To the Editor: Access to dermatologists is limited in many areas of the United States. This is especially notable in rural settings, among patients with Medicaid coverage or those without health insurance, minorities, and those treated by safety-net providers in the emergency department (ED).1,2 Telemedicine, especially teledermatology (TD), has the potential to increase access, reduce wait times, and provide cost-effective care.3,4 However, evaluation of the accuracy and feasibility of TD, specifically in the acute care setting of the ED, has not been as clearly demonstrated in the United States.

INTRODUCTION:Patient navigation programs can help people overcome barriers to outpatient care. Patient experiences with these programs are not well understood. The goal of this study was to understand patient experiences and satisfaction with an emergency department (ED)-initiated patient navigation (ED-PN) intervention for US Medicaid-enrolled frequent ED users.METHODS:We conducted a mixed-methods evaluation of patient experiences and satisfaction with an ED-PN program for patients who visited the ED more than four times in the prior year. Participants were Medicaid-enrolled, English- or Spanish-speaking, New Haven-CT residents over the age of 18. Pre-post ED-PN intervention surveys and post-ED-PN individual interviews were conducted. We analyzed baseline and follow-up survey responses as proportions of total responses. Interviews were coded by multiple readers, and interview themes were identified by consensus.RESULTS:A total of 49 participants received ED-PN. Of those, 80% (39/49) completed the post-intervention survey. After receiving ED-PN, participants reported high satisfaction, fewer barriers to medical care, and increased confidence in their ability to coordinate and manage their medical care. Interviews were conducted until thematic saturation was reached. Four main themes emerged from 11 interviews: 1) PNs were perceived as effective navigators and advocates; 2) health-related social needs were frequent drivers of and barriers to healthcare; 3) primary care utilization depended on clinic accessibility and quality of relationships with providers and staff; and 4) the ED was viewed as providing convenient, comprehensive care for urgent needs.CONCLUSIONS:Medicaid-enrolled frequent ED users receiving ED-PN had high satisfaction and reported improved ability to manage their health conditions.

Objectives Quality and safety review for performance improvement is important for systems of care and is required for US academic emergency departments (EDs). Assessment of the impact of patient safety initiatives in the context of increasing burdens of quality measurement compels standardized, meaningful, high-yield approaches for performance review. Limited data describe how quality and safety reviews are currently conducted and how well they perform in detecting patient harm and areas for improvement. We hypothesized that decades-old approaches used in many academic EDs are inefficient and low yield for identifying patient harm. Methods We conducted a prospective observational study to evaluate the efficiency and yield of current quality review processes at five academic EDs for a 12-month period. Sites provided descriptions of their current practice and collected summary data on the number and severity of events identified in their reviews and the referral sources that led to their capture. Categories of common referral sources were established at the beginning of the study. Sites used the Institute for Healthcare Improvement's definition in defining an adverse event and a modified National Coordinating Council for Medication Error Reporting and Prevention (MERP) Index for grading severity of events. Results Participating sites had similar processes for quality review, including a two-level review process, monthly reviews and conferences, similar screening criteria, and a grading system for evaluating cases. In 60 months of data collection, we reviewed a total of 4735 cases and identified 381 events. This included 287 near-misses, errors/events (MERP A–I) and 94 adverse events (AEs) (MERP E–I). The overall AE rate (event rate with harm) was 1.99 (95% confidence interval = 1.62%–2.43%), ranging from 1.24% to 3.47% across sites. The overall rate of quality concerns (events without harm) was 6.06% (5.42%–6.78%), ranging from 2.96% to 10.95% across sites. Seventy-two–hour returns were the most frequent referral source used, accounting for 47% of the cases reviewed but with a yield of only 0.81% in identifying harm. Other referral sources similarly had very low yields. External referrals were the highest yield referral source, with 14.34% (10.64%–19.03%) identifying AEs. As a percentage of the 94 AEs identified, external referrals also accounted for 41.49% of cases. Conclusions With an overall adverse event rate of 1.99%, commonly used referral sources seem to be low yield and inefficient for detecting patient harm. Approximately 6% of the cases identified by these criteria yielded a near miss or quality concern. New approaches to quality and safety review in the ED are needed to optimize their yield and efficiency for identifying harm and areas for improvement.

