.7%), and vascular imaging was performed in 70 (93.3%). The 90-day risk of recurrent TIA was seven out of 75 (9.3%; 95% confidence interval [CI] = 4.6% to 18.0%), one patient experienced stroke (1.3%; 95% CI = 0.2% to 7.2%), and three patients died (4.0%; 95% CI = 1.4% to 11.1%). Uneventful hospitalization occurred in 38 of 40 patients (95.0%).
Conclusions Implementation of a clinical pathway for the evaluation and management of TIA using computer-based clinical support is feasible in a community ED setting. This pilot study in knowledge translation provides a design framework for further studies to assess the safety and efficiency of a structured ED-based TIA clinical pathway.     

Asthma Coaching in the Pediatric Emergency Department

Objectives: Coaching and monetary incentives have been used to modify medical behavior of individuals with several chronic diseases, including asthma. The authors performed a randomized, controlled trial of an intervention combining asthma coaching during an emergency department (ED) visit for asthma, and monetary incentive to improve follow-up with primary care providers (PCP).
Methods: Subjects were parents of children 2–12 years of age, with Medicaid or no medical insurance, receiving treatment for asthma in the ED. The primary outcome was a verified PCP visit for asthma within two weeks of the index ED visit. All parents received 15 for their time in the ED. Parents in the intervention group were told that they would receive an additional 15 monetary incentive if a PCP visit was completed. The coach engaged in a dialogue with the parent during the ED visit, and discussed the importance and advantages of seeking follow-up care with the child's PCP. All parents received the usual discharge instructions, including advice to see the PCP within three days.
Results: The authors enrolled 92 parents; outcome data were available for 86 (42 controls, 50 intervention). Demographic characteristics were similar in both groups. There was no significant difference in the proportion of patients who had follow-up PCP visits between the intervention (22.0%; 95% confidence interval [95% CI] = 11.5% to 36.0%) and control (23.8%; 95% CI = 12.0% to 39.4%) groups (p = 0.99).
Conclusions: An intervention combining asthma coaching during acute ED visits and a monetary incentive to return for a PCP visit does not appear to increase follow-up with the PCP.     

Rapid Two-stage Emergency Department Intervention for Seniors: Impact on Continuity of Care

OBJECTIVES: A two-stage intervention comprising screening and a brief standardized nursing assessment and referral, for emergency department (ED) patients aged 65 years and over, reduced the rate of functional decline four months after the visit, without increasing societal costs. In this study, the authors investigated the effects of the intervention on the process of care at, and during the month after, the ED visit. METHODS: Patients at four Montreal hospital EDs were randomized by day of visit to the intervention or to usual care. Patients admitted to the hospital were excluded. Measures of process of care included: referrals and visits to the primary physician and to the local community health center, for home care or other services, and return ED visits. Data sources included hospital charts, patient questionnaires, and provincial administrative databases. RESULTS: The study sample included 166 intervention and 179 control group patients ready for discharge from the ED. Intervention group patients were more likely to have a chart-documented referral to their local community health center [adjusted odds ratio (OR) 4.0, 95% confidence interval (95% CI) = 1.7 to 9.5] and their primary physician [adjusted OR 1.9, 95% CI = 1.0 to 3.4], and to have received home care services one month after the ED visit [adjusted OR 2.3, 95% CI = 1.1 to 5.1]. Unexpectedly, they were also more likely to make a return visit to the ED [adjusted OR 1.6, 95% CI = 1.0 to 2.6]. CONCLUSIONS: The beneficial outcomes of the intervention appear to result primarily from the early provision of home care rather than early contact with the primary physician.     

Effect of a Practice Guideline for Emergency Department Care of Falls in Elder Patients on Subsequent Falls and Hospitalizations for Injuries

