Trends in Urinary Catheter Use by Indication in US Emergency Departments, 2002-2019.

This retrospective study examines trends in urinary catheter use in US emergency departments between 2002 and 2019.

Hospital Occupancy and its Effect on Emergency Department Evaluation.

STUDY OBJECTIVE: To examine whether hospital occupancy was associated with increased testing and treatment during emergency department (ED) evaluations, resulting in reduced admissions. METHODS: We analyzed the electronic health records of an urban academic ED. We linked data from all ED visits from October 1, 2010, to May 29, 2015, with daily hospital occupancy (inpatients/total staffed beds). Outcome measures included the frequency of laboratory testing, advanced imaging, medication administration, and hospitalizations. We modeled each outcome using multivariable negative binomial or logistic regression, as appropriate, and examined their association with daily hospital occupancy quartiles, controlling for patient and visit characteristics. We calculated the adjusted outcome rates and relative changes at each daily hospital occupancy quartile using marginal estimating methods. RESULTS: We included 270,434 ED visits with a mean patient age of 48.1 (standard deviation 19.8) years; 40.1% were female, 22.8% were non-Hispanic Black, and 51.5% were commercially insured. Hospital occupancy was not associated with differences in laboratory testing, advanced imaging, or medication administration. Compared with the first quartile, the third and fourth quartiles of daily hospital occupancy were associated with decreases of 1.5% (95% confidence interval [CI] -2.9 to -0.2; absolute change -0.6 percentage points [95% CI -1.2 to -0.1]) and 4.6% (95% CI -6.0 to -3.2; absolute change -1.9 percentage points [95% CI -2.5 to -1.3]) in hospitalizations, respectively. CONCLUSION: The lack of association between hospital occupancy and laboratory testing, advanced imaging, and medication administration suggest that changes in ED testing or treatment did not facilitate the decrease in admissions during periods of high hospital occupancy.

Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006-2015.

BACKGROUND: Acute pain from a vaso-occlusive crisis (VOC) is a leading reason patients with sickle cell disease (SCD) visit the emergency department (ED). Prior studies suggest that women and men receive disparate ED treatment for acute pain in EDs. We aim to determine sex differences in analgesic use among patients with SCD presenting to the ED. METHODS: This cross-sectional study uses data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006-2015. We identified ED patients with a primary diagnosis of SCD. Among patients with SCD, we evaluated sex differences in the use of opioid analgesia using logistic regression (adjusting for patient and visit characteristics). Analyses accounted for survey design and weighting. RESULTS: When evaluating the effect of sex on any opioid medication use in this population, though not significant, the odds that male patients were prescribed opioids was 1.5 (95% CI 0.8-2.8) times that of female patients after adjusting for age, the reason for visit, region, insurance status, and pain score. There was no significant difference in pain scores between male patients, 8.1 (95% CI 7.55-8.68) compared to female patients, 7.4 (95% CI 6.7-8.12). CONCLUSIONS: In this nationally representative sample of ED visits among patients with SCD, there was no conclusive evidence of sex disparities in opioid prescribing. Though there is evidence of a trend signaling that male patients with SCD were more likely than female patients to be prescribed an opioid.

Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care.

BACKGROUND: Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear. METHODS: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. We performed a cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest. RESULTS: After matching, we included 557 501 members in the HDHP group and 5 861 990 in the control group, with mean ages of 42.0 years, 48% to 49% female, and 67% to 68% non-Hispanic White individuals. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% CI, -5.9 to -2.7; absolute change, -4.5 [95% CI, -6.3 to -2.8] per 10 000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, -14.0 to -8.6) decrease (absolute change, -1.7 per 10 000 person-years [95% CI, -2.1 to -1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, -1.0 to 32.7]; absolute change, 0.3 per 10 000 person-years [95% CI, -0.01 to 0.5]) but was significant among members from higher-poverty neighborhoods. CONCLUSIONS: Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.

Where Skilled Nursing Facility Residents Get Acute Care: Is the Emergency Department the Medical Home?

