Disparities of Care in Post-Concussive Pediatric Patients

ObjectiveThe objective of this study was to examine the association between insurance status and prevalence of follow up care at a tertiary referral center compared to the emergency department.BackgroundConcussions are extremely common in today's society, affecting patients of all demographic backgrounds. There is concern that public insurance status may affect follow up care at tertiary treatments centers compared to children with private insurance, as evidenced by Copley et al. who documented insurance disparities between children presenting to a sports medicine clinic with orthopedic injuries verses concussion.Design/MethodsWe compared insurance status of patients presenting to our pediatric concussion clinic to the insurance status of patients diagnosed with concussion at the emergency department of our tertiary hospital. From 2018 to 2019, 725 patients received an ICD-10 diagnosis code for concussion in our clinic. Patients were excluded if insurance status was not available for the clinic visit (4), or if they were lost to follow up (380). ICD-10 codes for concussion during the same period were recorded from the COA emergency department (ED). The insurance status was then recorded for each patient.ResultsOf the 345 patients included from the COA concussion clinic, 253 (73%) patients had private insurance while only 92 (27%) had public insurance. In comparison, of the 1,160 patients diagnosed with concussion in the COA ED, 642 (55%) patients had private insurance, 478 (41%) had public insurance, 37 (3.1%) were self-pay, and 3 (0.3%) were listed as “other.”ConclusionsThere is a significant difference in the insurance status of patients with concussion that present to the COA ED when compared to those presenting to concussion clinic. As a result, children with public insurance may have prolonged recovery and more significant symptoms burden compared to children with private insurance.

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Socioeconomic Disparities in Pediatric Single-Sided Deafness

Otolaryngology ◽

10.1177/0194599820923634 ◽

2020 ◽

Vol 163 (4) ◽

pp. 829-834

Author(s):

Noga Lipschitz ◽

Gavriel D. Kohlberg ◽

Michael Scott ◽

Matthew M. Smith ◽

John H. Greinwald

Keyword(s):

Treatment Outcomes ◽

Employment Status ◽

Private Insurance ◽

Socioeconomic Disparities ◽

Insurance Status ◽

Poverty Level ◽

Public Insurance ◽

Device Use ◽

Single Sided Deafness

Objective To explore socioeconomic disparities in pediatric single-sided deafness (SSD) treatment. Study Design Retrospective chart review. Setting Tertiary referral academic center. Methods The charts of 190 pediatric patients with SSD were reviewed for demographic and clinical characteristics. Socioeconomic variables included race and insurance status. ZIP codes were used to obtain additional socioeconomic data from the American Community Survey, including mean and median income, percentage of families below the poverty level, and employment status. Socioeconomic status (SES) was classified by insurance status and income. Treatment outcomes were analyzed by socioeconomic variables. Results There were 105 males and 85 females with a mean follow-up of 55.2 months and a mean age at diagnosis of 4.4 years. Sixty-three percent of children received treatment at last follow-up. Thirty-five percent of children had public insurance and 65% had private insurance. Treatment rates were similar in the private and public insurance groups (60.6% vs 66.7%, P = .42), but device type was different between groups ( P = .02). Consistent device use was associated with private insurance (47.5% vs 38.9%, P = .003) and high SES (94.4% vs 80%, P = .04) on univariate but not on multivariate analysis. Aided audiometry results were similar between SES groups. No association was found between sex, race, income level, poverty level, or employment status and treatment outcomes. Conclusion Insurance type and SES were not associated with SSD treatment outcomes in children, although device use may be higher in children with private insurance and higher SES. Further research should focus on strategies to reduce barriers to treatment and improve adherence.

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1283. Attitudes and Practices Regarding HIV Post-Exposure Prophylaxis

Open Forum Infectious Diseases ◽

10.1093/ofid/ofz360.1146 ◽

2019 ◽

Vol 6 (Supplement_2) ◽

pp. S462-S462

Author(s):

William Sherrerd-Smith ◽

Katie O’Connell ◽

Shanedeep Gill ◽

Alice Kisteneff ◽

Catherine Derber ◽

...

