Outcome Disparities and Resource Utilization Among Limited English Proficient Patients After Tonsillectomy

2021 ◽  
pp. 000348942110619
Author(s):  
Michal Plocienniczak ◽  
Batsheva R. Rubin ◽  
Alekha Kolli ◽  
Jessica Levi ◽  
Lauren Tracy
Keyword(s):  
Emergency Department ◽  
Resource Utilization ◽  
Limited English Proficiency ◽  
English Proficiency ◽  
Surgical Care ◽  
Adverse Outcomes ◽  
Utilization Rate ◽  
Increased Risk ◽  
Significant Difference ◽  
The Impact

Objective: There is evidence to suggest adverse outcomes on patients’ medical and surgical care when there is language discordance in patient-physician relationships. No studies have evaluated the impact of limited English proficiency (LEP) on complications after common surgical procedures in otolaryngology. Furthermore, no studies have evaluated how patients with LEP utilize remote resources to connect with otolaryngology providers to better triage such complications. The purpose was to evaluate the incidence of post-tonsillectomy hemorrhage (PTH) comparing patients with LEP to those with English proficiency (EP). Patients with PTH were retrospectively evaluated to identify preceding telephone encounters, a marker of resource utilization. Methods: Demographics, English proficiency, and PTH management (surgical vs non-surgical) were evaluated in addition to PTH-associated triage telephone encounters with otolaryngology providers. Results: Of 2466 tonsillectomies, there were 141 episodes of reported hemorrhage (50 LEP vs 91 EP) in the 5 years studied. Rates were not significantly different between LEP and EP patients (4.9% vs 6.3%, P = .127). There was no statistically significant difference in rate of preceding telephone encounters between LEP and EP patients (24% vs 40%, P = .062). Of patients presenting directly to the Emergency Department without a triage telephone encounter, there was no difference in operative versus non-operative management when comparing LEP versus EP patients. However, patients presenting directly to the Emergency Department were nearly twice as likely to undergo operative intervention compared to patients with preceding telephone encounters (RR = 1.79). Conclusion: Patients with limited English proficiency are not at increased risk for developing PTH. There is equitable access to remote otolaryngologic triage care, although overall the utilization rate of this resource was low for both cohorts.

Abstract MP23: Neighborhood Disadvantage And Oral Anticoagulant Use In Patients With Atrial Fibrillation

Circulation ◽  
2021 ◽  
Vol 143 (Suppl_1) ◽  
Author(s):  
Anne M McDermott ◽  
Nadejda Kim ◽  
Maria Mor ◽  
MICHAEL J FINE ◽  
Utibe Essien
Keyword(s):  
Atrial Fibrillation ◽  
Oral Anticoagulants ◽  
Random Effect ◽  
Adverse Outcomes ◽  
System Level ◽  
Veterans Health ◽  
Health Administration ◽  
Increased Risk ◽  
Significant Difference ◽  
The Impact