OBJECTIVES: This study aimed to characterize the distribution of acute care visits among Medicare beneficiaries receiving skilled nursing facility (SNF) services. METHODS: We conducted a cross-sectional analysis of a 20% sample of continuously enrolled Medicare beneficiaries in the 2012 Chronic Condition Warehouse data set. Beneficiaries were grouped by the number of days of SNF services, and acute care visits were categorized as "before SNF," "during SNF," or "after SNF." RESULTS: Among the 10,717,786 Medicare beneficiaries analyzed, 384,312 (3.6%) had at least one SNF stay. DISCUSSION: Beneficiaries who received SNF services had a higher proportion of acute care visits made to emergency departments (EDs) than beneficiaries who did not receive SNF services. Also, a higher proportion of acute care visits were made to EDs by beneficiaries after a SNF stay in comparison to residents actively residing in a SNF. The acute care capabilities of SNFs and post-SNF transitions of care to the community setting are discussed.

High-deductible health plans and low-value imaging in the emergency department.

OBJECTIVE: To examine the effect of an employer-mandated switch to high-deductible health plans (HDHP) on emergency department (ED) low-value imaging. DATA SOURCES: Claims data of a large national insurer between 2003 and 2014. STUDY DESIGN: Difference-in-differences analysis with matched control groups. DATA COLLECTION/EXTRACTION METHODS: The primary outcome is low-value imaging during ED visits for syncope, headache, or low back pain. We included members aged 19-63 years whose employers offered only low-deductible (≤$500) plans for one (baseline) year and, in the next (follow-up) year, offered only HDHPs (≥$1000). Contemporaneous members whose employers offered only low-deductible plans for two consecutive years served as controls. The groups were matched by person and employer propensity for HDHP switch, employer size, baseline calendar year, and baseline year quarterly number of total and imaged ED visits for each condition. We modeled the visit-level probability of low-value imaging using multivariable logistic regression with member-clustered standard errors. We also calculated population level monthly cumulative ED visit rates and modeled their trends using generalized linear regression adjusting for serial autocorrelation. PRINCIPAL FINDINGS: After matching, we included 524 998 members in the HDHP group and 5 448 803 in the control group with a mean age of approximately 42 years and 48% female in both groups. On visit-level analyses, there were no significant differential changes in the probability of low-value imaging use in the HDHP and control groups. In population-level analyses, compared with control group members, members who switched to HDHPs experienced a relative decrease of 5.9% (95% CI - 10.3, -1.6) in ED visits for the study conditions and a relative decrease of 5.1% (95%CI -9.6, -0.6) in the subset of ED visits with low-value imaging. CONCLUSION: Though HDHP switches decreased ED utilization, they had no significant effect on low-value imaging use after patients have decided to seek ED care.

Prescription and Prescriber Specialty Characteristics of Initial Opioid Prescriptions Associated with Chronic Use.

OBJECTIVE: This study evaluated the characteristics of opioid prescriptions, including prescriber specialty, given to opioid-naïve patients and their association with chronic use. DESIGN: Cross-sectional analysis of the Ohio prescription drug monitoring program from January 2010 to November 2017. SETTING: Ohio, USA. SUBJECTS: Patients who had no opioid prescriptions from 2010 to 2012 and a first-time prescription from January 2013 to November 2016. METHODS: Chronic use was defined as at least six opioid prescriptions in one year and either one or more years between the first and last prescription or an average of ≤30 days not covered by an opioid during that year. RESULTS: A total of 4,252,809 opioid-naïve patients received their first opioid prescription between 2013 and 2016; 364,947 (8.6%) met the definition for chronic use. Those who developed chronic use were older (51.7 vs 45.6 years) and more likely to be female (53.6% vs 52.8%), and their first prescription had higher pill quantities (44.9 vs 30.2), higher morphine milligram equivalents (MME; 355.3 vs 200.0), and was more likely to be an extended-release formulation (2.9% vs 0.7%, all P < 0.001). When compared with internal medicine, the adjusted odds of chronic use were highest with anesthesiology (odds ratio [OR] = 1.46) and neurology (OR = 1.43) and lowest with ophthalmology (OR = 0.33) and gynecology (OR = 0.37). CONCLUSIONS: Eight point six percent of opioid-naïve individuals who received an opioid prescription developed chronic use. This rate varied depending on the specialty of the provider who wrote the prescription. The risk of chronic use increased with higher MME content of the initial prescription and use of extended-release opioids.