Background: Some Medicaid enrollees frequently utilize the emergency department (ED) due to barriers accessing health care services in other settings. Objectives: To determine whether an ED-initiated Patient Navigation program (ED-PN) designed to improve health care access for Medicaid-insured frequent ED users could decrease ED visits, hospitalizations, and costs. Methods: We conducted a prospective, randomized controlled trial comparing ED-PN with usual care (UC) among 100 Medicaid-enrolled frequent ED users (defined as 4-18 ED visits in the prior year), assessing ED utilization during the 12 months pre- and post-enrollment. Secondary outcomes included hospitalizations, outpatient utilization, hospital costs, and Medicaid costs. We also compared characteristics between ED-PN patients with and without reduced ED utilization. Results: Of 214 eligible patients approached, 100 (47%) consented to participate. Forty-nine were randomized to ED-PN and 51 to UC. Sociodemographic characteristics and prior utilization were similar between groups. ED-PN participants had a significant reduction in ED visits and hospitalizations during the 12-month evaluation period compared with UC, averaging 1.4 fewer ED visits per patient (p = 0.01) and 1.0 fewer hospitalizations per patient (p = 0.001). Both groups increased outpatient utilization. ED-PN patients showed a trend toward reduced perpatient hospital costs (-$10,201, p = 0.10); Medicaid costs were unchanged (-$5,765, p = 0.26). Patients who demonstrated a reduction in ED usage were older (mean age 42 vs. 33 years, p = 0.03) and had lower health literacy (78% low health literacy vs. 40%, p = 0.02). Conclusion: An EDPN program targeting Medicaid-insured high ED utilizers demonstrated significant reductions in ED visits and hospitalizations in the 12 months after enrollment. (C) 2020 Elsevier Inc. All rights reserved.