Background: Atrial Fibrillation (AF) is the most common heart rhythm disorder in the US and is treated with anticoagulation to mediate patients’ increased risk of ischemic stroke and death. Direct-acting oral anticoagulants (DOACs) are associated with better patient outcomes than warfarin, but prior studies show disparities in DOAC prescription. AF patients with low socioeconomic status (SES) have an increased risk of AF incidence, adverse outcomes, and mortality. Despite SES disparities in AF outcomes and prescribed medications, the impact of neighborhood SES (ADI) on AF management is unclear. We hypothesized that in comparison to patients with high ADI (e.g. the most disadvantaged), those with low ADI will be more likely to initiate any oral anticoagulants (OACs) and will be more likely to initiate DOACs. Methods: We conducted a retrospective observational study using national data from the Veterans Health Administration (VA) of newly diagnosed AF patients. Our independent variable was ADI, a marker of SES incorporating income, education, employment etc. Our model assessed numerous baseline patient, provider, and system-level covariates. We grouped patients into ADI quintiles, with Q1 being the lowest ADI (e.g., the least disadvantaged) and Q5 being the highest ADI, and used Q5 as a reference value. We used mixed effects logistic regression models, with site as a random effect, to determine the adjusted odds of initiating any OACs and of initiating DOACs by ADI quintile. Results: In our final cohort including 111,666 patients, 10,9386 (98.0%) were male and 2280 (2.0%) were female. The overall mean age at diagnosis was 72.86 (SD 10.4). Patients had the following medical comorbidities: Congestive heart failure: 18212, (16.3%); Hypertension: 84944, (76.1%); Diabetes: 70673, (63.3%); Vascular Disease: 46599, (41.7%). The ADI quintiles included the following patients: Q1: 21570, (20.3%); Q2: 21032, (19.8%); Q3: 21439, (20.2%); Q4: 20974, (19.8%); Q5: 21215, (20.0%). There was no significant difference in the odds of initiating any OAC between ADI quintiles compared to Q5 (Q1: adjusted odds ratio [95% CI], 0.95 [ 0.9, 1.01]; p=0.11). Among patients initiating DOAC, there was a significant association between low ADI and higher odds of initiating DOAC (Q1: 1.39 [1.29, 1.50]); (Q2: 1.18 [1.10, 1.27]); (Q3: 1.13 [1.06, 1.20]); (Q4: 1.09 [1.02, 1.16]). Each ADI quintile had a significantly higher odds of initiating DOACs compared to the highest ADI quintile. Conclusions: Patients with lower ADI are significantly more likely to be prescribed DOACs compared to patients with the highest levels of ADI. We found no significant difference in initiation of any OAC between ADI quintiles, which may result from high Warfarin utilization in the VA compared to the general population. Our data suggests that differences in neighborhood deprivation contribute to disparities in the prescribing DOACs in the VA.

scholarly journals LO54: A descriptive analysis of ED length of stay of admitted patients ‘boarded’ in the emergency department

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S46
Author(s):  
L. Salehi ◽  
P. Phalpher ◽  
R. Valani
Keyword(s):  
Emergency Department ◽  
Length Of Stay ◽  
Descriptive Analysis ◽  
High Volume ◽  
Increased Risk ◽  
Significant Difference ◽  
Ed Overcrowding ◽  
Day Of The Week ◽  
The Mean ◽  
The Impact

Introduction: Previous studies have shown a link between Emergency Department (ED) overcrowding and worse clinical outcomes, increased risk of in-hospital mortality, higher costs, and longer times to treatment. Prolonged ED Length of Stay (LoS) of admitted patients awaiting a bed on in-patient units has been identified as a major driver of ED overcrowding. The purpose of this study is to provide a descriptive analysis of ED LoS among admitted patients, and determine the impact of prolonged ED LoS on total hospital in-patient length of stay (IP LoS). Methods: We conducted a single-site retrospective study for the period between January 1-December 31, 2015 at a very high volume community hospital. All patients aged ≥18 years admitted from the ED to acute in-patient Medicine units were identified. We carried out overall descriptive analysis (including analysis of day-of-the-week variability) on ED LoS. The mean total IP LoS for those patients with ED LoS<12 hours, 12-24 hours, and ≥24 hours were calculated and analyzed using ANOVA and Tukey HSD tests. Results: A total of 6,961 individuals were admitted to the medical units over the 12-month period. The median and mean ED LoS for admitted patients were 22.9 hrs (IQR: 13.9 hrs- 33.1 hrs) and 25.6 hrs respectively. Using ANOVA, there was a statistically significant difference in means of ED LoS as a function of the day of the week (p<0.0001), with Mondays having the highest mean ED LoS (27.6 hrs), and Fridays having the lowest (23.1 hrs). The mean IP LoS for those with ED LoS<12 hours, 12-24 hours, and ≥24 hours, were 6.8 days, 6.9 days, and 8.5 days respectively, with a statistically significant difference between group means (p<0.0001). Multiple pairwise comparisons of group means showed a statistically significant (p<0.05) difference between mean IP LOS of those with an EDLOS≥24 hours and those with an EDLOS<24 hours. Conclusion: Preliminary results indicate that ED LoS≥24 hours among admitted patients was associated with an increase in total IP LoS.*In the next 1-2 months, we intend to explore the role of other independent variables (age, sex, comorbidity, isolation status, and telemetry) on total ED LoS, and its association with IP LoS.