Advanced imaging and trends in hospitalizations from the emergency department.

OBJECTIVE: The proportion of US emergency department (ED) visits that lead to hospitalization has declined over time. The degree to which advanced imaging use contributed to this trend is unknown. Our objective was to examine the association between advanced imaging use during ED visits and changes in ED hospitalization rates between 2007-2008 and 2015-2016. METHODS: We analyzed data from the National Hospital Ambulatory Medical Care Survey. The primary outcome was ED hospitalization, including admission to inpatient and observation units and outside transfers. The primary exposure was advanced imaging during the ED visit, including computed tomography, magnetic resonance imaging, and ultrasound. We constructed a survey-weighted multivariable logistic regression with binary outcome of ED hospitalization to examine changes in adjusted hospitalization rates from 2007-2008 to 2015-2016, comparing ED visits with and without advanced imaging. RESULTS: ED patients who received advanced imaging (versus those who did not) were more likely to be 65 years or older (25.3% vs 13.0%), non-Hispanic white (65.3% vs 58.5%), female (58.4% vs 54.1%), and have Medicare (26.5% vs 16.0%). Among ED visits with advanced imaging, adjusted annual hospitalization rate declined from 22.5% in 2007-2008 to 17.3% (adjusted risk ratio [aRR] 0.77; 95% CI 0.68, 0.86) in 2015-2016. In the same periods, among ED visits without advanced imaging, adjusted annual hospitalization rate declined from 14.3% to 11.6% (aRR 0.81; 95% CI 0.73, 0.90). The aRRs between ED visits with and without advanced imaging were not significantly different. CONCLUSION: From 2007-2016, ED visits with advanced imaging did not have a greater reduction in admission rate compared to those without advanced imaging. Our results suggest that increasing advanced imaging use likely had a limited role in the general decline in hospital admissions from EDs. Future research is needed to further validate this finding.

Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey.

INTRODUCTION: Emergency departments (ED) in the United States (US) have increasingly taken the central role for the expedited diagnosis and treatment of acute episodic illnesses and exacerbations of chronic diseases, allowing outpatient management to be possible for many conditions that traditionally required hospitalization and inpatient care. The goal of this analysis was to examine the changes in ED care intensity in this context through the changes in ED patient population and ED care provided. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007-2016. Incorporating survey design and weight, we calculated the changes in ED patient characteristics and ED care provided between 2007 and 2016. We also calculated changes in the proportion of visits with low-severity illnesses that may be safely managed at alternative settings. Lastly, we compared ED care received and final ED dispositions by calculating adjusted relative risk (aRR) comparing ED visits in 2007 to 2016, using survey weighted multivariable logistic regression. RESULTS: NHAMCS included 35,490 visits in 2007 and 19,467 visits in 2016, representing 117 million and 146 million ED visits, respectively. Between 2007 and 2016, there was an increase in the proportion of ED patients aged 45-64 (21.0% to 23.6%) and 65-74 (5.9% to 7.5%), while visits with low-severity illnesses decreased from 37.3% to 30.4%. There was a substantial increase in the proportion of Medicaid patients (22.2% to 34.0%) with corresponding decline in the privately insured (36.2% to 28.3%) and the uninsured (15.4% to 8.6%) patients. After adjusting for patient and visit characteristics, there was an increase in the utilization of advanced imaging (aRR 1.29; 95% confidence interval [CI], 1.17-1.41), blood tests (aRR 1.16; 95% CI, 1.10-1.22), urinalysis (aRR 1.22; 95% CI, 1.13-1.31), and visits where the patient received four or more medications (aRR 2.17; 95% CI, 1.88-2.46). Lastly, adjusted hospitalization rates declined (aRR 0.74; 95% CI, 0.64-0.84) while adjusted discharge rates increased (aRR 1.06; 95%CI 1.03-1.08). CONCLUSION: From 2007 to 2016, ED care intensity appears to have increased modestly, including aging of patient population, increased illness severity, and increased resources utilization. The role of increased care intensity in the decline of ED hospitalization rate requires further study.

Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care.

BACKGROUND: Prior studies have found conflicting effects of Medicaid expansion on emergency department (ED) utilization but have not studied the reasons patients go to EDs. OBJECTIVES: Examine the changes in reasons for ED use associated with Medicaid expansion. RESEARCH DESIGN: Difference-in-difference analysis. SUBJECTS: We included sample adults from the 2012 to 2017 National Health Interview Survey who were US citizens and reported a total family income below 138% federal poverty level (n=30,259). MEASURES: We examined changes in the proportion of study subjects reporting: (1) any ED visits; (2) ED visits due to perceived illness severity; (3) office not open; and (4) barriers to outpatient care, comparing expansion and nonexpansion states. RESULTS: Overall, 30.6% of low-income adults reported ED use in the past year, of which 74.1% reported illness acuity, 12.4% reported office not open, 9.5% reported access barriers, and 4.0% did not report any reason. Medicaid expansion was not associated with statistically significant changes in overall ED use [-2.2% (95% confidence interval-CI), -5.5% to 1.2%), P=0.21], ED visits due to perceived illness severity [0.5% (95% CI, -2.4% to 3.5%), P=0.73], or office not open [-0.9% (95% CI, -2.3% to 0.5%); P=0.22], but was associated with significant decrease in ED visits due to access barriers [-1.4% (95% CI, -2.6% to -0.2%), P=0.022]. CONCLUSIONS: Medicaid expansion was associated with a decrease in low-income adults who reported outpatient care barriers as reasons for ED visits. There were no significant changes in overall ED utilization, likely because the majority of respondent reported ED use due to concerns with illness severity or outpatient office was closed.

Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition.

Importance: Studies of public hospitals have reported increasing incidence of emergency department (ED) transfers of uninsured patients for hospitalization, which is perceived to be associated with financial incentives. Objective: To examine the differences in risk-adjusted transfer and discharge rates by patient insurance status among hospitals capable of providing critical care. Design, Setting, and Participants: A cross-sectional analysis of the 2015 National Emergency Department Sample was conducted, including visits between January 2015 and December 2015. Adult ED visits throughout 2015 (n = 215 028) for the 3 common medical conditions of pneumonia, chronic obstructive pulmonary disease, and asthma, at hospitals with intensive care capabilities were included. Only hospitals with advanced critical care capabilities for pulmonary care were included. Main Outcomes and Measures: The primary outcomes were patient-level and hospital-level risk-adjusted ED discharges, ED transfers, and hospital admissions. Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare beneficiaries, and privately insured patients are reported. Hospital ownership status was used for the secondary analysis. Results: Of the 30 542 691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215 028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care-capable hospitals. These visits were made by patients with a median (interquartile range [IQR]) age of 55 (40-71) years and who were predominantly female (124 931 [58.1%]). Substantial variation in unadjusted and risk-standardized ED discharge, ED transfer, and hospital admission rates was found across EDs. Compared with privately insured patients, uninsured patients were more likely to be discharged (odds ratio [OR], 1.66; 95% CI, 1.57-1.76) and transferred (adjusted OR [aOR], 2.41; 95% CI, 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge (aOR, 1.00; 95% CI, 0.97-1.04) but higher odds of transfer (aOR, 1.19; 95% CI, 1.05-1.33). Conclusions and Relevance: After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.