The article by Raven1Raven M. Homelessness and the practice of emergency medicine: challenges, gaps in care, and moral obligations.Ann Emerg Med. 2019; 74: S33-S37Scopus (4) Google Scholar highlights that the ED homeless population has different needs than other populations using the ED. This basic concept is crucial for successful population health management, but she also points out limitations in our ability to identify homeless individuals. How can we develop programs specific to the homeless population when we cannot identify patients who are eligible to participate in such programs? Raven1Raven M. Homelessness and the practice of emergency medicine: challenges, gaps in care, and moral obligations.Ann Emerg Med. 2019; 74: S33-S37Scopus (4) Google Scholar observes in her article that “accurately screening for and identifying homelessness among our patients is a necessary first step,” and I could not agree with her more, and echo her view that challenges associated with such a question are complex. In evaluation of the literature on homelessness and ED use, there is often a focus on individuals who experience substance use problems or severe mental health issues.2Capp R. Rosenthal M.S. Desai M.M. et al.Characteristics of Medicaid enrollees with frequent ED use.Am J Emerg Med. 2013; 31: 1333-1337Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 3Liu S.W. Nagurney J.T. Chang Y. et al.Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints?.Am J Emerg Med. 2013; 31: 1512-1515Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar If you were to ask a health care provider to describe his or her last encounter with a homeless client, I can almost guarantee that you would hear about a frequent ED user who presents to the ED with alcohol intoxication. If you ask policymakers about frequent ED users, they think of “Million Dollar Murray,” a homeless patient who had alcoholism and cost the health care system greater than a million dollars.4Gladwell M. Million-Dollar Murray.http://www.newyorker.com/magazine/2006/02/13/million-dollar-murrayGoogle Scholar In summary, for many homeless patients, using the ED is equated with being a frequent ED user, having a substance use problem, or both.2Capp R. Rosenthal M.S. Desai M.M. et al.Characteristics of Medicaid enrollees with frequent ED use.Am J Emerg Med. 2013; 31: 1333-1337Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar, 3Liu S.W. Nagurney J.T. Chang Y. et al.Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints?.Am J Emerg Med. 2013; 31: 1512-1515Abstract Full Text Full Text PDF PubMed Scopus (51) Google Scholar, 4Gladwell M. Million-Dollar Murray.http://www.newyorker.com/magazine/2006/02/13/million-dollar-murrayGoogle Scholar, 5Doran K.M. Curry L.A. Vashi A.A. et al.“Rewarding and challenging at the same time”: emergency medicine residents’ experiences caring for patients who are homeless.Acad Emerg Med. 2014; 21: 683-689Google Scholar, 6Ku B.S. Fields J.M. Santana A. et al.The urban homeless: super-users of the emergency department.Popul Health Manag. 2014; 17: 366-371Crossref PubMed Scopus (29) Google Scholar If standardized homeless screenings were used in the ED, would the homeless patient population be seen through a different lens? I believe so. In 2014, I developed a program called Hot Spotters to educate prehealth students about social determinants of health.7Harpin S.B. Druck J. Schroeder A. et al.Transforming health care education to address social determinants of health: the 2014 Hot Spotters student program.J Interprof Educ Pract. 2016; 5: 33-36Crossref Scopus (4) Google Scholar Part of the program involved teaching students in a classroom setting about social determinants of health and how to address them. They then received hands-on training to become patient navigators, nonhealth professionals who are able to provide health and social care coordination for patients according to patients’ needs. One of the social health screening questions we used to identify homeless patients was this: “In the past 30 days, have you spent one or more nights in any place other than your own home (eg, couch surfing with friends or living in a motel, in a car, or on the streets)?” One student said, “I guess, the housing question was the toughest for me. I never really found a good way to ask [it]. Sometimes, I just felt like… If you look at me like I’m crazy, we’ll just say you stayed at your own house,” at which point another student pointed out, “I think unless you get someone who thinks that’s really below them, you’re not really going to offend anybody.” At the end of the summer, after surveying approximately 500 patients, we found that 33% of patients answered yes to the homeless question. None of those patients were in the ED for alcohol intoxication because this was an exclusion criterion for the survey, and only 1 out of 3 was a frequent ED user (≥4 ED visits/year).8Capp R, Favaro C, Jones C, et al. Frequent emergency department users: taking into account social determinants of health. A product of the 2014 Hot-Spotters student summer program. Presented at: SAEM; May 12-15, 2015; San Diego, CA.Google Scholar Our study results far surpassed national estimates from the National Hospital Ambulatory Medical Care Survey, which reported between 0.4% and 0.6% of ED patients as being homeless.9Oates G. Tadros A. Davis S.M. A comparison of national emergency department use by homeless versus non-homeless people in the United States.J Health Care Poor Underserved. 2009; 20: 840-845Crossref PubMed Scopus (35) Google Scholar The Hot Spotters experience helped me identify a few reasons why the question related to housing is challenging. Among other learnings, these things became clear: in medical school and in residency training, there is little training on asking patients about social determinants of health; there is a culture of avoiding this question for fear that an affirmative answer will prolong the patient’s ED length of stay; and the provider may think that the question is futile when the surrounding community may be unable to provide the appropriate resources. To the first aforementioned challenge associated with homeless identification, Raven1Raven M. Homelessness and the practice of emergency medicine: challenges, gaps in care, and moral obligations.Ann Emerg Med. 2019; 74: S33-S37Scopus (4) Google Scholar points out that medical providers often fail to ask patients about housing because they do not know how to ask the question or what to do with the answer. In 2015, the National Academy of Medicine released a report on developing a framework to educate health professionals on how to address social determinants of health, which supports the incorporation of a social determinants of health training curriculum into medical schools and residency training.10National Academies of Sciences, Engineering, and MedicineA Framework for Educating Health Professionals to Address the Social Determinants of Health. National Academies Press, Washington, DC2016Google Scholar Agencies such as the Association of American Medical Colleges, in collaboration with the Camden Coalition, have also initiated a few pilot Hotspotting programs that teach students about social determinants of health and care coordination.11Association of American Medical Colleges (AAMC)Interprofessional student Hotspotting learning collaborative.https://news.aamc.org/medical-education/article/student-hotspotters-improve-outcomesGoogle Scholar Efforts like these are vital to educate the health care community, but quite slow to be adapted nationwide. As for the second challenge associated with homeless identification, the ED length-of-stay quality metric reflects our specialty’s focus on operations metrics as quality metrics. Nationally, the Centers for Medicare & Medicaid Services rates our quality according to our ED length-of-stay metric. Although EDs are equipped to handle large volumes of patients and have been innovative in developing flow redesigns to address ED length of stay, we have ignored the fact that successful care management service delivery is not quick. In fact, when done properly, care management services can take longer than the medical care the patient receives while in the ED.12Carson K. Guest commentary: not all are celebrating Medicaid’s anniversary.http://www.denverpost.com/2015/07/28/guest-commentary-not-all-are-celebrating-medicaids-anniversary/Google Scholar ED operations directors are reluctant to add such services when it may increase their overall department’s length of stay. Carson,12Carson K. Guest commentary: not all are celebrating Medicaid’s anniversary.http://www.denverpost.com/2015/07/28/guest-commentary-not-all-are-celebrating-medicaids-anniversary/Google Scholar a social work student who participated in the 2015 Hot Spotters program, described the care coordination services she provided to a homeless patient using the ED for a diabetic foot infection in this way: “In total, I worked with him for two and a half hours, time the ED [physicians] simply do not have. In fact, the man’s medical evaluation and treatment took less time than figuring out his ED after-care plan.” If we want to provide patients with the appropriate care management resources in our fast-paced ED environment to avoid an ED revisit or hospital (re)admission, then we must also address our national ED length-of-stay quality metric. The third and final challenge associated with homeless identification has to do with how public health and health care systems do not function as one entity in most states. An article by Kassler et al13Kassler W.J. Tomoyasu N. Conway P. Beyond a traditional payer—CMS’s role in improving population health.N Engl J Med. 2015; 372: 109-111Crossref PubMed Scopus (48) Google Scholar discussed the subject of social determinants of health screening and lack of referral sites to fulfill a need. I always find it interesting when I hear providers offer this explanation for not asking questions about housing status. When I started the Hot Spotters program, I gathered resources throughout the community. By the end, I had a list of greater than 500 resources. If anything, there are too many resources available to our community members; they appear to be infinite, but are scattered and challenging to put together. From a patient’s perspective, it can be quite difficult to navigate through all these different sites. On average, a patient who lives in poverty has to visit 3 to 9 agencies per year, and adding more agencies and community sites to that list can be overwhelming and time consuming.14DeVol P.E. Bridges to Sustainable Communities: A System-wide, Cradle-to-Grave Approach to Ending Poverty in America. Aha! Process, Inc, Highlands, TX2010Google Scholar The public health system ought to be thoughtful and more involved in how to bring these much-needed resources together in a digestible form. Finally, although the community resources available for homeless patients are numerous, the ultimate resource that will make a difference is scarce and difficult to obtain: a home. Housing First, which Raven1Raven M. Homelessness and the practice of emergency medicine: challenges, gaps in care, and moral obligations.Ann Emerg Med. 2019; 74: S33-S37Scopus (4) Google Scholar brought up as a successful population health approach to homelessness, is a first step in addressing the chronically homeless population, many of whom have long-term physical or mental health illnesses. A notable Housing First program is one started by former Mayor Annise Parker in Houston, TX. The city of Houston notes that for every 2,500 homeless clients, the city spends $103 million, a large proportion of which is spent on health care–related services. Housing these clients turns out to be a cheaper option. Rather than developing new programs, the team of agencies and providers aligned resources using the collective impact framework to initiate a “no wrong door approach” to chronically homeless clients. This meant that chronically homeless clients could walk up to any agency or health care facility and apply for housing or check on their housing placement status at any time. The joint efforts between Houston’s homeless service providers, the Houston Coalition for Homeless, the business community, and philanthropic funders led to the housing of 11,000 people during 6 years.15Brown S. 2017 Homeless Count. 2017; (Available at:)http://www.homelesshouston.org/wp-content/uploads/2017/05/Final-2017-PIT-Fact-Sheet-Digital.pdfGoogle Scholar Marc Eichenbaum, special assistant to the mayor for homeless initiatives, noted that a key aspect of the program is to provide supportive services, in addition to housing. In summary, although homelessness is primarily a social issue, it is also a social determinant of health. As such, emergency physicians have a duty to screen for it and to address it. Not doing so leads to worse outcomes for the patient and higher costs for the entire system. To succeed at treating the whole person, we must find community partners who can help us address this vital social determinant of health.

