scholarly journals Older Patients’ Perspectives on Factors Contributing to Frequent Visits to the Emergency Department: A Qualitative Interview Study

2020 ◽  
Author(s):  
Daisy Kolk ◽  
Anton F. Kruiswijk ◽  
Janet L. MacNeil-Vroomen ◽  
Milan L. Ridderikhof ◽  
Bianca M. Buurman
Keyword(s):  
Emergency Department ◽  
Acute Care ◽  
Older Patients ◽  
Structured Interviews ◽  
Post Discharge ◽  
Qualitative Interview Study ◽  
Before And After ◽  
Ed Visits ◽  
The Relationship

Abstract Background: Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to collect older patients’ perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits.Methods: We performed semi-structured interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling to achieve maximum variation in heterogeneity. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached.Results: In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients’ untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit.Conclusions: This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.

scholarly journals Older patients’ perspectives on factors contributing to frequent visits to the emergency department: a qualitative interview study

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Daisy Kolk ◽  
Anton F. Kruiswijk ◽  
Janet L. MacNeil-Vroomen ◽  
Milan L. Ridderikhof ◽  
Bianca M. Buurman
Keyword(s):  
Emergency Department ◽  
Acute Care ◽  
Older Patients ◽  
Qualitative Description ◽  
Post Discharge ◽  
Individual Interviews ◽  
Qualitative Interview Study ◽  
Before And After ◽  
Ed Visits

Abstract Background Older patients are at high risk of unplanned revisits to the emergency department (ED) because of their medical complexity. To reduce the number of ED visits, we need more knowledge about the patient-level, environmental, and healthcare factors involved. The aim of this study was to describe older patients’ perspectives and experiences before and after an ED visit, and to identify factors that possibly contribute to frequent ED revisits. Methods This was a qualitative description study. We performed semi-structured individual interviews with older patients who frequently visited the ED and were discharged home after an acute visit. Patients were enrolled in the ED of a university medical centre using purposive sampling. Interviews were recorded, transcribed, and coded independently by two researchers. Theoretical analysis was used to identify recurring patterns and themes in the data. Interviews were conducted until thematic saturation was reached. Results In-depth interviews were completed with 13 older patients. Three main themes emerged: 1) medical events leading to feelings of crisis, 2) patients’ untreated health problems, and 3) persistent problems in health and daily functioning post discharge. Participants identified problems before and after their ED visit that possibly contributed to further ED visits. These problems included increasing symptoms leading to feelings of crisis, the relationship with the general practitioner, incomplete discharge information at the ED, and inadequate follow-up and lack of recovery after an ED visit. Conclusions This qualitative study identified multiple factors that may contribute to frequent ED visits among older patients. Older patients in need of acute care might benefit from hospital-at-home interventions, or acute care provided by geriatric emergency teams in the primary care setting. Identifying frailty in the ED is needed to improve discharge communication and adequate follow-up is needed to improve recovery after an acute ED visit.

scholarly journals Geriatric screening, fall characteristics and 3- and 12 months adverse outcomes in older patients visiting the emergency department with a fall

2021 ◽  
Vol 29 (1) ◽  
Author(s):  
Laura C. Blomaard ◽  
Simon P. Mooijaart ◽  
Leonie J. van Meer ◽  
Julia Leander ◽  
Jacinta A. Lucke ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Older Patients ◽  
Clinical Care ◽  
Adverse Outcomes ◽  
Increased Risk ◽  
Geriatric Screening ◽  
Ed Visits ◽  
Screening Result