Primary Care Office Visits For Acute Care Dropped Sharply In 2002-15, While ED Visits Increased Modestly.

The traditional model of primary care practices as the main provider of care for acute illnesses is rapidly changing. Over the past two decades the growth in emergency department (ED) visits has spurred efforts to reduce "inappropriate" ED use. We examined a nationally representative sample of office and ED visits in the period 2002-15. We found a 12 percent increase in ED use (from 385 to 430 visits per 1,000 population), which was dwarfed by a decrease of nearly one-third in the rate of acute care visits to primary care practices (from 938 to 637 visits per 1,000 population). The decrease in primary care acute visits was also present among two vulnerable populations: Medicaid beneficiaries and adults ages sixty-five and older, either in Medicare or privately insured. As acute care delivery shifts away from primary care practices, there is a growing need for integration and coordination across an increasingly diverse spectrum of venues where patients seek care for acute illnesses.

Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy.

OBJECTIVES: To describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered "low-value", and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations. METHODS: We analyzed 2002-2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression. RESULTS: From 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: -3.1%; 95%CI -4.7, -1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: -2.2%; 95%CI -3.0, -1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: -0.6%; 95%CI -2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI -1.9, 2.0]; -0.9% [95%CI -3.1, 1.3]; and -1.2% [95%CI -5.3, 2.9], respectively). CONCLUSIONS: Before and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.

Patient centered medical homes did not improve access to timely follow-up after ED visit.

BACKGROUND: Patients newly insured through coverage expansion under the Affordable Care Act (ACA) may have difficulty obtaining timely primary care follow-up appointments after emergency department (ED) discharge. We evaluated the association between availability of timely follow-up appointment with practice access improvements, including patient-centered medical home (PCMH) designations or extended-hours appointments. METHODS: We performed a secret-shopper audit of primary care practices in greater New Haven, Connecticut. Two callers, posing as patients discharged from the ED, called these practices requesting follow-up appointments. They followed standardized scripts varying in ED diagnosis (uncontrolled hypertension, acute back pain) and insurance status (commercial, exchange, Medicaid). We linked our findings with data from a previously completed survey that assessed practice characteristics and examined the associations between appointment availability and practice access improvements. RESULTS: Of the 58 included primary care practices, 49 (84.5%) completed both the audit and the survey. Overall, 167/536 calls (31.2%) obtained an appointment in 7days. Practices with PCMH designation were less likely to offer appointments within 7days (23.4% vs. 33.1%, p=0.03). However, callers were more likely to obtain an appointment in 7days from practices offering after-hour appointments (36.3% vs. 27.8%, p=0.04). After adjusting for insurance type, there were no significant associations between practice improvements and 7-day appointment availability or appointment wait time. CONCLUSION: PCMH designation and extended-hours appointments were not associated with improved availability of timely primary care follow-up appointment for discharged ED patients. EDs should engage local clinicians and other stakeholders to strengthen linkage and care transition with outpatient practices.

Analysis of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses.