OBJECTIVE: To determine the effect of a practice guideline for the ED management of falls in community-dwelling elders on selected health outcomes. METHODS: The experimental design was a prepost-intervention comparison with one-year pre- and post-intervention phases. The guideline was presented to emergency physicians and nurses during a two-week interval between these two periods. The intervention also included health information provided to the subjects and a one-time educational intervention directed at primary care providers. The number of falls in the year following the ED visit was determined by telephone interview. The number of hospitalizations for falls was determined from the HMO database of all health care encounters. RESULTS: 1,899 patients were eligible for the study; 1,140 pre-intervention and 759 post-intervention patients. Of these, 1,504 (79%) were interviewed by telephone 12 to 15 months after their initial ED visits. Eighteen percent of the pre-intervention and 21% of the post-intervention subjects reported at least one fall in the 12 months following their ED visits (p = 0.162). The rate of falls per 100 patient years was 36.2 in both groups. Three percent of both groups were hospitalized at least once for a fall in the year following their ED visits. One percent in each group were hospitalized for a hip fracture. CONCLUSIONS: The attempted implementation of a practice guideline for the ED management of falls in community-dwelling elders did not result in a reduction in total falls, or in hospitalizations for falls, injuries, or fractures.     

Injury patterns and preventability in prehospital motor vehicle crash fatalities in Victoria

Objective: To examine the pattern of anatomical injury in victims of motor vehicle crashes who die prior to reaching hospital. Cases were identified where death was an unexpected outcome. Methods: A retrospective review of autopsy case records including police reports, of all persons who died in motor vehicle crashes between 1 January 1998 and 31 December 1999 and underwent full autopsy at the Victorian Institute of Forensic Medicine (VIFM). Those cases where the victim died in the prehospital phase were examined. Abbreviate Injury Scores and Injury Severity Scores were calculated in each case. Bull's probit analysis was used to identify unexpected deaths. Results: There were 352 motor road crash fatalities identified that underwent autopsy at the VIFM in the study period. Two hundred and six of these were prehospital deaths involving motor vehicles, which satisfied specified criteria. 82% (95% CI: 77.7–86.3%) of cases had Abbreviated Injury Scores of 5 (critical) or 6 (incompatible with life). 80.1% (95% CI: 75.7–84.5%) had an Injury Severity Score greater than 40. 36.9% (95% CI: 34.5–39.3%) of cases had the maximum Injury Severity score of 75. 88.8% (95% CI: 85–92.7%) of cases sustained a head injury and 83.9% (95% CI: 79.8–88.2%) a chest injury. Possibly preventable fatality was identified in 30 (14.6% 95% CI: 13.9–15.3%) cases. Conclusion: In motor vehicle crash fatalities, most victims who die before reaching hospital do so because of major injury, with the head and chest the commonest regions involved. A large proportion of these injuries could be considered unsurvivable regardless of treatment. Earlier intervention or retrieval of such patients is unlikely to influence outcome in the majority of cases.     

Motivation for Stopping Tobacco Use among Emergency Department Patients

Objectives: To determine the feasibility of new models for reinforcing tobacco‐use‐cessation interventions initiated in the emergency department (ED). The authors assessed the level of motivation to quit tobacco use among a general population of ED patients; the proportion who receive tobacco‐use assessments, information, and interventions from ED providers; and the desired timing of tobacco‐use interventions. Methods: Face‐to‐face interviews with a convenience sample of 376 adult patients receiving care in the ED at the Mayo Clinic in Rochester, Minnesota. Results: Of the 376 participants, 27% (100/376; 95% CI = 22% to 31%) currently used one or more forms of tobacco. Thirty percent (30/100; 95% CI = 21% to 40%) of tobacco users were in the preparation stage of change for tobacco cessation. The median score on the Contemplation Ladder was 6 (range: 0–10). Twenty‐seven percent (27/100; 95% CI = 19% to 37%) of all tobacco users would have been interested in a tobacco‐use treatment after the ED visit, such as telephone‐based counseling. Of the current tobacco users either receiving or desiring a tobacco‐use intervention, 74% (25/34; 95% CI = 56% to 87%) would be interested in receiving an intervention component after the ED visit. Conclusions: ED patients who use tobacco demonstrate motivation to quit and express interest in receiving interventions to assist them after the ED visit. Previous investigations have observed that ED patients do not attend interventions prescribed after the initial ED encounter. These findings suggest that the development of new models for reinforcing tobacco‐use interventions initiated in the ED deserve exploration, such as linking them to a tobacco quitline.     