Keyword(s):

Emergency Department ◽

Unprotected Sex ◽

Post Exposure Prophylaxis ◽

Provider Education ◽

Post Exposure ◽

Attitudes And Practices ◽

Significant Difference ◽

Follow Up Care ◽

Exposure Prophylaxis

Abstract Background Research suggests nonoccupational Post Exposure Prophylaxis (nPEP) is underprescribed when indicated in the Emergency Department (ED). This study is an assessment of ED providers’ attitudes and practices regarding administration of HIV nPEP. Methods This was an anonymous survey based on literature review and modified Delphi technique. We approached 153 ED providers at work over a 4-month period from 5 hospital-based and 2 freestanding EDs with an annual census between 35,000 and 75,000 patients. The EDs are a combination of urban, suburban, and rural EDs. There were 152 completed surveys: 80 attendings, 27 residents, and 44 physician assistants. Results The majority of surveyed providers (133/149, 89.3%) believe it is their responsibility as an emergency provider to provide HIV nPEP in the emergency department (Figure 1). Although 91% (138/151) and 87% (132/151) of respondents are willing to prescribe nPEP to a patient in the ED for IV drug use and unprotected sex, respectively, only 40% (61/152) of participants felt they could confidently prescribe the appropriate regimen. Ultimately, only 25% (37/151) of participants prescribed nPEP in the last year. Number of years in practice, age, and gender did not result in a significant difference in nPEP administration. Respondents noted time (27%), access to follow-up care (26%), cost to patients (23%), patients’ perceived interest in HIV counseling (15%), and concern for ongoing risky behaviors (9%) as barriers to prescribing nPEP (Figure 2). 64% (95/149) of respondents feel that it is their responsibility as an ED provider to refer patients at risk of nonoccupational exposures for risk-reduction counseling. Conclusion This study identified an opportunity for HIV prevention in the emergency department. The majority of participants had not prescribed nPEP in the past 12 months. Although most were willing to prescribe nPEP and felt it was their responsibility, the majority of participants were not confident in prescribing it. Future interventions to increase the use of nPEP in the ED should target provider education, cost, access to follow-up care and counseling. Disclosures All authors: No reported disclosures.

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The Association between Health Insurance and All-Cause, Cardiovascular Disease, Cancer and Cause-Specific Mortality: A Prospective Cohort Study

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph17051525 ◽

2020 ◽

Vol 17 (5) ◽

pp. 1525 ◽

Cited By ~ 1

Author(s):

Liying Song ◽

Yan Wang ◽

Baodong Chen ◽

Tan Yang ◽

Weiliang Zhang ◽

...

Keyword(s):

Mortality Risk ◽

Private Insurance ◽

Cox Proportional Hazards ◽

Current Evidence ◽

Insurance Status ◽

Public Insurance ◽

Risk Of Mortality ◽

Increased Risk ◽

Specific Mortality

The purpose of this study was to evaluate the association of insurance status with all-cause and cause-specific mortality. A total of 390,881 participants, aged 18–64 years and interviewed from 1997 to 2013 were eligible for a mortality follow-up in 31 December 2015. Cox proportional hazards models were used to calculate the hazards ratios (HR) and 95% confidence intervals (CI) to determine the association between insurance status and all-cause and cause-specific mortality. The sample group cumulatively aged 4.22 million years before their follow-ups, with a mean follow-up of 10.4 years, and a total of 22,852 all-cause deaths. In fully adjusted models, private insurance was significantly associated with a 17% decreased risk of mortality (HR = 0.83; 95% CI = 0.80–0.87), but public insurance was associated with a 21% increased risk of mortality (HR = 1.21; 95% CI = 1.15–1.27). Compared to noninsurance, private coverage was associated with about 21% lower CVD mortality risk (HR = 0.79, 95% CI = 0.70–0.89). In addition, public insurance was associated with increased mortality risk of kidney disease, diabetes and CLRD, compared with noninsurance, respectively. This study supports the current evidence for the relationship between private insurance and decreased mortality risk. In addition, our results show that public insurance is associated with an increased risk of mortality.