Abstract Background Falls in older Emergency Department (ED) patients may indicate underlying frailty. Geriatric follow-up might help improve outcomes in addition to managing the direct cause and consequence of the fall. We aimed to study whether fall characteristics and the result of geriatric screening in the ED are independently related to adverse outcomes in older patients with fall-related ED visits. Methods This was a secondary analysis of the observational multicenter Acutely Presenting Older Patient (APOP) study, of which a subset of patients aged ≥70 years with fall-related ED visits were prospectively included in EDs of two Dutch hospitals. Fall characteristics (cause and location) were retrospectively collected. The APOP-screener was used as a geriatric screening tool. The outcome was 3- and 12-months functional decline and mortality. We assessed to what extent fall characteristics and the geriatric screening result were independent predictors of the outcome, using multivariable logistic regression analysis. Results We included 393 patients (median age 80 (IQR 76–86) years) of whom 23.0% were high risk according to screening. The cause of the fall was extrinsic (49.6%), intrinsic (29.3%), unexplained (6.4%) or missing (14.8%). A high risk geriatric screening result was related to increased risk of adverse outcomes (3-months adjusted odds ratio (AOR) 2.27 (1.29–3.98), 12-months AOR 2.20 (1.25–3.89)). Independent of geriatric screening result, an intrinsic cause of the fall increased the risk of 3-months adverse outcomes (AOR 1.92 (1.13–3.26)) and a fall indoors increased the risk of 3-months (AOR 2.14 (1.22–3.74)) and 12-months adverse outcomes (AOR 1.78 (1.03–3.10)). Conclusions A high risk geriatric screening result and fall characteristics were both independently associated with adverse outcomes in older ED patients, suggesting that information on both should be evaluated to guide follow-up geriatric assessment and interventions in clinical care.

scholarly journals Implementation of the acutely presenting older patient (APOP) screening program in routine emergency department care

2021 ◽  
Author(s):  
Laura C. Blomaard ◽  
Bas de Groot ◽  
Jacinta A. Lucke ◽  
Jelle de Gelder ◽  
Anja M. Booijen ◽  
...  
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
Older Patients ◽  
Screening Program ◽  
Admission Rate ◽  
Older Patient ◽  
Hospital Admission Rate ◽  
High Risk Patients ◽  
Risk Patients

Abstract Objective The aim of this study was to evaluate the effects of implementation of the acutely presenting older patient (APOP) screening program for older patients in routine emergency department (ED) care shortly after implementation. Methods We conducted an implementation study with before-after design, using the plan-do-study-act (PDSA) model for quality improvement, in the ED of a Dutch academic hospital. All consecutive patients ≥ 70 years during 2 months before and after implementation were included. The APOP program comprises screening for risk of functional decline, mortality and cognitive impairment, targeted interventions for high-risk patients and education of professionals. Outcome measures were compliance with interventions and impact on ED process, length of stay (LOS) and hospital admission rate. Results Two comparable groups of patients (median age 77 years) were included before (n = 920) and after (n = 953) implementation. After implementation 560 (59%) patients were screened of which 190 (34%) were high-risk patients. Some of the program interventions for high-risk patients in the ED were adhered to, some were not. More hospitalized patients received comprehensive geriatric assessment (CGA) after implementation (21% before vs. 31% after; p = 0.002). In 89% of high-risk patients who were discharged to home, telephone follow-up was initiated. Implementation did not influence median ED LOS (202 min before vs. 196 min after; p = 0.152) or hospital admission rate (40% before vs. 39% after; p = 0.410). Conclusion Implementation of the APOP screening program in routine ED care did not negatively impact the ED process and resulted in an increase of CGA and telephone follow-up in older patients. Future studies should investigate whether sustainable changes in management and patient outcomes occur after more PDSA cycles.

scholarly journals Factors Associated with Family Physician Follow-up 30 Days Post-discharge from a Local Canadian Community Emergency Department

Cureus ◽  
2020 ◽  
Author(s):  
Kelly Lien ◽  
Barrett A Grattan ◽  
Alexandra L Reynard ◽  
Jocelynn Peters ◽  
Jennifer L Parr
Keyword(s):  
Emergency Department ◽  
Family Physician ◽  
Post Discharge ◽  
Factors Associated

scholarly journals Comparison of Real-world Outcomes Between Patients Treated with Tapentadol ER or Oxycodone CR

10.36469/9905 ◽  
2015 ◽  
Vol 2 (2) ◽  
pp. 221-232
Author(s):  
Mike Durkin ◽  
Jacqueline Pesa ◽  
Jessica Lopatto ◽  
Rachel Halpern ◽  
Damon Van Voorhis ◽  
...  
Keyword(s):  
Emergency Department ◽  
Emergency Department Visit ◽  
Healthcare Costs ◽  
Index Date ◽  
Opioid Therapy ◽  
Care Utilization ◽  
Research Database ◽  
Before And After ◽  
Pain Patients