Importance: Insurers have increasingly adopted policies to reduce emergency department (ED) visits that they consider unnecessary. One common approach is to retrospectively deny coverage if the ED discharge diagnosis is determined by the insurer to be nonemergent. Objective: To characterize ED visits that may be denied coverage if the ED coverage denial policy of a large national insurer, Anthem, Inc, is widely adopted. Design, Setting, and Participants: A cross-sectional analysis of probability-sampled ED visits from the nationally representative National Hospital Ambulatory Medical Care Survey ED subsample occurring from January 1, 2011, to December 31, 2015, was conducted. Visits by commercially insured patients aged 15 to 64 years were examined. Those with ED discharge diagnoses defined by Anthem's policy as nonemergent and therefore subject to possible denial of coverage were classified as denial diagnosis visits. The primary presenting symptoms among denial diagnosis visits were identified, and all visits by commercially insured adults presenting with these primary symptoms were classified as denial symptom visits. Main Outcomes and Measures: Each visit cohort as a weighted proportion of commercially insured adult ED visits. The proportion of each visit cohort that received ED-level care, defined as visits where patients were triaged as urgent or emergent, received 2 or more diagnostic tests, or were admitted or transferred, was also examined. Results: From 2011 to 2015, 15.7% (95% CI, 15.0%-16.4%) of commercially insured adult ED visits (4440 of 28 304) were denial diagnosis visits (mean [SD] patient age, 36.6 [14.0] years; 2592 [58.7%] female and 2962 [63.5%] white). Among these visits, 39.7% (95% CI, 37.1%-42.3%) received ED-level care: 24.5% (95% CI, 21.7%-27.4%) were initially triaged as urgent or emergent and 26.0% (95% CI, 23.8%-28.3%) received 2 or more diagnostic tests. These denial diagnosis visits shared the same presenting symptoms as 87.9% (95% CI, 87.3%-88.4%) of commercially insured adult ED visits (24 882 of 28 304) (mean [SD] patient age, 38.5 [14.1] years; 14 362 [57.9%] female and 17 483 [68.7%] white). Among these denial symptom visits, 65.1% (95% CI, 63.4%-66.9%) received ED-level care: 43.2% (95% CI, 40.2%-46.4%) were triaged as urgent or emergent, 51.9% (95% CI, 50.0%-53.9%) received 2 or more diagnostic tests, and 9.7% (95% CI, 8.8%-10.6%) were admitted or transferred. Conclusions and Relevance: Anthem's nonemergent ED discharge diagnoses were not associated with identification of unnecessary ED visits when assessed from the patient's perspective. This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial.

Insurance Status and Access to Urgent Primary Care Follow-up After an Emergency Department Visit in 2016.

STUDY OBJECTIVE: We examine the availability of follow-up appointments for emergency department (ED) patients without established primary care by insurance and clinical condition. METHODS: We used "secret shopper" methodology, employing 2 black men to telephone all 53 primary care practices in greater New Haven, posing as new patients discharged from the ED and requesting follow-up appointments. Each practice received 6 scripted calls from each caller during an 8-month period, reflecting all possible scenarios based on 3 insurance types (Medicaid, state exchange, and commercial) and 2 conditions (hypertension and back pain). Primary outcome was the proportion of calls that obtained an appointment in 7 calendar days (7-day appointment rate). Secondary outcomes included overall appointment rate and appointment wait time. RESULTS: Among the total of 604 calls completed, the 7-day appointment rate was 30.7% (95% confidence interval [CI] 22.6% to 38.8%). Compared with commercial insurance, Medicaid calls had lower 7-day rate (25.5% versus 35.7%; difference 10.2%; 95% CI 2.2% to 18.1%) and overall appointment rate (53.5% versus 77.8%; difference 24.4%; 95% CI 13.4% to 35.4%). There was no significant difference between state exchange and commercial insurance calls in 7-day rate (30.9% versus 35.7%; difference 4.8%; 95% CI -3.1% to 12.6%) or overall appointment rate (73.4% versus 77.8%; difference 4.4%; 95% CI -2.7% to 11.6%). Back pain, compared with hypertension, had lower 7-day appointment rate (27.6% versus 33.7%; difference 6.1%; 95% CI 1.0% to 11.2%), but no significant difference in overall appointment rates (67.0% versus 69.4%; difference 2.4%; 95% CI -2.7% to 7.5%). CONCLUSION: For patients without established primary care, obtaining timely follow-up after acute care in the ED is difficult, particularly for Medicaid beneficiaries.

ED utilization of medical clearance testing for psychiatric admission: National Hospital Ambulatory Medical Care Survey analysis.