Feasibility of ED triage sepsis screening, before diagnostic testing has been performed, has not been established. In a retrospective, outcome-blinded chart review of a one-year cohort of ED adult septic shock patients ("derivation cohort") and three additional, non-consecutive months of all adult ED visits ("validation cohort"), we evaluated the qSOFA score, the Shock Precautions on Triage (SPoT) vital-signs criterion, and a triage concern-for-infection (tCFI) criterion based on risk factors and symptoms, to screen for sepsis. There were 19,670 ED patients in the validation cohort; 50 developed ED septic shock, of whom 60% presented without triage hypotension, and 56% presented with non-specific symptoms. The tCFI criterion improved specificity without substantial reduction of sensitivity. At triage, sepsis screens (positive qSOFA vital-signs and tCFI, or positive SPoT vital-signs and tCFI) were 28% (95% CI: 16-43%) and 56% (95% CI: 41-70%) sensitive, respectively, p < 0.01. By the conclusion of the ED stay, sensitivities were 80% (95% CI: 66-90%) and 90% (95% CI: 78-97%), p > 0.05, and specificities were 97% (95% CI: 96-97%) and 95% (95% CI: 95-96%), p < 0.001. ED patients who developed septic shock requiring vasopressors often presented normotensive with non-specific complaints, necessitating a low threshold for clinical concern-for-infection at triage.