Evaluating the Effectiveness of Dispatch-assisted Cardiopulmonary Resuscitation Instructions

Objectives: To determine the frequency of agonal breathing during cardiac arrest (CA), its impact on the ability of 9‐1‐1 dispatchers to identify CA, and the impact of dispatch‐assisted cardiopulmonary resuscitation (CPR) instructions on bystander CPR rates. Methods: A before‐after observational study enrolling out‐of‐hospital adult CA patients where resuscitation was attempted in a single city with basic life support with defibrillation/advanced life support tiered emergency medical services. Victim, caller, and system characteristics were measured during two successive nine‐month periods before (control group) and after (intervention group) the introduction of dispatch‐assisted CPR instructions. Results: There were 529 CAs between July 1, 2003, and December 31, 2004. Victim characteristics were similar in the control (n= 295) and intervention (n= 234) period; mean age was 68.3 years; 66.7% were male; 50.1% of CAs were witnessed; call‐to‐vehicle stop was 6 minutes, 37 seconds; ventricular fibrillation/ventricular tachycardia occurred in 29.9%; and the survival rate was 4.0%. Dispatchers identified 56.3% (95% confidence interval [CI] = 48.9% to 63.0%) of CA cases; agonal breathing was present in 37.0% (95% CI = 30.1% to 43.9%) of all CA cases and accounted for 50.0% (95% CI = 39.1% to 60.9%) of missed diagnoses. Callers provided ventilations in 17.2% and chest compressions in 8.3% of cases as a result of the intervention. Long time intervals were observed between call to diagnosis (2 minutes, 38 seconds) and during ventilation instructions (2 minutes, 5 seconds). Bystander CPR rates increased from 16.7% in the control phase to 26.4% in the intervention phase (absolute rate, 9.7%; 95% CI = 8.5% to 11.3%; p = 0.006). Conclusions: This trial demonstrates an increase in bystander CPR rate after the introduction of dispatch‐assisted CPR. Agonal breathing occurred frequently and had a negative impact on the recognition of CA. There were long time intervals between call initiation and diagnosis of CA and during mouth‐to‐mouth ventilation instructions.     

Child Health Insurance Outreach through the Emergency Department A Pilot Study

In 1997 the U.S. government funded the Children's Health Insurance Program (CHIP), but the 48 billion dollars initiative has had limited success in finding and enrolling uninsured children. While such children are more likely to receive care in emergency departments (EDs), no national initiative has targeted EDs for child health insurance outreach. OBJECTIVE: As a pilot study for a national multicenter study, this study evaluated the effectiveness of child health insurance outreach in an ED setting. METHODS: This was a prospective observational study of the outreach efforts of a single case manager from August 1998 to July 1999, performed at Foote Hospital ED in Jackson, Michigan (45,000 visits/year). All patients 相似文献   

Clinical Factors Predicting Fractures Associated with an Anterior Shoulder Dislocation

OBJECTIVES: To identify risk factors for fractures associated with an anterior shoulder dislocation treated in an emergency department (ED). METHODS: A retrospective case-control study over five years of patients with an anterior shoulder dislocation was accomplished in a university-affiliated ED. Chart review identified possible predictors of fractures. Comparing the profile of patients having a clinically important fracture associated with their shoulder dislocation (cases) with those sustaining a noncomplicated dislocation (controls) provided the outcome measure. RESULTS: A total of 334 patients were included in the study. Eighty-five (25.5%) had a clinically important fracture-dislocation, and the remaining 249 (74.5%) sustained a noncomplicated shoulder dislocation. Chi-square, logistic regression, and recursive partitioning analysis showed three significant factors for the presence of fracture-dislocation: 1) age 40 years or older, 2) a first episode of dislocation, and 3) mechanism of injury (i.e., a fall greater than one flight of stairs, a fight/assault episode, or a motor vehicle crash). A multiple logistic regression model estimated the significant adjusted odds ratios (and their 95% confidence intervals [95% CIs]) for each of the three factors: 5.18 (95% CI = 2.74 to 9.78), 4.23 (95% CI = 1.82 to 9.87), and 4.06 (95% CI = 1.95 to 8.48), respectively. A predictive model using any one of the three factors reached a sensitivity of 97.7% (95% CI = 91.8% to 99.4%), a specificity of 22.9% (95% CI = 18.1% to 28.5%), and a negative predictive value of 96.6% (95% CI = 88.3% to 99.6%). CONCLUSIONS: Three risk factors predict clinically important fractures that are associated with shoulder dislocation: age, first episode, and mechanism of dislocation. A prospective validation may lead to standardized use of prereduction radiographs of the shoulder in the ED.     

