Search

OBJECTIVES: To develop two practice‐site‐level measures of comprehensiveness and examine their associations with patient outcomes, and how their performance differs from physician‐level measures. DATA SOURCES: Medicare fee‐for‐service claims. STUDY DESIGN: We calculated practice‐site‐level comprehensiveness measures (new problem management and involvement in patient conditions) across 5286 primary care physicians (PCPs) at 1339 practices in the Comprehensive Primary Care initiative evaluation in 2013. We assessed their associations with practices’ attributed beneficiaries’ 2014 total Medicare expenditures, hospitalization rates, ED visit rates. We also examined variation in PCPs’ comprehensiveness across PCPs within practices versus between primary care practices. Finally, we compared associations of practice‐site and PCP‐level measures with outcomes. PRINCIPAL FINDINGS: The measures had good variation across primary care practices, strong validity, and high reliability. Receiving primary care from a practice at the 75th versus 25th percentile on the involvement in patient conditions measure was associated with $21.93 (2.8%) lower total Medicare expenditures per beneficiary per month (P

Objective To examine whether randomization to permanent supportive housing (PSH) versus usual care reduces the use of acute health care and other services among chronically homeless high users of county-funded services. Data sources Between 2015 and 2019, we assessed service use from Santa Clara County, CA, administrative claims data for all county-funded health care, jail and shelter, and mortality. Study design We conducted a randomized controlled trial among chronically homeless high users of multiple systems. We compared postrandomization outcomes from county-funded systems using multivariate regression analysis. Data collection We extracted encounter data from an integrated database capturing health care at county-funded facilities, shelter and jails, county housing placement, and death certificates. Principal findings We enrolled 423 participants (199 intervention; 224 control). Eighty-six percent of those randomized to PSH received housing compared with 36 percent in usual care. On average, the 169 individuals housed by the PSH intervention have remained housed for 28.8 months (92.9 percent of the study follow-up period). Intervention group members had lower rates of psychiatric ED visits IRR 0.62; 95% CI [0.43, 0.91] and shelter days IRR 0.30; 95% CI [0.17, 0.53], and higher rates of ambulatory mental health services use IRR 1.84; 95% CI [1.43, 2.37] compared to controls. We found no differences in total ED or inpatient use, or jail. Seventy (37 treatment; 33 control) participants died. Conclusions The intervention placed and retained frequent user, chronically homeless individuals in housing. It decreased psychiatric ED visits and shelter use, and increased outpatient mental health care, but not medical ED visits or hospitalizations. Limitations included more than one-third of usual care participants received another form of subsidized housing, potentially biasing results to the null, and loss of power due to high death rates. PSH can house high-risk individuals and reduce emergent psychiatric services and shelter use. Reductions in hospitalizations may be more difficult to realize.

Background The NEXUS Chest CT clinical decision rules (CDRs) have been proposed to safely guide selective chest CT use in blunt trauma evaluation. We conducted a cost-effectiveness analysis of the NEXUS Chest CT CDR to determine its impact on missed injuries, cost, and radiation exposure. Methods We constructed a decision model comparing two strategies: implementation of the NEXUS Chest CDR vs. usual care in the evaluation of adults with blunt trauma. We derived probabilities, clinical outcomes, effective radiation dose (ERD) from the NEXUS Chest CT validation cohort and costs from the Charge-master at the primary study site. Our primary outcomes were cost and effective radiation dose (ERD) per missed clinically significant injury (CSI). Results Using a hypothetical cohort of 1000 adults with blunt chest trauma in each arm, the base case model projected that the implementation of the CDR would result in 161 fewer chest CTs, 0.08 additional missed CSIs, a cost savings of $136,432 and a decrease in 1435 mSv, as compared to Usual Care. To detect one additional CSI, the Usual Care strategy would require 2015 more chest CTs with a cost of $1.8 million and 17,934 mSv more radiation. Conclusions Compared to usual care, implementation of the NEXUS Chest CT Major CDR in the evaluation of adults with blunt trauma would greatly reduce CT associated costs and radiation exposure with a slight increased risk of missed CSIs.