Background: The objective of this study was to compare health care utilization and costs between matched cohorts of chronic pain patients treated with the opioids tapentadol extended release (ER) or oxycodone controlled release (CR). Methods: This retrospective study used claims data from the Optum Research Database. Commercial and Medicare Advantage adult patients with ≥1 prescription fill for oxycodone CR or tapentadol ER between September 1, 2011 and September 30, 2012 were eligible. The date of the first observed oxycodone CR or tapentadol ER claim was the index date. Patients had continuous health plan enrollment for 6 months before and after the index date, ≥ 90 days supply of opioid therapy, and no index drug claims in the preindex period. Patients were propensity score matched in a 1:2 ratio (tapentadol ER : oxycodone CR). Results: The attributes of the matched cohorts (1,120 tapentadol ER and 2,240 oxycodone CR patients) appeared similar. In the 6 month post-index period, lower proportions of the tapentadol ER cohort than the oxycodone CR cohort had ≥1 inpatient stay (14.6% versus 20.5%; p<0.001) and ≥1 emergency department visit (33.4% versus 37.5%; p=0.021). The tapentadol ER compared with the oxycodone CR cohort had higher mean pharmacy costs ($4,263 versus $3,694; p <0.001), lower mean inpatient costs ($3,625 versus $6,309; p<0.001), and lower mean total healthcare costs ($16,510 versus $19,330; p=0.004). Conclusions: During follow-up, total mean healthcare costs were lower among tapentadol ER patients than oxycodone CR patients, and tapentadol ER patients were less likely to have an inpatient admission or emergency department visit.

Identification of patients at high risk for preventable emergency department visits and inpatient admissions after starting chemotherapy: Machine learning applied to comprehensive electronic health record data.

2021 ◽  
Vol 39 (15_suppl) ◽  
pp. 1511-1511
Author(s):  
Dylan J. Peterson ◽  
Nicolai P. Ostberg ◽  
Douglas W. Blayney ◽  
James D. Brooks ◽  
Tina Hernandez-Boussard
Keyword(s):  
Machine Learning ◽  
Emergency Department ◽  
Electronic Health Record ◽  
Acute Care ◽  
Cancer Care ◽  
Model Performance ◽  
Emergency Department Visits ◽  
Health Record ◽  
Patients At Risk ◽  
Ed Visits

1511 Background: Acute care use is one of the largest drivers of cancer care costs. OP-35: Admissions and Emergency Department Visits for Patients Receiving Outpatient Chemotherapy is a CMS quality measure that will affect reimbursement based on unplanned inpatient admissions (IP) and emergency department (ED) visits. Targeted measures can reduce preventable acute care use but identifying which patients might benefit remains challenging. Prior predictive models have made use of a limited subset of the data available in the Electronic Health Record (EHR). We hypothesized dense, structured EHR data could be used to train machine learning algorithms to predict risk of preventable ED and IP visits. Methods: Patients treated at Stanford Health Care and affiliated community care sites between 2013 and 2015 who met inclusion criteria for OP-35 were selected from our EHR. Preventable ED or IP visits were identified using OP-35 criteria. Demographic, diagnosis, procedure, medication, laboratory, vital sign, and healthcare utilization data generated prior to chemotherapy treatment were obtained. A random split of 80% of the cohort was used to train a logistic regression with least absolute shrinkage and selection operator regularization (LASSO) model to predict risk for acute care events within the first 180 days of chemotherapy. The remaining 20% were used to measure model performance by the Area Under the Receiver Operator Curve (AUROC). Results: 8,439 patients were included, of whom 35% had one or more preventable event within 180 days of starting chemotherapy. Our LASSO model classified patients at risk for preventable ED or IP visits with an AUROC of 0.783 (95% CI: 0.761-0.806). Model performance was better for identifying risk for IP visits than ED visits. LASSO selected 125 of 760 possible features to use when classifying patients. These included prior acute care visits, cancer stage, race, laboratory values, and a diagnosis of depression. Key features for the model are shown in the table. Conclusions: Machine learning models trained on a large number of routinely collected clinical variables can identify patients at risk for acute care events with promising accuracy. These models have the potential to improve cancer care outcomes, patient experience, and costs by allowing for targeted preventative interventions. Future work will include prospective and external validation in other healthcare systems.[Table: see text]

Does improved radiographic alignment truly enhance dynamic functional balance?