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High incidence of patients lost to follow-up after venous thromboembolism diagnosis – Identifying an unmet need for targeted transition of care

Vascular ◽

10.1177/17085381211020969 ◽

2021 ◽

pp. 170853812110209

Author(s):

Rae S Rokosh ◽

Jack H Grazi ◽

David Ruohoniemi ◽

Eugene Yuriditsky ◽

James Horowitz ◽

...

Keyword(s):

Emergency Department ◽

Pulmonary Embolism ◽

Venous Thromboembolism ◽

Venous Thrombosis ◽

Deep Venous Thrombosis ◽

Time Of Day ◽

Transition Of Care ◽

Initial Discharge ◽

Significant Difference

Objectives Venous thromboembolism, including deep venous thrombosis and pulmonary embolism, is a major source of morbidity, mortality, and healthcare utilization. Given the prevalence of venous thromboembolism and its associated mortality, our study sought to identify factors associated with loss to follow-up in venous thromboembolism patients. Methods This is a single-center retrospective study of all consecutive admitted (inpatient) and emergency department patients diagnosed with acute venous thromboembolism via venous duplex examination and/or chest computed tomography from January 2018 to March 2019. Patients with chronic deep venous thrombosis and those diagnosed in the outpatient setting were excluded. Lost to venous thromboembolism-specific follow-up (LTFU) was defined as patients who did not follow up with vascular, cardiology, hematology, oncology, pulmonology, or primary care clinic for venous thromboembolism management at our institution within three months of initial discharge. Patients discharged to hospice or dead within 30 days of initial discharge were excluded from LTFU analysis. Statistical analysis was performed using STATA 16 (College Station, TX: StataCorp LLC) with a p-value of <0.05 set for significance. Results During the study period, 291 isolated deep venous thrombosis, 25 isolated pulmonary embolism, and 54 pulmonary embolism with associated deep venous thrombosis were identified in 370 patients. Of these patients, 129 (35%) were diagnosed in the emergency department and 241 (65%) in the inpatient setting. At discharge, 289 (78%) were on anticoagulation, 66 (18%) were not, and 15 (4%) were deceased. At the conclusion of the study, 120 patients (38%) had been LTFU, 85% of whom were discharged on anticoagulation. There was no statistically significant difference between those LTFU and those with follow-up with respect to age, gender, diagnosis time of day, venous thromboembolism anatomic location, discharge unit location, or anticoagulation choice at discharge. There was a non-significant trend toward longer inpatient length of stay among patients LTFU (16.2 days vs. 12.3 days, p = 0.07), and a significant increase in the proportion of LTFU patients discharged to a facility rather than home ( p = 0.02). On multivariate analysis, we found a 95% increase in the odds of being lost to venous thromboembolism-specific follow-up if discharged to a facility (OR 1.95, CI 1.1–3.6, p = 0.03) as opposed to home. Conclusions Our study demonstrates that over one-third of patients diagnosed with venous thromboembolism at our institution are lost to venous thromboembolism-specific follow-up, particularly those discharged to a facility. Our work suggests that significant improvement could be achieved by establishing a pathway for the targeted transition of care to a venous thromboembolism-specific follow-up clinic.

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Abstract P076: Increased Burden Of Chronic Illness Among Insured Compared To Uninsured Sudden Death Victims

Circulation ◽

10.1161/circ.143.suppl_1.p076 ◽

2021 ◽

Vol 143 (Suppl_1) ◽

Author(s):

Reaves Houston ◽

Susan Keen ◽

Chelsea Deitelzweig ◽

Hannah Jones ◽

Sarah Laible ◽

...