scholarly journals The negative effects of COVID-19 and national lockdown on emergency surgery morbidity due to delayed access

2021 ◽  
Vol 16 (1) ◽  
Author(s):  
Francesco A. Ciarleglio ◽  
Marta Rigoni ◽  
Liliana Mereu ◽  
Cai Tommaso ◽  
Alessandro Carrara ◽  
...  
Keyword(s):  
Emergency Department ◽  
Blood Transfusion ◽  
Emergency Surgery ◽  
Surgical Care ◽  
Close Correlation ◽  
Negative Effects ◽  
Group 2 ◽  
Retrospective Comparative Study ◽  
The Impact ◽  
Group 1

Abstract Background The aim of this retrospective comparative study was to assess the impact of COVID-19 and delayed emergency department access on emergency surgery outcomes, by comparing the main clinical outcomes in the period March–May 2019 (group 1) with the same period during the national COVID-19 lockdown in Italy (March–May 2020, group 2). Methods A comparison (groups 1 versus 2) and subgroup analysis were performed between patients’ demographic, medical history, surgical, clinical and management characteristics. Results Two-hundred forty-six patients were included, 137 in group 1 and 109 in group 2 (p = 0.03). No significant differences were observed in the peri-operative characteristics of the two groups. A declared delay in access to hospital and preoperative SARS-CoV-2 infection rates were 15.5% and 5.8%, respectively in group 2. The overall morbidity (OR = 2.22, 95% CI 1.08–4.55, p = 0.03) and 30-day mortality (OR = 1.34, 95% CI 0.33–5.50, =0.68) were significantly higher in group 2. The delayed access cohort showed a close correlation with increased morbidity (OR = 3.19, 95% CI 0.89–11.44, p = 0.07), blood transfusion (OR = 5.13, 95% CI 1.05–25.15, p = 0.04) and 30-day mortality risk (OR = 8.00, 95% CI 1.01–63.23, p = 0.05). SARS-CoV-2-positive patients had higher risk of blood transfusion (20% vs 7.8%, p = 0.37) and ICU admissions (20% vs 2.6%, p = 0.17) and a longer median LOS (9 days vs 4 days, p = 0.11). Conclusions This article provides enhanced understanding of the effects of the COVID-19 pandemic on patient access to emergency surgical care. Our findings suggest that COVID-19 changed the quality of surgical care with poorer prognosis and higher morbidity rates. Delayed emergency department access and a “filter effect” induced by a fear of COVID-19 infection in the population resulted in only the most severe cases reaching the emergency department in time.

Impact of Weight-Band Dosing of Tinzaparin for Venous Thromboembolism Prophylaxis on Persistent Wound Drainage in Adult Patients Undergoing Hip and Knee Arthroplasty

2021 ◽  
pp. 106002802110242
Author(s):  
Cassandra Cooper ◽  
Ouida Antle ◽  
Jennifer Lowerison ◽  
Deonne Dersch-Mills ◽  
Ashley Kenny
Keyword(s):  
Body Weight ◽  
Venous Thromboembolism ◽  
Knee Arthroplasty ◽  
Total Joint Arthroplasty ◽  
Joint Arthroplasty ◽  
Thromboembolism Prophylaxis ◽  
Wound Drainage ◽  
Increased Risk ◽  
Significant Difference ◽  
The Impact