Impact of Helical Computed Tomography on the Outcomes of Emergency Department Patients with Suspected Appendicitis

OBJECTIVES: To assess the impact of an emergency department (ED) guideline employing selective use of helical computed tomography (CT) on clinical outcomes of female patients with suspected appendicitis. METHODS: All patients presenting with suspected appendicitis were prospectively enrolled and managed in accordance with a guideline incorporating selective use of helical CT. Although not the objective of this investigation, male patients were included for purposes of comparison. Patients with clinically evident appendicitis were referred to the surgical service, and patients with equivocal presentations were studied with helical CT. Patients were followed to final surgical or clinical outcomes. Outcome measures included time from ED presentation to laparotomy and rate of appendiceal perforation. These measures were compared with those of a historical cohort of patients preceding the use of helical CT. RESULTS: A total of 310 consecutive patients with suspected appendicitis were enrolled; 92 had appendicitis. Sixty patients were referred to the surgical service without helical CT, and 41 had appendicitis (68%). Helical CT was performed on 250 patients; 51 had appendicitis (20%). For males, the mean interval from ED presentation to laparotomy was 559 minutes (95% CI = 444 to 674 minutes) during guideline use and 480 minutes (95% CI = 405 to 555 minutes) before. This interval for females was 433 minutes (95% CI = 326 to 540 minutes) during guideline use and 710 minutes (95% CI = 558 to 862 minutes) before. Appendiceal perforation rate for males was 0.25 (95% CI = 0.14 to 0.36) during guideline use and 0.38 (95% CI = 0.29 to 0.47) before; perforation rate for females was 0.06 (95% CI = -0.05 to 0.17) during guideline use and 0.23 (95% CI = 0.14 to 0.32) before. Helical CT had 92% sensitivity, 97% specificity, and 96% accuracy in diagnosing appendicitis. CONCLUSIONS: Helical CT is highly accurate in detecting appendicitis in patients with equivocal ED presentations. The use of a guideline employing selective helical CT was associated with a decline in the time from ED presentation to operative intervention in females.     

Nontraumatic Headaches in the Emergency Department: Evaluation of a Clinical Pathway

Objective.— To determine the impact and efficacy of a clinical pathway in the management of patients with nontraumatic and afebrile headache (NTAH) in the emergency department (ED). Background.— Nontraumatic and afebrile headache is one of the most common neurological symptoms in the ED. However, data about the application of an evidence‐based operative protocol are lacking. Methods.— A before–after intervention study comparing adult patients presenting to the ED with atraumatic headache was conducted during a 6‐month period from April to September 2005 and with the same type of patients in the same period in 2006 after a clinical pathway had been implemented. According to their clinical presentations, patients of the 2006 group were divided into 3 subgroups and managed following the established protocol. Study results were based on analysis of 6 months of clinical outcome, the number of CT head scans in the ED, number of neurological consultations in the ED, number of admissions, and length of stay in the ED. Results.— A total of 686 patients were enrolled in the study, of which 374 were those presenting to our ED with NTAH in 2006 and managed with the aid of the study protocol; the other 312 patients were those who presented in 2005, before the intervention. The study protocol was strictly applied to 247 patients (66%) of the 2006 group. There were fewer neurological consultations after the intervention (41.2% vs 52.5%, difference: ?11.3%, 95% confidence intervals [CI]: ?18.7% to ?3.9%; P = .003); likewise, admissions were significantly reduced after the intervention (9.0% vs 14.7%, difference: ?5.7%, 95% CI: ?10.6% to ?0.8%; P = .02). No significant differences were found between the 2 groups for number of CT head scans (42.2% vs 38.4%, difference: 3.7%, 95% CI: ?3.5% to 11%; P = .3). Mean length of stay in the ED was lower after the intervention, though not significantly (170.6 ± 102 minutes vs 180.5 ± 105 minutes, difference: ?9.8 minutes, 95% CI: ?20.3 to 5.7; P = .09). A 6‐month follow‐up was completed involving 302 (96.7%) patients in the first group and 370 (98.9%) in the second group. There was only one misdiagnosis after the intervention while 2 incorrect diagnoses were made before the intervention (0.27% vs 0.6%, difference: ?0.33%, 95% CI: ?2.1% to 0.9%; P = .5). Conclusions.— Our diagnostic protocol for NTAH appears to be safe and sensitive in diagnosing malignant headaches. In addition, it may improve use of resources by reducing the need for neurological consultations and admissions without increasing the number of CT scans or prolonging length of stay in the ED. Furthermore, when using the protocol ED physicians seem more confident in their evaluations of headache resulting in fewer requests for specialist input.     