INTRODUCTION: Routine medical clearance testing of emergency department (ED) patients with acute psychiatric illnesses in the absence of a medical indication has minimal proven utility. Little is known about the variations in clinical practice of ordering medical clearance tests. METHODS: This study was an analysis of data from the annual United States National Hospital Ambulatory Medical Care Survey from 2010 to 2014. The study population was defined as ED visits by patients ≥18years old admitted to a psychiatric facility. We sought to determine the percentage of these ED visits in which at least one medical clearance test was ordered. Using a multivariate logistic regression model, we also evaluated whether patient visit factors or regional variation was associated with use of medical clearance tests. RESULT: A medical clearance test was ordered in 80.4% of ED visits ending with a psychiatric admission. Multivariate logistic regression demonstrated a statistically significant increased odds ratio (OR) of medical clearance testing based on age (OR 1.02, 95%CI 1.01, 1.03), among visits involving an injury or poisoning (OR 2.38, 95%CI 1.54, 3.68), and in the Midwest region as compared to the Northeast region (OR 2.2, 95% confidence interval [CI] 1.09, 4.46), after adjusting for other predictors. DISCUSSION: Our study demonstrated that, on a national level, 4 out of 5 ED visits resulting in a psychiatric facility admission had a medical clearance test ordered. Future research is needed to investigate the reasons underlying the discrepancies in ordering patterns across the U.S., including the effect of local psychiatric admission policies.

Emergency Departments in Connecticut: A Report Utilizing the National Emergency Department Inventory Survey.

OBJECTIVE: To describe the current state of emergency departments in Connecticut. METHODS: We analyzed Connecticut data from the National Emergency Department Inventory - Nev England survey. We categorized emergency departments (EDs) into high-volume (> 50 000 annual vis its) vs low-volume (< 50000 visits). RESULTS: 31 (89%) Connecticut EDs responded. The median annual ED visit volume was 45,000 visits with 20 (65%) EDs reported being "at or over capacity," including nearly all high-volume EDs. Only 1: (35%) EDs had pediatric emergency care coordinators, and access to specialties varied with notable shortages in neurology, neurosurgery, plastic sur- gery, and hand surgery. Electronic health records had near universal adoption but video consultation utilization was limited. Computer tomography and point-of-care ultrasound was widely available. CONCLUSION: While Connecticut EDs reported the ability to provide a broad array of emergency care services, policymakers seeking to improve acute care access should focus efforts on crowding and pediatric emergency care, as well as video consultation adoption.

Racial/ethnic differences in the presentation and management of severe bronchiolitis.

BACKGROUND AND OBJECTIVE: Bronchiolitis is the leading cause of hospitalization for US infants and is associated with increased risk of childhood asthma. Although studies have shown differences in the presentation and management of asthma across race/ethnicity, it is unclear if such differences are present for bronchiolitis. We examined if racial/ethnic differences exist in the presentation and management of severe bronchiolitis. METHODS: We performed a 16-center, prospective cohort study from 2007 to 2010. Children <2 years old hospitalized with a diagnosis of bronchiolitis were included. A structured interview, chart review, and 1-week phone follow-up were completed. Multivariable logistic regression was used to examine the independent association between race/ethnicity and diagnostic imaging, treatment (eg, albuterol, corticosteroids, and continuous positive airway pressure/intubation), management (eg, intensive care unit admission and length of stay), discharge on inhaled corticosteroids, and bronchiolitis relapse. RESULTS: Among 2130 patients, 818 (38%) were non-Hispanic white (NHW), 511 (24%) were non-Hispanic black (NHB), and 801 (38%) were Hispanic. Compared with all groups, NHB children were most likely to receive albuterol before admission (odds ratio [OR]: 1.58; 95% confidence interval [CI]: 1.20-2.07) and least likely to receive chest x-rays during hospitalization (OR: 0.66; 95% CI: 0.49-0.90). Hispanic children were most likely to be discharged on inhaled corticosteroids (OR: 1.92; 95% CI: 1.19-3.10). CONCLUSION: We observed differences between NHW and minority children regarding preadmission albuterol use, inpatient diagnostic imaging, and prescription of inhaled corticosteroids at discharge, practices that deviate from the American Academy of Pediatrics guidelines. The causes of these differences require further study, but they support implementation of care pathways for severe bronchiolitis.