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities.

OBJECTIVE:To assess patient- and hospital-level factors associated with home health care (HHC) referrals following nonelective U.S. patient hospitalizations in 2012.DATA SOURCE:The 2012 National Inpatient Sample (NIS).STUDY DESIGN:Retrospective, cross-sectional multivariable logistic regression modeling to assess patient- and hospital-level variables in patient discharges with versus without HHC referrals.DATA COLLECTION:Analysis included 1,109,905 discharges in patients ≥65 years with Medicare.PRINCIPAL FINDINGS:About 29.2 percent of discharges were referred to HHC, which were more likely with older age, female sex, urban location, low income, longer length of stay, higher severity of illness scores, diagnoses of heart failure or sepsis, and hospital location in New England (referent: Pacific).CONCLUSIONS:As health policy changes influence postacute HHC, defining specific diagnoses and regional patterns associated with HHC is a first step to optimize postacute HHC services.

Background Over a quarter of Medicare patients admitted to the hospital are discharged to post‐acute care ( PAC ) facilities, but face high rates of readmission. Timing of readmission may be an important factor in identifying both risk for and preventability of future readmissions. This study aims to define factors associated with readmission within the first week of discharge to PAC facilities following hospitalization. Design and Measurements This was a secondary analysis of the 2011 Healthcare Cost and Utilization Project ( HCUP ) State Inpatient Databases ( SID ) for California, Massachusetts, and Florida. The primary outcome was all‐cause readmission within 7 days after hospital discharge, compared to readmission on days 8–30, for patients aged 65 and older who were discharged from the hospital to a PAC facility. Predictor variables included patient, index hospitalization, and hospital characteristics; multivariable logistic regression was used to identify significant predictors of readmission within 7 days. Results There were 81,173 hospital readmissions from PAC facilities in the first 30 days after hospital discharge. Patients readmitted within the first week were older, white, urban, had fewer comorbid illnesses, had a higher number of previous hospital admissions, and less commonly had Medicare as a payer. Longer index hospital length of stay (LOS) was associated with decreased risk of early readmission ( OR 0.74; 95% CI 0.70–0.74 for LOS 4–7 days and 0.60; 95% CI 0.56–0.64 for LOS ≥8 days). Conclusions Shorter length of index hospital stay is associated with earlier readmission and suggests that for this comorbid, older population, a shorter hospital stay may be detrimental. Readmission after 1 week is associated with increased chronic disease burden, suggesting they may be associated with factors that are less modifiable.

Objectives: To evaluate effectiveness of a community health worker (CHW) program designed to address client objectives among frequent emergency department (ED) users. Design: Program evaluation using secondary analysis of client objectives from program records. Client objectives were characterized according to the World Health Organization's social determinants of health framework. Hierarchical generalized linear modeling was used to assess factors associated with objective achievement. Setting: An ED and the surrounding community in an economically disadvantaged area of Buffalo, New York. Participants: A total of 1600 adults over age 18 eligible for Medicaid and/or Medicare and who had at least 2 ED visits in the prior year. Intervention: Clients worked with CHWs in the community to identify diverse needs and objectives. Community health workers provided individualized services to help achieve objectives. Main Outcome Measure: Achievement of client-focused objectives. Results: Most objectives pertained to linkage to community resources and health care navigation, emphasizing chronic medical conditions and connection to primary care. Clients and CHWs together achieved 43% of total objectives. Objective achievement was positively associated with greater client engagement in CHW services. Conclusions: Low objective achievement may stem from system- and policy-level barriers, such as lack of affordable housing and access to primary care. Strategies for improving client engagement in CHW services are needed. Community health workers and their clients were most successful in areas in which public health policies and systems made resources easy to access or where the program had formalized relationships with resources, such as primary care.