Background: Persistent wound drainage and venous thromboembolism (VTE) are potential complications of total joint arthroplasty, and these risks can be challenging to balance in clinical practice. Anecdotal observation has suggested that following joint arthroplasty, persistent wound drainage occurs more frequently with higher body weight and higher doses of tinzaparin when compared with lower body weight and lower doses of tinzaparin. Objective: The overall purpose of this study was to describe the impact of a tinzaparin weight-band dosing table for VTE prophylaxis on wound healing, thrombosis, and bleeding outcomes in patients undergoing total joint arthroplasty. Methods: This retrospective chart review included patients who underwent total hip or knee arthroplasty and received tinzaparin for thromboprophylaxis per their weight-banding category. The primary outcome was the incidence of persistent wound drainage. Secondary outcomes include the occurrence of VTE and clinically important bleeding during hospital admission. Results: A total of 231 patients were included in the analysis. There was no significant difference in persistent wound drainage between the 3 weight categories, and there were no differences in rates of VTE or clinically important bleeding. Concurrent use of low-dose acetylsalicylic acid was associated with a 3-fold increased risk of persistent wound drainage (risk ratio = 3.35; 95% CI = 2.14-5.24; P = 0.00003). Conclusion and Relevance: In joint arthroplasty patients, we observed no significant difference in rates of persistent wound drainage between various weight categories receiving different weight-banded doses of tinzaparin. Our results do not suggest that the current weight-band dosing table for tinzaparin needs to be adjusted to optimize patient outcomes.

Primary care physician services and the frequency of comorbidities in patients with acute myocardial infarction

2021 ◽  
Vol 28 (Supplement_1) ◽  
Author(s):  
R King ◽  
D Giedrimiene
Keyword(s):  
Myocardial Infarction ◽  
Primary Care ◽  
Acute Myocardial Infarction ◽  
Primary Care Physician ◽  
Care Physician ◽  
Adverse Outcomes ◽  
Coronary Syndrome ◽  
Number Of Patients ◽  
Significant Difference ◽  
The Impact

Abstract Funding Acknowledgements Type of funding sources: None. Background The management of patients with multiple comorbidities represents a significant burden on healthcare each year. Despite requiring regular medical care to treat chronic conditions, a large number of these patients may not receive proper care. Significant disparities have been identified in patients with multiple comorbidities and those who experience acute coronary syndrome or acute myocardial infarction (AMI). Only limited data exists to identify the impact of comorbidities and utilization of primary care physician (PCP) services on the development of adverse outcomes, such as AMI. Purpose The primary objective was to analyze how PCP services utilization can be associated with comorbidities in patients who experienced an AMI. Methods This study was based on retrospective data analysis which included 250 patients admitted to the Hartford Hospital Emergency Department (ED) for an AMI. Out of these, 27 patients were excluded due to missing documentation. Collected data included age, gender, medications and recorded comorbidities, such as hypertension, hyperlipidemia, diabetes mellitus (DM), chronic kidney disease (CKD) and previous arrhythmia. Each patient was assessed regarding utilization of PCP services. Statistical analysis was performed in order to identify differences between patients with documented PCP services and those without by using the Chi-square test. Results The records allowed for identification of documented PCP services for 172 out of 223 (77.1%) patients. The most common comorbidities were hypertension and hyperlipidemia: in 165 (74.0%) and 157 (70.4%) cases respectively. The most frequent comorbidity was hypertension: 137 out of 172 (79.7%) in pts with PCP vs 28 out of 51 (54.9%) without PCP, and significantly more often in patients with PCP, p< 0.001. Hyperlipidemia was the second most frequent comorbidity: in 130 out of 172 (75.6%) vs 27 out of 51 (52.9%) accordingly, and also significantly more often (p< 0.002) in patients with PCP services. The number of comorbidities ranged from 0-5, including 32 (14.3%) patients without comorbidities: 16 (9.3%) with a PCP and 16 (31.4%) without PCP services. The majority of patients - 108 (48.5% of 223), had 2-3 documented comorbidities: 89 (51.8%) had two and 19 (34.6%) had three. The remaining 40 (17.9%) patients had 4-5 comorbidities: 37 (21.5%) of them with a PCP and 3 (10.3%) without, with a significant difference (p < 0.001) found for patients with a higher number of comorbidities who utilized PCP services. Conclusions Our study shows that the majority of patients who presented with an AMI had one or more comorbidities. Furthermore, patients who did not utilize PCP services had fewer identified comorbidities. This suggests that there may be a significant number of patients who experienced AMI with undiagnosed comorbidities due to not having access to PCP services.