This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grants M21PR3278.

IntroductionAfter having an acute myocardial infarction (AMI), racial and ethnic minorities have less access to care, decreased rates of invasive treatments such as percutaneous coronary intervention (PCI), and worse outcomes compared with white patients. The objective of this study was to determine whether the Affordable Care Act’s expansion of Medicaid eligibility was associated with changes in racial disparities in access, treatments, and outcomes after AMI.MethodsQuasi-experimental, difference-in-differences-in-differences analysis of non-Hispanic white and minority patients with acute myocardial infarction in California and Florida from 2010–2015, using linear regression models to estimate the difference-in-differences. This population-based sample included all Medicaid and uninsured patients ages 18–64 hospitalized with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act beginning as early as July 2011 in certain counties, and Florida, which did not expand Medicaid. The main outcomes included rates of admission to hospitals capable of performing PCI, rates of transfer for patients who first presented to hospitals that did not perform PCI, rates of PCI during hospitalization and rates of early (within 48 hours of admission) PCI, rates of readmission to the hospital within 30 days, and rates of in-hospital mortality.ResultsA total of 55,991 hospital admissions met inclusion criteria, 32,540 of which were in California and 23,451 were in Florida. Among patients with AMI who initially presented to a non-PCI hospital, the likelihood of being transferred increased by 12 percentage points (95% CI 2 to 21) for minority patients relative to white patients after the Medicaid expansion. The likelihood of undergoing PCI increased by 3 percentage points (95% CI 0 to 5) for minority patients relative to white patients after the Medicaid expansion. We did not find an association between the Medicaid expansion and racial disparities in overall likelihood of admission to a PCI hospital, hospital readmissions, or in-hospital mortality.ConclusionsThe Medicaid expansion was associated with a decrease in racial disparities in transfers and rates of PCI after AMI. We did not find an association between the Medicaid expansion and admission to a PCI hospital, readmissions, and in-hospital mortality. Additional factors outside of insurance coverage likely continue to contribute to disparities in outcomes after AMI. These findings are crucial for policy makers seeking to reduce racial disparities in access, treatment and outcomes in AMI.

RESEARCH OBJECTIVE: More comprehensive primary care is associated with lower costs and better outcomes for patients. Several primary care interventions under the ACA target practice site level redesign. Thus, it is helpful to have measures to assess whether the comprehensiveness of the practice site is associated with beneficiary outcomes. Building on prior work developing and validating primary care physician‐level measures of comprehensiveness, we developed two practice‐level measures of primary care comprehensiveness and tested their associations with beneficiary outcomes. STUDY DESIGN: Lagged analysis of claims‐based outcomes for Medicare FFS beneficiaries during a year to practice‐level comprehensiveness measures in the previous year. Data are from 2013‐2014 from the evaluation of the Comprehensive Primary Care Initiative. The practice‐level measures assessed, across all primary care physicians in a practice site, the extent to which the physicians in the practice were involved in care for their patients’ conditions (IPC = involved in patient conditions) and managed their patients’ new problems (NPM = new problem management). Regression models controlled for beneficiary, practice, and market characteristics. POPULATION STUDIED: 1,343 primary care practices where 5,336 physicians cared for over 1 million Medicare fee‐for‐service beneficiaries. PRINCIPAL FINDINGS: The two measures varied across primary care practices and captured different aspects of comprehensiveness, as intended. Comparing practices in the 75th versus 25th percentile for each of these measures of comprehensiveness, practices where physicians had greater involvement in patient conditions (IPC) had 2.3% lower Medicare expenditures (P = .03), and 1.7% lower ED visit rates per 1000 beneficiaries (P = .08). Practices where physicians demonstrated greater new problem management (NPM) had 1.6% lower Medicare expenditures (P = .04), 1.8%, lower hospitalization rates per 1000 beneficiaries (P = .03), 2.6% lower overall ED visit rates (P = .00), and 2.6% lower ED outpatient visit rates (P = .01). CONCLUSIONS: These measures demonstrate strong content and predictive validity and reliability. Medicare beneficiaries in primary care practices where physicians deliver more comprehensive care had slightly lower Medicare expenditures, and lower rates of hospitalizations, ED visits, and ED outpatient visits. IMPLICATIONS FOR POLICY OR PRACTICE: These new measures may be useful indicators of 2 aspects of practice‐level comprehensiveness (involvement in patient conditions and new problem management) for studies that target the practice as the unit of change. Additional research should focus on the robustness of these findings for the full Medicare population as well as for other populations. Future research to test interventions to promote primary care comprehensiveness may also be useful. PRIMARY FUNDING SOURCE: Centers for Medicare and Medicaid Services.