2021 ◽  
Author(s):  
R Haddas ◽  
S Kisinde ◽  
D Mar ◽  
I Lieberman
Keyword(s):  
Patient Reported Outcomes ◽  
Added Value ◽  
Functional Balance ◽  
Radiographic Measurements ◽  
Patient Reported ◽  
Before And After ◽  
Gait Abnormalities ◽  
The Relationship ◽  
Radiographic Alignment

Prospective, concurrent-cohort study. To establish the relationship between radiographic alignment parameters and functional CoE measurements at one week before and at three months after realignment surgery in ADS patients. Adult degenerative scoliosis (ADS) represents a significant healthcare burden with exceedingly high and increasing prevalence, particularly among the elderly. Radiographic alignment measures and patient-reported outcomes currently serve as the standard means to assess spinal alignment, deformity, and stability. Neurological examinations have served as qualitative measures for indicating muscle strength, motor deficits, and gait abnormalities. Three-Dimensional motion analysis is increasingly being used to identify and measure gait and balance instability. Recently, techniques have been established to quantify balance characteristics described by Dubousset as the “cone of economy” (CoE). The relationship between radiographic alignment parameters and CoE balance measures of ADS patients before and after realignment surgery is currently unknown. 29 ADS patients treated with realignment surgery. Patients were evaluated at one week before realignment surgery and at their three-month follow-up examination. During each evaluation, patients completed self-reported outcomes (visual analog scales for pain, Oswestry Disability Index, SRS22r) and a functional balance test. Mean changes in dependent measures from before to after surgery were compared using paired t-tests. Pearson correlations were used to test for significant correlations between changes in radiographic and CoE measures. Significant improvements were found for all patient-reported outcomes, in several radiographic measures, and in CoE measures. Improvements of scoliosis Cobb angle, coronal pelvic tilt, lumbar lordosis, and thoracic kyphosis showed significant correlations with CoE sway and total distance measures at both the center of mass and center of the head. Improved radiographic alignment measures significantly correlated with improved CoE balance measures among ADS patients treated with realignment surgery at their three-month follow-up. These findings indicate that functional balance evaluations when used in conjunction with radiographic measurements, may provide a more robust and improved patient-specific sensitivity for postoperative assessments. CoE balance may represent a new measure of added value for surgical intervention of ADS.

The Affordable Care Act and emergency department use by low acuity patients in a US hospital

2020 ◽  
pp. 095148482094359
Author(s):  
Daniel Keyes ◽  
Hisham Valiuddin ◽  
Hassan Mouzaihem ◽  
Patrick Stone ◽  
Jaqueline Vidosh
Keyword(s):  
Emergency Department ◽  
Affordable Care Act ◽  
Cohort Analysis ◽  
Severity Index ◽  
Chi Square ◽  
Before And After ◽  
Primary Care Patients ◽  
Ed Visits ◽  
The Affordable Care Act ◽  
Status Data

Background The Affordable Care Act (ACA) is one of the biggest healthcare reforms in US history. A key issue is the ACAs effect on low acuity, potentially primary care patients. This study evaluates the effect of the ACA on low acuity patients seen in the emergency department (ED). Methods This is an age-period-cohort analysis for a community hospital ED in Michigan, from 2009 to 2015. Patients were stratified by age, year seen, emergency severity index (ESI) and insurance status. Data were compared between before and after ACA along with descriptive statistics, Chi-square and Student t-tests. The primary outcome was the change in ED usage by low acuity. Patients > 65 were used as a temporal control. Results 305,350 ED visits were analyzed. ED visits with ESI 4/5 increased from 11.9% to 14.8%. Patients < 19 years increased from 25.5% to 34.3% (p = .0026). Ages 19–25 increased from 16.3% to 19.7% (p = 0.0515). Ages 26–64 increased from 11% to 14.9% (p = 0.0129). Ages > 65 increased from 5.1% to 6.5%. Patients < 65 showed a decreased uninsured rate from 12.30% to 6.28% (p < 0.0001). Comparatively, for age > 65: uninsured rate remained the same 0.46% to 0.49%. Conclusion Low acuity ED visits increased with the ACA reform in conjunction with a more insured population.

Results after Laparoscopic Fundoplication: Does Age Matter?