Introduction: Despite treatment guidelines suggesting alternatives, as well as evidence of a lack of benefit and evidence of poor long-term outcomes, opioid analgesics are commonly prescribed for back pain from the emergency department (ED). Variability in opioid prescribing suggests a lack of consensus and an opportunity to standardize and improve care. We evaluated the variation in attending emergency physician (EP) opioid prescribing for patients with uncomplicated, low acuity back pain (LABP). Methods: This retrospective study evaluated the provider-specific proportion of LABP patients discharged from an urban academic ED over a seven-month period with a prescription for opioids. LABP was strictly defined as (1) back pain chief complaint, (2) discharged from ED with no interventions, and (3) predefined discharge diagnosis of back pain. We excluded providers if they had less than 25 LABP patients in the study period. The primary outcome was the physician-specific proportion of LABP patients discharged with an opioid analgesic prescription. We performed a descriptive analysis and then risk standardized prescribing proportion by adjusting for patient and clinical characteristics using hierarchical logistic regression. Results: During the seven-month study period, 23 EPs treated and discharged at least 25 LABP patients and were included. Eight (34.8%) were female, and six (26.1%) were junior attendings (≤ 5 years after residency graduation). There were 943 LABP patients included in the analysis. Provider-specific proportions ranged from 3.7% to 88.1% (mean 58.4% [SD +/− 22.2]), and we found a 22-fold variation in prescribing proportions. There was a six-fold variation in the adjusted, risk-standardized prescribing proportion with a range from 12.0% to 78.2% [mean 50.4% (SD +/−16.4)]. Conclusion: We found large variability in opioid prescribing practices for LABP that persisted after adjustment for patient and clinical characteristics. Our findings support the need to further standardize and improve adherence to treatment guidelines and evidence suggesting alternatives to opioids.

Background: Although mental health disorders (MHDs) affect as many as 1 in 4 adults in the U.S., the national trends in emergency department (ED) use for adults who have MHD comorbidities are unknown. Objective: To evaluate the role of mental health disorder co-morbidities for adults who use the ED and how this utilization differs by insurance type. Methods: This is a retrospective analysis of the National Emergency Department Survey (NEDS) dataset of adults 18 to 64 years of age that was conducted from 2006 to 2011. We defined individuals with MHD comorbidities by applying the MHD Clinical Classification Software groupings to any of the 1 to 15 diagnostic fields available in the NEDS. We further evaluated ED visits made for a primary diagnosis of MHD by applying the same aforementioned codes to the primary diagnosis. We constructed ED visit rates using the U.S. Census Bureau's Current Population Survey. We used descriptive statistics and tested for differences in trends in visits and visit rates by payer using an ordinary least squares regression. Results: The number of ED visits increased by 8.6% from 2006 to 2011. The number of ED visits made by adults primarily for MHDs and with MHD comorbidities increased by 20.5% and 53.3%, respectively (p < 0.0001); ED visits made adults without MHDs decreased by 1.1% (p = 0.72) for the same time period. When accounting for the population growth rate, ED visit rates made by adults with MHD comorbidities increased for all insurance types, but decreased for those without MHD comorbidities. Conclusion : MHD comorbidities play a significant role in the increasing number of ED visits, regardless of insurance coverage. Additional studies are needed to understand the role of patients with MHDs and ED use. (C) 2016 Elsevier Inc. All rights reserved.

OBJECTIVEThis study aimed to develop an emergency department (ED) trigger tool to improve the identification of adverse events in the ED and that can be used to direct patient safety and quality improvement. This work describes the first step toward the development of an ED all-cause harm measurement tool by experts in the field.METHODSWe identified a multidisciplinary group of emergency medicine safety experts from whom we solicited candidate triggers. We then conducted a modified Delphi process consisting of 4 stages as follows: (1) a systematic literature search and review, including an independent oversampling of review for inclusion, (2) solicitation of empiric triggers from participants, (3) a Web-based survey ranking triggers on specific performance constructs, and (4) a final in-person meeting to arrive at consensus triggers for testing. Results of each step were shared with participants between each stage.RESULTSAmong an initial 804 unique articles found using our search criteria, we identified 94 that were suitable for further review. Interrater reliability was high (κ = 0.80). Review of these articles yielded 56 candidate triggers. These were supplemented by 58 participant-submitted triggers yielding a total of 114 candidate triggers that were shared with team members electronically along with their definitions. Team members then voted on each measure via a Web-based survey, ranking triggers on their face validity, utility for quality improvement, and fidelity (sensitivity/specificity). Participants were also provided the ability to flag any trigger about which they had questions or they felt merited further discussion at the in-person meeting. Triggers were ranked by combining the first 2 categories (face validity and utility), and information on fidelity was reviewed for decision making at the in-person meeting. Seven redundant triggers were eliminated. At an in-person meeting including representatives from all facilities, we presented the 50 top-ranked triggers as well as those that were flagged on the survey by 2 or more participants. We reviewed each trigger individually, identifying 41 triggers about which there was a clear agreement for inclusion. Of the seven additional triggers that required subsequent voting via e-mail, 5 were adopted, arriving at a total of 46 consensus-derived triggers.CONCLUSIONSOur modified Delphi process resulted in the identification of 46 final triggers for the detection of adverse events among ED patients. These triggers should be pilot field tested to quantify their individual and collective performance in detecting all-cause harm to ED patients.