Keyword(s):

Health Insurance ◽

Chronic Illness ◽

Sudden Death ◽

Private Insurance ◽

Chronic Illnesses ◽

Categorical Variables ◽

Insurance Status ◽

Public Insurance ◽

Status Data ◽

Lower Frequencies

Introduction: Lack of health insurance is associated with reduced access to medical care and increased mortality. Chronic illness is associated with sudden death, a major cause of natural death. Insurance status of sudden death victims has not been characterized. Hypothesis: Uninsured compared to insured sudden death victims will have more chronic illnesses. Methods: From 2013-2015, emergency medical services-attended out of hospital deaths among ages 18-64 in Wake County, NC were screened to adjudicate sudden deaths. Medical records were reviewed for demographic, clinical, and health insurance status data. Insurance status was characterized as private, public, or no insurance. Cases were excluded from the analysis if no information on insurance was available. Comparisons of demographic and clinical characteristics were made between the three insurance status groups using Student’s t-test and ANOVA for continuous and categorical variables, respectively. Results: Of 399 cases of sudden death, insurance status data was available for 130: 25 (19.2%) had no insurance, 62 (47.7%) had public insurance, 31 (23.8%) had private insurance, and 12 (9.2%) had insurance of unknown type. Uninsured victims had lower frequencies of hypertension, hyperlipidemia, and chronic respiratory disease than those with private or public insurance, and lower frequencies of diabetes mellitus, mental illness, and substance abuse than those publicly insured (Table 1). No significant differences were found in coronary artery disease, age, gender, race, marital status, or years of education. Conclusion: Uninsured sudden death victims have less chronic illnesses than those insured. This counterintuitive finding suggests that uninsured sudden death victims have undiagnosed chronic illnesses that are treatable and preventable and contribute to their death. Our results suggest that expanding health insurance among working age adults may reduce the incidence of sudden death.

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Low-Income Senior Housing Residents’ Emergency Department Use and Care Transition Problems

Journal of Pharmacy Practice ◽

10.1177/0897190017734763 ◽

2017 ◽

Vol 31 (6) ◽

pp. 610-616 ◽

Cited By ~ 2

Author(s):

Antoinette B. Coe ◽

Leticia R. Moczygemba ◽

Kelechi C. Ogbonna ◽

Pamela L. Parsons ◽

Patricia W. Slattum ◽

...

Keyword(s):

Emergency Department ◽

Low Income ◽

Personal Health Record ◽

Primary Care Providers ◽

Adverse Outcomes ◽

Transitions Of Care ◽

Care Providers ◽

Senior Housing ◽

Follow Up Care

Older adults may be at risk of adverse outcomes after emergency department (ED) visits due to ineffective transitions of care. Semi-structured interviews were employed to identify and categorize reasons for ED use and problems that occur during transition from the ED back to home among 14 residents of low-income senior housing. Qualitative thematic and descriptive analyses were used. Ambulance use, timely ED use or a wait-and-see approach, and lack of health-care provider contact before ED visit were emergent themes. Delayed medication receipt, no current medication list, and medication knowledge gaps were identified. Lack of a personal health record, follow-up care instruction, and worsening symptoms education emerged as transition problems from ED to home. After an ED visit, education opportunities exist around seeing primary care providers for nonurgent conditions, follow-up care, medications, and worsening condition symptoms. Timely receipt of discharge medications and medication education may improve medication-related transition problems.

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Implementing a Diversion Clinic To Treat Lower-Acuity Emergency Department Patients and Provide Follow-Up Care

Annals of Emergency Medicine ◽

10.1016/j.annemergmed.2013.07.107 ◽

2013 ◽

Vol 62 (4) ◽

pp. S102-S103

Author(s):

J.M. Lansburg ◽

P. Roque ◽

P. Debartolo ◽

N. Anand

Keyword(s):

Emergency Department ◽

Follow Up Care ◽

Emergency Department Patients

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The economic impact of ventriculoperitoneal shunt failure

Journal of Neurosurgery Pediatrics ◽

10.3171/2011.9.peds11192 ◽

2011 ◽

Vol 8 (6) ◽

pp. 593-599 ◽

Cited By ~ 29

Author(s):

Chevis N. Shannon ◽

Tamara D. Simon ◽

Gavin T. Reed ◽

Frank A. Franklin ◽

Russell S. Kirby ◽

...