2006 ◽  
Vol 72 (9) ◽  
pp. 778-784 ◽  
Author(s):  
Sarah M. Cowgill ◽  
Dean Arnaoutakis ◽  
Desiree Villadolid ◽  
Sam Al-Saadi ◽  
Demetri Arnaoutakis ◽  
...  
Keyword(s):  
Myocardial Infarction ◽  
High Risk ◽  
Older Patients ◽  
Laparoscopic Fundoplication ◽  
Nissen Fundoplication ◽  
Younger Patients ◽  
Before And After ◽  
Laparoscopic Nissen ◽  
Age Range

Antireflux fundoplications are undertaken with hesitation in older patients because of presumed higher morbidity and poorer outcomes. This study was undertaken to determine if symptoms of gastroesophageal reflux disease (GERD) could be safely abrogated in a high-risk/reward population of older patients. One hundred eight patients more than 70 years of age (range, 70–90 years) underwent laparoscopic Nissen fundoplications undertaken between 1992 and 2005 and were compared with 108 concurrent patients less than 60 years of age (range, 18–59 years) to determine relative outcomes. Before and after fundoplication, patients scored the severity of reflux and dysphagia on a Likert Scale (0 = minor, 10 = severe). Before fundoplication, older patients had lower reflux scores ( P < 0.01), but not lower dysphagia scores or DeMeester scores. One patient (86 years old) died from myocardial infarction; otherwise, complications occurred infrequently, inconsequentially, and regardless of age. At similar durations of follow-up, reflux and dysphagia scores significantly improved ( P < 0.01) for older and younger patients. After fundoplication, older patients had lower dysphagia scores ( P < 0.01) and lower reflux scores ( P < 0.01). At the most recent follow-up, 82 per cent of older patients rated their relief of symptoms as good or excellent. Similarly, 81 per cent of the younger patients reported good or excellent results. Ninety-one per cent of patients 70 years of age or more versus 85 per cent of patients less than 60 years would undergo laparoscopic Nissen fundoplication again, if necessary. With fundoplication, symptoms of GERD improve for older and younger patients, with less symptomatic dysphagia and reflux in older patients after fundoplication. Laparoscopic fundoplication safely ameliorates symptoms of GERD in elderly patients with symptomatic outcomes superior to those seen in younger patients.

scholarly journals Can Chemotherapy-Related Acute Care Visits Be Accurately Identified in Administrative Data?

2018 ◽  
Vol 14 (1) ◽  
pp. e51-e58 ◽  
Author(s):  
Monika K. Krzyzanowska ◽  
Katherine Enright ◽  
Rahim Moineddin ◽  
Lingsong Yun ◽  
Melanie Powis ◽  
...  
Keyword(s):  
Breast Cancer ◽  
Emergency Department ◽  
Adjuvant Chemotherapy ◽  
Acute Care ◽  
Administrative Data ◽  
Validation Cohort ◽  
Early Stage ◽  
Early Stage Breast Cancer ◽  
Algorithm Validation ◽  
Ed Visits

Purpose: There is increasing interest in using administrative data to examine treatment-related complications that lead to emergency department (ED) visits or hospitalizations (H). The purpose of this study was to evaluate the reliability of billing codes for identifying chemotherapy-related acute care visits (CRVs) among women with early-stage breast cancer. Materials and Methods: The cohort was identified by using deterministically linked health databases and consisted of women who were diagnosed with early-stage breast cancer who started adjuvant chemotherapy between 2007 and 2009 in Ontario, Canada. A random sample of 496 patient cases was chosen as the validation cohort. Sensitivity (SN) and specificity (SP) were calculated for three scenarios: chemotherapy-related ED visit, chemotherapy-related H, and febrile neutropenia (FN)–related visit. For FN-related visits, three definitions were considered: general, moderate, and strict. Results: The administrative cohort consisted of 8,359 patients, 43.4% of whom had at least one ED or H, including 1,496 women who had multiple visits that resulted in 6,293 unique visits. Of these, 73.1% were considered CRVs. The algorithm performed well in identifying CRVs that included H either from ED (SN, 90%; SP, 100%) or directly from home (SN, 91%; SP, 93%), but less well for ED visits that did not result in H (SN, 65%; SP, 80%). Depending on which FN algorithm was used, 4.8% to 24% of visits were considered related. The moderate FN algorithm provided the best tradeoff between SN (69% to 97%) and SP (83% to 98%). Conclusion: Administrative data can be valuable in evaluating chemotherapy-related serious events. Algorithm validation in other cohorts is needed.

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