Purpose Changing market forces increasingly are leading academic medical centers (AMCs) to form or join health systems. But it is unclear how this shift is affecting the tripartite academic mission of education, research, and high-quality patient care. To explore this topic, the authors identified and characterized the types of health systems that owned or managed AMCs in the United States in 2016. Method The authors identified AMCs as any general acute care hospitals that had a resident-to-bed ratio of at least 0.25 and that were affiliated with at least one MD- or DO-granting medical school. Using the Agency for Healthcare Research and Quality 2016 Compendium of U.S. Health Systems, the authors also identified academic-affiliated health systems (AHSs) as those health systems that owned or managed at least one AMC. They compared AMCs and other general acute care hospitals, AHSs and non-AHSs, and AHSs by type of medical school relationship, using health system size, hospital characteristics, undergraduate and graduate medical education characteristics, services provided, and ownership. Results Health systems owned or managed nearly all AMCs (361, 95.8%). Of the 626 health systems, 230 (36.7%) met the definition of an AHS. Compared with other health systems, AHSs included more hospitals, provided more services, and had a lower ratio of primary care doctors to specialists. Most AHSs (136, 59.1%) had a single, shared medical school relationship, whereas 38 (16.5%) had an exclusive medical school relationship and 56 (24.3%) had multiple medical school relationships. Conclusions These findings suggest that several distinct types of relationships between AHSs and medical schools exist. The traditional vision of a medical school having an exclusive relationship with a single AHS is no longer prominent.

BACKGROUND: Standard clinical protocols for repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD) apply 10 Hz pulses over left prefrontal cortex, yet little is known about the effects of rTMS in more diagnostically complex depressed patients. OBJECTIVE/HYPOTHESIS: Posttraumatic stress disorder (PTSD) is commonly comorbid with MDD, and while rTMS has been shown to alleviate PTSD symptoms in preliminary studies, ideal parameters remain unclear. We conducted a prospective, open-label study of 5 Hz rTMS for patients with comorbid PTSD+MDD and hypothesized stimulation would reduce symptoms of both disorders. METHODS: Outpatients (N=40) with PTSD+MDD and at least moderate global severity were enrolled. 5 Hz rTMS included up to 40 daily sessions followed by a 5-session taper. Symptoms were measured using the PTSD Checklist (PCL-5) and Inventory of Depressive Symptomatology, Self-Report (IDS-SR). Baseline-to-endpoint changes were analyzed. RESULTS: The intent-to-treat population included 35 participants. Stimulation significantly reduced PTSD symptoms (PCL-5 baseline mean±SD score 52.2±13.1 versus endpoint 34.0±21.6; p

Many frequent emergency department (ED) users do not sustain high use over time, which makes it difficult to create targeted interventions to address their health needs. We performed a retrospective analysis of nonelderly adult frequent ED users in California to measure the persistence of frequent ED use in the period 2005-15, describe characteristics of persistent and nonpersistent frequent users, and identify predictors of persistent frequent use. Of the frequent ED users in 2005, 30.5 percent remained frequent users in 2006. A small but nontrivial population (16.5 percent, 5.7 percent, and 1.9 percent) exhibited persistent frequent use for three, six, and eleven consecutive years, respectively. The strongest predictor of persistent frequent ED use was the intensity of ED use in the baseline study year. The rate at which frequent users stopped using the ED frequently decreased over time, leaving a core group of chronic persistent users. These persistent frequent users differ from nonpersistent frequent users, who engaged in temporary intense use of the ED. Identifying and differentiating persistent frequent users is important, as they may be candidates for distinct interventions.

