Racial and Ethnic Differences in Emergency Department Wait Times for Patients with Substance Use Disorder.

BACKGROUND: Substance use-related morbidity and mortality rates are at an all-time high in the United States, yet there remains significant stigma and discrimination in emergency medicine about patients with this condition. OBJECTIVES: The purpose of this study was to determine whether there are racial and ethnic differences in emergency department (ED) wait times among patients with substance use disorder. METHODS: The study uses pooled data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2016 to 2018. The dependent variable is length of time the patient with a diagnosis of substance use disorder waited in the ED before being admitted for care. The independent variable is patient race and ethnicity. Adjusted analyses were conducted using a generalized linear model. RESULTS: There were a total of 3995 reported ED events among patients reporting a substance use disorder in the NHAMCS sample between 2016 and 2018. After adjusting for covariates, Black patients with substance use disorder were significantly more likely to wait longer in the ED (35% longer) than White patients with substance use disorder (p < 0.01). CONCLUSIONS: The findings showed that Black patients with substance use disorder are waiting 35% longer, on average, than White patients with the same condition. This is concerning, given that emergency medicine is a critical frontline of care, and often the only source of care, for these patients. Furthermore, longer wait times can increase the likelihood of leaving the ED without being seen. Programs and policies should address potential stigma and discrimination among providers, and EDs should consider adding people with lived experiences to the staff to serve as peer recovery specialists and bridge the gap for care.

Costs and Savings Associated With the Police Use of the interRAI Brief Mental Health Screener.

Background: The police response to calls for service identified as being related to mental health continues to be highly controversial. Strategies to improve the police response include Crisis Intervention Team (CIT) training and various forms of co-response models neither of which have been subjected to comprehensive evaluations, particularly as to cost-efficiency. A new approach is the use of the interRAI Brief Mental Health Screener to enhance police officer ability to identify persons with serious mental disorders. The purpose of the current study is to evaluate the costs and cost efficiency of the police response to mental health calls using the interRAI Brief Mental Health Screener. Method: Secondary data was analyzed from the use of the screener from 2018 to 2020 by police officers in a mid-sized Canadian city. Changes were measured in the overall number of interactions police officers had with persons with mental health disorders, the number of incidents where police officers referred the person to hospital, and the time officers remained in the emergency department. Results: A total of 6,727 assessments were completed with involuntary referrals decreasing by 30%, and voluntary referrals by 34%. The overall time police officers were involved in involuntary referrals decreased from 123 min in 2018 to 113 min in 2020. The average emergency department wait time for voluntary referrals dropped from 41 min in 2018 to 27 min in 2020, while involuntary referrals decreased from 61 min in 2018 to 42 min in 2020. Each averted involuntary referral to the emergency department resulted in a savings of $81, on average during the study period. Conclusion: An analysis of the costs and costs savings associated with the use of the screener demonstrate that it is a worthwhile investment for police services. An additional benefit is its ability to collect mental health statistics that may be useful to police leaders to justify budgets. Future studies should attempt to devise some method of collecting pre-implementation data that would reveal the true costs and cost-efficiency of using the BMHS, which have been shown to be significant in the current study however, undoubtedly are under-estimated.

Service utilization in Medicaid HIV specialty plans versus standard plans among enrollees diagnosed with HIV/AIDS in Florida, U.S.A.

In the United States (U.S.), to contain costs many state Medicaid programs offer specialty health insurance plans for costly conditions such as HIV/AIDS. This study compared service utilization between Florida Medicaid enrollees diagnosed with HIV/AIDS in standard Medicaid managed care plans to enrollees in HIV/AIDS specialty plans. We found lower mean utilization among HIV/AIDS enrollees in specialty plans compared to enrollees with HIV/AIDS in standard MMA plans for all services except inpatient which was approximately the same. While fewer emergency visits is a desired outcome, lower rates of other services may indicate suboptimal management of patients or lower engagement in care among enrollees in HIV/AIDS specialty plans. Continuous monitoring of experiences of patients in HIV/AIDS specialty plans is warranted to determine whether the observed utilization patterns represent better management through reductions in low value care or reduced engagement in care, and whether these utilization patterns persist.

Sociodemographic Influences of Emergency Department Care for Anxiety Disorders.

This study examines variations in content of care for anxiety-related emergency department (ED) visits in the USA across various sociodemographic strata. The 2009-2012 National Hospital Ambulatory Medical Care Survey was used to identify all visits to general hospital EDs in which an anxiety diagnosis was recorded (n = 1930). Content and equitability of care was assessed utilizing logistic regression models. There were an estimated 1,856,000 ED visits with anxiety-related discharge diagnoses in the USA annually. Content of care and disposition varied by age, race/ethnicity, and insurance status. Visits by Medicaid patients were more likely than visits by privately insured patients to include a toxicology screen (OR = 1.67, p < .05) and visits by patients with either Medicaid or Medicare were less likely to include an EKG (OR = 0.53, p < .05 and OR = 0.52, p < .05, respectively). Understanding variations in ED care for anxiety can identify opportunities for intervention, both in the ED and upstream in appropriate healthcare settings.