scholarly journals The Management of Myelomeningocele Study: Short-Term Neonatal Outcomes

2020 ◽  
Vol 47 (12) ◽  
pp. 865-872 ◽  
Author(s):  
Natalie E. Rintoul ◽  
Roberta L. Keller ◽  
William F. Walsh ◽  
Pamela K. Burrows ◽  
Elizabeth A. Thom ◽  
...  
Keyword(s):  
New England ◽  
Gestational Age ◽  
Periventricular Leukomalacia ◽  
Ductus Arteriosus ◽  
Outcome Data ◽  
Neonatal Outcomes ◽  
Increased Risk ◽  
Significant Difference ◽  
The Impact ◽  
Prenatal Surgery

<b><i>Introduction:</i></b> The Management of Myelomeningocele Study was a multicenter randomized trial to compare prenatal and standard postnatal repair of myelomeningocele (MMC). Neonatal outcome data for 158 of the 183 randomized women were published in <i>The New England Journal of Medicine</i> in 2011. <b><i>Objective:</i></b> Neonatal outcomes for the complete trial cohort (<i>N</i> = 183) are presented outlining the similarities with the original report and describing the impact of gestational age as a mediator. <b><i>Methods:</i></b> Gestational age, neonatal characteristics at delivery, and outcomes including common complications of prematurity were assessed. <b><i>Results:</i></b> Analysis of the complete cohort confirmed the initial findings that prenatal surgery was associated with an increased risk for earlier gestational age at birth. Delivery occurred before 30 weeks of gestation in 11% of neonates that had fetal MMC repair. Adverse pulmonary sequelae were rare in the prenatal surgery group despite an increased rate of oligohydramnios. There was no significant difference in other complications of prematurity including patent ductus arteriosus, sepsis, necrotizing enterocolitis, periventricular leukomalacia, and intraventricular hemorrhage. <b><i>Conclusion:</i></b> The benefits of prenatal surgery outweigh the complications of prematurity.

scholarly journals P070: Mixed effectiveness of emergency department diversion strategies: a systematic review

CJEM ◽  
2017 ◽  
Vol 19 (S1) ◽  
pp. S102
Author(s):  
S.W. Kirkland ◽  
A. Soleimani ◽  
B.H. Rowe ◽  
A.S. Newton
Keyword(s):  
Systematic Review ◽  
Health Care ◽  
Emergency Department ◽  
Health Care Services ◽  
Grey Literature ◽  
Study Data ◽  
Care Utilization ◽  
Alternative Source ◽  
Increased Risk ◽  
The Impact