Objective To better characterize and understand the nature of a very conservative definition of 'avoidable' emergency department (ED) visits in the United States to provide policymakers insight into what interventions can target non-urgent ED visits. Design/setting We performed a retrospective analysis of a very conservative definition of 'avoidable' ED visits using data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011. Participants We examined a total of 115 081 records, representing 424 million ED visits made by patients aged 18-64 years who were seen in the ED and discharged home. Main outcome measures We defined 'avoidable' as ED visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home. Results In total, 3.3% (95% CI: 3.0-3.7) of all ED visits were 'avoidable.' The top five chief complaints included toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. Alcohol abuse, dental disorders and depressive disorders were among the top three ICD-9 discharge diagnoses. Alcohol-related disorders and mood disorders accounted for 6.8% (95% CI: 5.7-8.0) of avoidable visits, and dental disorders accounted for 3.9% (95% CI: 3.0-4.8) of CCS-grouped discharge diagnoses. Conclusions A significant number of 'avoidable' ED visits were for mental health and dental conditions, which the ED is not fully equipped to treat. Our findings provide a better understanding of what policy initiatives could potentially reduce these 'avoidable' ED visits to address the gaps in our healthcare system, such as increased access to mental health and dental care.

Repetitive transcranial magnetic stimulation (TMS) has been shown to be safe and effective for treatment-resistant depression (TRD) in the general adult population. Efficacy among older (≥60 years) patients, who have a greater burden of cognitive, physical, and functional impairment compared to their younger counterparts, remains unclear. The current study aimed to characterize antidepressant response to an acute course of TMS therapy among patients aged ≥60 years compared to those60 years in naturalistic clinical practice settings.Data were retrospectively collected and pooled for adults with TRD (N =231; n =75 aged ≥60 years and n = 15660 years) who underwent an acute course of outpatient TMS therapy at two outpatient clinics. Self-report depression scales were administered at baseline and end of acute treatment. Change on continuous measures and categorical outcomes were compared across older vs. younger patients.Both age groups showed significant improvements in depression symptoms. Response and remission rates did not differ between groups. Age group was not a significant predictor of change in depression severity, nor of clinical response or remission, in a model controlling for other predictors (all p.05).Limitations include reliance on self-report clinical measures and variability in comorbidity and concurrent pharmacotherapy due to the naturalistic nature of the study.Results suggest that effectiveness of TMS for TRD is not differentially modified by age. Based on these naturalistic data, age alone should not be considered a contraindication or poor prognostic indicator of the antidepressant efficacy of TMS.

Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.

Objective To test the hypothesis that the earned income tax credit (EITC)-the largest US poverty alleviation program-affects short-term health care expenditures among US adults. Data sources Adult participants in the 1997-2012 waves of the US Medical Expenditure Panel Survey (MEPS) (N = 1 282 080). Study design We conducted difference-in-differences analyses, comparing health care expenditures among EITC-eligible adults in February (immediately following EITC refund receipt) with expenditures during other months, using non-EITC-eligible individuals to difference out seasonal variation in health care expenditures. Outcomes included total out-of-pocket expenditures as well as spending on specific categories such as outpatient visits and inpatient hospitalizations. We conducted subgroup analyses to examine heterogeneity by insurance status. Principal findings EITC refund receipt was not associated with short-term changes in total expenditures, nor any expenditure subcategories. Results were similar by insurance status and robust to numerous alternative specifications. Conclusions EITC refunds are not associated with short-term changes in health care expenditures among US adults. This may be because the refund is spent on other expenses, because of income smoothing, or because of similar refund-related variation in health care expenditures among noneligible adults. Future studies should examine whether other types of income supplementation affect health care expenditures, particularly among individuals in poverty.