Impacts of Initial Transformation to a Patient-Centered Medical Home on Diabetes Outcomes in Federally Qualified Health Centers in Florida.

OBJECTIVE: Federally qualified health centers (FQHCs) in Florida see large numbers of vulnerable patients with diabetes. Patient-centered medical home (PCMH) models can lead to improvements in health for patients with chronic conditions and cost savings for providers. Therefore, FQHCs are increasingly moving to PCMH models of care. The study objective was to examine the effects of initial transformation to a level 3 National Committee for Quality Assurance (NCQA) certified PCMH in 2011, on clinical diabetes outcomes among 27 clinic sites from a network of FQHCs in Florida. METHODS: We used de-identified, longitudinal electronic health record (EHR) data from 2010-2012 and multivariate logistic regression to analyze the effects of initial transformation on the odds of having well-controlled HbA1c, body mass index (BMI), and blood pressure (BP) among vulnerable patients with diabetes. Models controlled for clustering by year, patient, and organizational characteristics. RESULTS: Overall, transformation to a PCMH was associated with 19% greater odds of having well-controlled HbA1c values with no statistically significant impact on BMI or BP. Subanalyses showed transformation had less of an effect on BP for African American patients and HbA1c control for Medicare enrollees but a greater effect on weight control for patients older than 35 years. CONCLUSION: Transformation to a PCMH in FQHCs appears to improve the health of vulnerable patients with diabetes, with less improvement for subsets of patients. Future research should seek to understand the heterogeneous effects of patient-centered transformation on various subgroups.

Epidemiology of Emergency Department Visits for Anxiety in the United States: 2009-2011.

OBJECTIVE: The purpose of this study was to describe the epidemiology of anxiety-related emergency department (ED) visits in the United States and assess the care provided during those visits. METHODS: Data from the 2009-2011 National Hospital Ambulatory Medical Care Survey were used to identify all ED visits in which the patient received a primary anxiety diagnosis or declared anxiety as the reason for the visit (N=1,029). Patient characteristics, treatment provided, and dispositions of these nationally representative visits were assessed. RESULTS: There were an estimated 1,247,000 anxiety-related ED visits annually, representing .93% of all ED visits. The proportion of total ED visits that were anxiety related was higher among women than men (1.05% versus .77%) and among nonelderly adults (1.28%) versus other age groups, non-Hispanic whites (1.06%) versus other racial-ethnic groups, and self-pay visits (1.20%) versus other forms of insurance. Among anxiety-related visits, a small percentage (9.6%) involved admission to the hospital, and approximately 67% involved a referral back to the patient's medical care professional. Regarding content of care, most visits for anxiety involved diagnostic or screening services, and one-fourth involved medical procedures. Anxiolytics and benzodiazepines were prescribed most often when drug therapy was offered during anxiety visits in the ED. CONCLUSIONS: EDs were frequently used by patients experiencing anxiety symptoms. In the vast majority of visits, follow-up visits with providers were planned. The most common treatment provided during these ED visits was benzodiazepines, which can offer immediate anxiety symptom relief but are potentially dangerous because of risk of overdose and addiction.

Opioid prescribing by physicians with and without electronic health records.

BACKGROUND: Physicians in the U.S. are adopting electronic health records (EHRs) at an unprecedented rate. However, little is known about how EHR use relates to physicians' care decisions. Using nationally representative data, we estimated how using practice-based EHRs relates to opioid prescribing in primary care. METHODS: This study analyzed 33,090 visits to primary care physicians (PCPs) in the 2007-2010 National Ambulatory Medical Care Survey. We used logistic regression to compare opioid prescribing by PCPs with and without EHRs. RESULTS: Thirteen percent of all visits and 33 % of visits for chronic noncancer pain resulted in an opioid prescription. Compared to visits without EHRs, visits to physicians with EHRs had 1.38 times the odds of an opioid prescription (95 % CI, 1.22-1.56). Among visits for chronic noncancer pain, physicians with EHRs had significantly higher odds of an opioid prescription (adj. OR = 1.39; 95 % CI, 1.03-1.88). Chronic pain visits involving electronic clinical notes were also more likely to result in an opioid prescription compared to chronic pain visits without (adj. OR = 1.51; 95 % CI, 1.10-2.05). Chronic pain visits involving electronic test ordering were also more likely to result in an opioid prescription compared to chronic pain visits without (adj. OR = 1.31; 95 % CI, 1.01-1.71). CONCLUSIONS: We found higher levels of opioid prescribing among physicians with EHRs compared to those without. These results highlight the need to better understand how using EHR systems may influence physician prescribing behavior so that EHRs can be designed to reliably guide physicians toward high quality care.