BACKGROUND:The Affordable Care Act initiated several care coordination programs tailored to reduce emergency department (ED) use for Medicaid-enrolled frequent ED users. It is important to clarify from the patient's perspective why Medicaid enrollees who want to receive care coordination services to improve primary care utilization frequently use the ED.METHODS:We conducted a qualitative data analysis of patient summary reports obtained from Medicaid enrolled frequent ED users who agreed to participate in a randomized control trial (RCT) evaluating the impact of patient navigation intervention compared with standard of care on ED use and hospital admissions. We defined frequent ED users as those who used the ED four to 18 times in the past year. The study was conducted at an urban, teaching hospital ED with approximately 90,000 visits per year. The research staff conducted interviews (~30-40 minutes), regarding the patient's medical history, reasons for ED visits, health care access issues, and social distresses. The aforementioned findings were summarized in a 1- to 2-page report and presented to the RCT's project team (social worker, emergency medicine physician, primary care physician, and patient navigators) on a weekly basis to further understand the needs of this patient population. A diverse team of researchers (program staff and physicians) coded all reports and reached consensus using reflexive team analysis. We reconciled differences in code interpretations and generated themes.RESULTS:One-hundred patients enrolled in the RCT from March 2013 to February 2014, and all 100 patient summary reports were evaluated. We identified three key themes associated with Medicaid enrollee frequent ED use: 1) negative personal experiences with the healthcare system, 2) challenges associated with having low socioeconomic status, and 3) significant chronic mental and physical disease burden.CONCLUSIONS:Medicaid frequent ED users engaged in receiving patient navigation services with the goal to reduce ED use and hospital admissions describe barriers that go beyond timely primary care access issues. These include sociodeterminants of health, lack of trust in primary care providers, and healthcare system.

Introduction: Adult Medicaid enrollees are more likely to have mental health disorders (MHDs) than privately insured patients and also have high rates of emergency department (ED) visits for ambulatory care-sensitive conditions (ACSCs). We aimed to evaluate the association of MHD and insurance type with ED admissions for ACSC in the United States.Methods: We conducted a cross-sectional study of ED visits made by adults aged 18 to 64 years using the corrected 2011 National Emergency Department Survey. Using multivariable logistic regression analysis, we controlled for sociodemographics and clinical variables to determine the association between insurance type, MHD, Medicaid, and MHD (as an interaction variable) and ED admissions for ACSC.Results: There were 131 million ED visits in 2011; after exclusions, 1.4 million admissions were included in our study. Of all ED visits, 44.7% had an MHD, of which 49.9% were covered by Medicaid and 38.1% were covered by private insurance. A total of 32.6% (95% confidence interval, 32.5%-32.7%) of ED admissions were for an ACSC. Medicaid-covered ED visits were more likely to result in ACSC hospital admission (odds ratio, 1.32; 95% confidence interval, 1.30-1.35) compared with visits covered by private insurance. Among patients with MHD, those with Medicaid insurance had 1.6 times the odds of ACSC admission compared with those privately insured.Conclusion: Among all ED admissions, patients covered by Medicaid are more likely to be admitted for an ACSC when compared with those covered by private insurance, with a larger association being present among patients with MHD comorbidities. (C) 2016 Elsevier Inc. All rights reserved.