Introduction: Diverting patients away from the emergency department (ED) has been proposed as a solution for reducing ED overcrowding. The objective of this systematic review is to examine the effectiveness of diversion strategies designed to either direct patients seeking care at an ED to an alternative source of care. Methods: Seven electronic databases and grey literature were searched. Randomized/controlled clinical trials and cohort studies assessing the effectiveness of pre-hospital and ED-based diversion interventions with a comparator were eligible for inclusion. Two reviewers independently screened the studies for relevance, inclusion, and risk of bias. Intervention effects are reported as proportions (%) or relative risks (RR) with 95% confidence intervals (CI). Methodological and clinical heterogeneity prohibited pooling of study data. Results: From 7,306 citations, ten studies were included. Seven studies evaluated a pre-hospital diversion strategy and three studies evaluated an ED-based diversion strategy. The impact of diversion on subsequent health services was mixed. One study of paramedic practitioners reported increased ED attendance within 7 days (11.9% vs. 9.5%; p=0.049) but no differences in return visits for similar conditions (75.2% vs. 72.1%; p=0.64). The use of paramedic practitioners was associated with an increased risk of subsequent contact with health care services (RR=1.21, 95% CI 1.06, 1.38), while the use of deferred care was associated with no increase in risk of subsequently seeking physician care (RR=1.09, 95% CI 0.23, 5.26). While two studies reported that diverted patients were at significantly reduced risk for hospitalization, two other studies reported no significant differences between diverted or standard care patients. Conclusion: The evidence regarding the impact of pre-hospital and ED-based diversion on ED utilization and subsequent health care utilization is mixed. Additional high-quality comparative effectiveness studies of diversion strategies are required prior to widespread implementation.

scholarly journals Sleep Deprivation and Sleep-Onset Insomnia are Associated with Blunted Physiological Reactivity to Stressors

2021 ◽  
Vol 186 (Supplement_1) ◽  
pp. 246-252
Author(s):  
Devon A Hansen ◽  
Brieann C Satterfield ◽  
Matthew E Layton ◽  
Hans P A Van Dongen
Keyword(s):  
Sleep Deprivation ◽  
Laboratory Study ◽  
Salivary Cortisol ◽  
Sleep Onset ◽  
Deprivation Condition ◽  
Increased Risk ◽  
Significant Difference ◽  
Sleep Deficiency ◽  
The Impact ◽  
Chronic Sleep

ABSTRACT Introduction Military operations often involve intense exposure to stressors combined with acute sleep deprivation, while military personnel also experience high prevalence of chronic sleep deficiency from insomnia and other sleep disorders. However, the impact of acute and chronic sleep deficiency on physiologic stressor responses is poorly understood. In a controlled laboratory study with normal sleepers and individuals with chronic sleep-onset insomnia, we measured responses to an acute stressor administered in a sleep deprivation condition or a control condition. Methods Twenty-two adults (aged 22-40 years; 16 females)—11 healthy normal sleepers and 11 individuals with sleep-onset insomnia—completed a 5-day (4-night) in-laboratory study. After an adaptation day and a baseline day, subjects were assigned to a 38-hour total sleep deprivation (TSD) condition or a control condition; the study ended with a recovery day. At 8:00 PM after 36 hours awake in the sleep deprivation condition or 12 hours awake in the control condition, subjects underwent a Maastricht Acute Stress Test (MAST). Salivary cortisol was measured immediately before the MAST at 8:00 PM, every 15 minutes after the MAST from 8:15 PM until 9:15 PM, and 30 minutes later at 9:45 PM. Baseline salivary cortisol was collected in the evening of the baseline day. Additionally, before and immediately upon completion of the MAST, self-report ratings of affect and pain were collected. Results The MAST elicited a stressor response in both normal sleepers and individuals with sleep-onset insomnia, regardless of the condition, as evidenced by increases in negative affect and pain ratings. Relative to baseline, cortisol levels increased immediately following the MAST, peaked 30 minutes later, and then gradually returned to pre-MAST levels. At the cortisol peak, there was a significant difference across groups and conditions, reflecting a pronounced blunting of the cortisol response in the normal sleepers in the TSD condition and the sleep-onset insomnia group in both the TSD and control conditions. Conclusions Blunted stressor reactivity as a result of sleep deficiency, whether acute or chronic, may reflect reduced resiliency attributable to allostatic load and may put warfighters at increased risk in high-stakes, rapid response scenarios.

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