Retrospective Chart Analysis of Concussion Discharge Instructions in the Emergency Department

Background

Recognition and diagnosis of concussion is increasing, but current research shows these patients are discharged from the emergency department (ED) with a wide variability of recommendations and instructions.

Clinically Meaningful Changes in Quantitative Measures of Asthma Severity

OBJECTIVE: To determine minimum clinically meaningful improvements in peak expiratory flow rate (PEFR) and dyspnea visual analog score (VAS) in patients with acute asthma exacerbation. METHODS: Patients presenting to the emergency department (ED) with acute asthma exacerbation were eligible. The PEFR and VAS were assessed at presentation and after initial asthma therapy. During reassessment, subjects were asked to describe their asthma symptoms as "much better," "a little better," "no change," "a little worse," or "much worse." Correspondence between self-reported improvement and changes in PEFR and VAS was assessed. The "minimum clinically significant change" in either index was defined as the difference between pre- and posttreatment measures in subjects reporting their symptoms "a little better." RESULTS: One hundred fifty-six subjects were included. Asthma symptoms were "much better" in 99 (64%), "a little better" in 41 (26%), and "unimproved" (composed of patients describing symptoms as "no change," "a little worse," or "much worse") in 16 (10%). The mean VAS change among the "a little better" subjects was 2.2 cm (95% CI = 1.1 to 3.4), significantly greater than the -0.4 cm (95% CI = -2.1 to 1.4) change in the "unimproved" subjects. The mean change in percent predicted PEFR among the "a little better" subjects was 11.9 (95% CI = 7.3 to 16.1), not statistically different from the change of 6.1 (95% CI = 1.1 to 11.3) in the "no change" subjects. The "much better" group showed significantly greater changes in both measures than either of the other groups. A VAS change of > or =0.5 cm reliably discriminated between subjects with and without symptom improvement. CONCLUSIONS: Improvements in VAS of 2.2 cm and in predicted PEFR of about 12 percentage points are minimal clinically significant improvements during ED asthma therapy. The dyspnea VAS is valid in assessing symptomatic changes and may detect small subjective improvements better than the PEFR.     

Compliance with Recommended Cancer Screening among Emergency Department Patients: A Multicenter Survey

Objectives: The objectives were to measure compliance with, and possible sociodemographic disparities for, cancer screening among emergency department (ED) patients. Methods: This was a cross‐sectional survey in three academic EDs in Boston. The authors enrolled consecutive adult patients during two 24‐hour periods at each site. Self‐reported compliance with standard recommendations for cervical, breast, testicular, and prostate cancer screening were measured. The chi‐square test was used test to evaluate associations between demographic variables and cancer screening compliance. Results: The authors enrolled 387 patients (81% of those eligible). The participants had a mean (±standard deviation) age of 44 (±18) years and were 52% female, 16% Hispanic, and 65% white. Sixty‐seven percent (95% confidence interval [CI] = 60% to 73%) of all women reported Pap smear examinations in the past 3 years, 92% (95% CI = 85% to 96%) of women aged ≥40 years reported clinical breast examinations, and 88% (95% CI = 81% to 94%) of women aged ≥40 years reported mammography. Fifty‐one percent (95% CI = 40% to 61%) of men aged 18–39 years reported testicular self‐examinations, and among men aged ≥40 years, 79% (95% CI = 69% to 87%) reported digital rectal examinations (DREs) and 51% (95% CI = 40% to 61%) reported prostate‐specific antigen (PSA) testing. Racial and ethnic minorities reported slightly lower rates of clinical breast examinations and testicular self‐examinations. Conclusions: Most women and a majority of men in our ED‐based study were compliant with recommended measures of cervical, breast, testicular, and prostate cancer screening. No large sociodemographic disparities in our patient population were identified. Based on these data, and the many other pressing public health needs of our ED population, the authors would be reluctant to promote ED‐based cancer screening initiatives at this time.