INTRODUCTION:Accurate field triage of critically injured patients to trauma centers is vital for improving survival. We sought to estimate the national degree of undertriage of trauma patients who die in emergency departments (EDs) by evaluating the frequency and characteristics associated with triage to non-trauma centers.METHODS:This was a retrospective cross-sectional analysis of adult ED trauma deaths in the 2010 National Emergency Department Sample (NEDS). The primary outcome was appropriate triage to a trauma center (Level I, II or III) or undertriage to a non-trauma center. We subsequently focused on urban areas given improved access to trauma centers. We evaluated the associations of patient demographics, hospital region and mechanism of injury with triage to a trauma versus non-trauma center using multivariable logistic regression.RESULTS:We analyzed 3,971 included visits, representing 18,464 adult ED trauma-related deaths nationally. Of all trauma deaths, nearly half (44.5%, 95% CI [43.0-46.0]) of patients were triaged to non-trauma centers. In a subgroup analysis, over a third of urban ED visits (35.6%, 95% CI [34.1-37.1]) and most rural ED visits (86.4%, 95% CI [81.5-90.1]) were triaged to non-trauma centers. In urban EDs, female patients were less likely to be triaged to trauma centers versus non-trauma centers (adjusted odds ratio [OR] 0.83, 95% CI [0.70-0.99]). Highest median household income zip codes (≥$67,000) were less likely to be triaged to trauma centers than lowest median income ($1-40,999) (OR 0.54, 95% CI [0.43-0.69]). Compared to motor vehicle trauma, firearm trauma had similar odds of being triaged to a trauma center (OR 0.90, 95% CI [0.71-1.14]); however, falls were less likely to be triaged to a trauma center (OR 0.50, 95 %CI [0.38-0.66]).CONCLUSION:We found that nearly half of all trauma patients nationally and one-third of urban trauma patients, who died in the ED, were triaged to non-trauma centers, and thus undertriaged. Sex and other demographic disparities associated with this triage decision represent targeted opportunities to improve our trauma systems and reduce undertriage.

Frequent emergency department (ED) users are an important population to target for health services. We evaluated individual, hospital, and community characteristics to determine which factors are associated with hospital variation in frequent ED use. Using databases from the states of California and Florida, we conducted a retrospective cohort analysis of ED visits across a wide range of hospitals. We evaluated hospital level variation of the percent of frequent ED user visits and determined patient, community, and hospital characteristics associated with this hospital-level variation. Hospital characteristics were obtained from the American Hospital Association database, while community characteristics were obtained from the RWJ Healthy Roadmap database. We used hierarchical modeling and variance partition coefficients to determine factors associated with variation in frequent ED use and which of the aforementioned factors (patient, hospital, or community) contributes the most to this variation. In total, there were 12,490,953 ED visits from 333 hospitals. Figure 1 shows the association of frequent ED use by hospital, community and individual visit characteristics. The variance partition coefficient (VPC) estimate for variation at the hospital level was 0.081 (95% CI: 0.061, 0.104) compared to the community level estimate of 0.006 (95% CI: 0.000, 0.033). This suggests that hospital level factors contribute more to the variability in frequent ED visits compared to community level factors where visit level factors contribute far greater compared to both hospital and community level factors. Our findings suggest that programs focused on the individual visit, in addition to the community and hospital, may be the most successful way of addressing the needs of frequent ED users.

BACKGROUND:The rates of annual visits for adult Medicaid enrollees to the emergency department (ED) are increasing. Many programs throughout the country are focused on engaging patients in the use of their primary care providers (PCP) rather than the ED for low acuity conditions. It is unclear, however, the proportion of patients who are willing to use primary care services rather than the ED if they are given the choice.METHODS:Cross-sectional study of adult Medicaid enrollees (18 y and older) presenting to a large, urban, academic ED from June to August 2012 with a low acuity condition was performed. We excluded patients who did not have a PCP or active Medicaid insurance. Our primary goal was to determine the proportion of patients who prefer to use the ED, rather than their PCP clinic, if an appointment was immediately available. Our second goal was to understand why patients would prefer ED over PCP care.RESULTS:A total of 150 patients agreed to complete the survey, and 95 (63.3%) met our inclusion criteria. Forty-three patients (45.3%) stated preferring to use their PCPs rather than the ED if an appointment was available at that time. Thirteen (48.1%) cited that the ED had more technology or specialty care services available when compared with their PCP's clinic, 8 (15.4%) were in significant pain, and 6 (11.5%) felt the care they received in the ED was better than what they would receive in their PCP clinic.CONCLUSIONS:Our study shows that a little less than half of adult Medicaid enrollees presenting to the ED with low acuity conditions would have preferred to use their PCP rather than the ED, if an appointment had been immediately available.