Keyword(s):

Demographic Data ◽

Private Insurance ◽

Third Party ◽

Shunt Failure ◽

Public Insurance ◽

Shunt Placement ◽

Significant Difference ◽

Out Of Pocket Expenses ◽

The Cost ◽

Median Rate

Object Detailed costs to individuals with hydrocephalus and their families as well as to third-party payers have not been previously described. The purpose of this study was to determine the primary caregiver out-of-pocket expenses and the third-party payer reimbursement rate associated with a shunt failure episode. Methods A retrospective study of children born between 2000 and 2005 who underwent initial ventriculoperitoneal (VP) shunt placement and who subsequently experienced a shunt failure requiring surgical intervention within 2 years of their initial shunt placement was conducted. Institutional reimbursement and demographic data from Children's Hospital of Alabama (CHA) were augmented with a caregiver survey of any out-of pocket expenses encountered during the shunt failure episode. Institutional reimbursements and caregiver out-of-pocket expenses were then combined to provide the cost for a shunt failure episode at CHA. Results For shunt failures, the median reimbursement total was $5008 (interquartile range [IQR] $2068–$17,984), the median caregiver out-of-pocket expenses was $419 (IQR $251–$1112), and the median total cost was $5411 (IQR $2428–$18,582). Private insurance reimbursed at a median rate of $5074 (IQR $2170–$14,852) compared with public insurance, which reimbursed at a median rate of $4800 (IQR $1876–$19,395). Caregivers with private insurance reported a median $963 (IQR $322–$1741) for out-of-pocket expenses, whereas caregivers with public insurance reported a median $391 (IQR $241–$554) for out-of-pocket expenses (p = 0.017). Conclusions This study confirmed that private insurance reimbursed at a higher rate, and that although patients had a shorter length of stay as compared with those with public insurance, their out-of-pocket expenses associated with a shunt failure episode were greater. However, it could not be determined if the significant difference in out-of-pocket expenses between those with private and those with public insurance was due directly to the cost of shunt failure. This model does not take into consideration community resources and services available to those with public insurance. These resources and services could offset the out-of-pocket burden, and therefore should be considered in future cost models.

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Medicaid Payer Status Is a Predictor of Early Postoperative Pain Following Upper Extremity Procedures

Hand ◽

10.1177/1558944720912565 ◽

2020 ◽

pp. 155894472091256

Author(s):

Michael T. Scott ◽

Allison L. Boden ◽

Stephanie A. Boden ◽

Lauren M. Boden ◽

Kevin X. Farley ◽

...

Keyword(s):

Postoperative Pain ◽

Upper Extremity ◽

Private Insurance ◽

Insurance Status ◽

Preoperative Pain ◽

Pain Scores ◽

Patient Reported ◽

Before And After ◽

Subjective Pain

Background: The purpose of this study was to investigate the relationship between insurance status and patient-reported pain both before and after upper extremity surgical procedures. We hypothesized that patients with Medicaid payer status would report higher levels of pre- and postoperative pain and report less postoperative pain relief. Methods: In all, 376 patients who underwent upper extremity procedures by a single surgeon at an academic ambulatory surgery center were identified. Patient information, including insurance status and Visual Analog Scale pain score (VAS-pain) at baseline, 2 weeks, and 1, 3, and 6 months, were collected. VAS-pain scores were compared with t-tests and linear regression. Results: Preoperatively and at 2-week, 1-month, and 3-month follow-up, Medicaid patients reported statistically significant higher pain levels than patients with Private insurance, finding a mean adjusted increase of 0.51 preoperatively, 0.39 at 1 month, and 0.79 at 3 months. Preoperatively and at 3-month follow-up, Medicaid patients reported statistically significant higher pain than patients with Medicare, finding increases in VAS-pain of 0.99 preoperatively and 0.94 at 3 months. There was no difference in pain improvement between any insurance types at any time point (all P values > .05). Conclusions: Patients with Medicaid report higher levels of preoperative pain and early postoperative pain, but reported the same improvement in pain as patients with other types of insurance. As healthcare systems are becoming increasingly dependent on patient-reported outcomes, including pain, it is important to consider that differences may exist in subjective pain depending on insurance status.

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