Little is known about mortality risk among frequent emergency department (ED) users. Using California hospital data for 2005-13 linked to vital statistics data, we found that frequent ED use in the past year was predictive of mortality among the nonelderly in both the short and longer terms.

Key Points Question Are ambulance 9-1-1 times longer in high-income compared with low-income areas, and how do response times compare with national benchmarks across income quartiles? Findings In this US national, cross-sectional study of 63 600 patients with out-of-hospital cardiac arrest, EMS times remained 10% longer in the poorest areas and were more likely to meet 8-minute and 15-minute cutoffs in high-income areas. Meaning Patients with cardiac arrest from the poorest neighborhoods had longer EMS times that were less likely to meet national benchmarks compared with those from the wealthiest neighborhoods, which may lead to increased disparities in the delivery of prehospital care over time., This cross-sectional study investigates whether ambulance response time to 9-1-1 calls were longer in low-income vs high-income areas and compares response times with national benchmarks of 4, 8, or 15 minutes across income quartiles., Importance Emergency medical services (EMS) provide critical prehospital care, and disparities in response times to time-sensitive conditions, such as cardiac arrest, may contribute to disparities in patient outcomes. Objectives To investigate whether ambulance 9-1-1 times were longer in low-income vs high-income areas and to compare response times with national benchmarks of 4, 8, or 15 minutes across income quartiles. Design, Setting, and Participants A retrospective cross-sectional study was performed of the 2014 National Emergency Medical Services Information System data in June 2017 using negative binomial and logistic regressions to examine the association between zip code–level income and EMS response times. The study used ambulance 9-1-1 response data for out-of-hospital cardiac arrest from 46 of 50 state repositories (92.0%) in the United States. The sample included 63 600 cardiac arrest encounters of patients who did not die on scene and were transported to the hospital. Main Outcomes and Measures Four time measures were examined, including response time, on-scene time, transport time, and total EMS time. The study compared response times with EMS response time benchmarks for responding to cardiac arrest calls within 4, 8, and 15 minutes. Results The study sample included 63 600 cardiac arrest encounters of patients (mean [SD] age, 60.6 [19.0] years; 57.9% male), with 37 550 patients (59.0%) from high-income areas and 8192 patients (12.9%) from low-income areas. High-income areas had greater proportions of white patients (70.1% vs 62.2%), male patients (58.8% vs 54.1%), privately insured patients (29.4% vs 15.9%), and uninsured patients (15.3% vs 7.9%), while low-income areas had a greater proportion of Medicaid-insured patients (38.3% vs 15.8%). The mean (SD) total EMS time was 37.5 (13.6) minutes in the highest zip code income quartile and 43.0 (18.8) minutes in the lowest. After controlling for urban zip code, weekday, and time of day in regression analyses, total EMS time remained 10% longer (95% CI, 9%-11%; P

Background The Affordable Care Act has provided health insurance to a large portion of the uninsured in the United States. However, different types of health insurance provide varying amounts of reimbursements to providers, which may lead to different types of treatment, potentially worsening health outcomes in patients covered by low‐reimbursement insurance plans, such as Medicaid. The objective was to determine differences in access, treatment, and health outcomes by insurance type, using hospital fixed effects. Methods and Results We conducted a multivariate regression analysis using patient‐level data for nonelderly adult patients with acute myocardial infarction in California from January 1, 2001, to December 31, 2014, as well as hospital‐level information to control for differences between hospitals. The probability of Medicaid‐insured and uninsured patients having access to catheterization laboratory was higher by 4.50 and 3.75 percentage points, respectively, relative to privately insured patients. When controlling for access to percutaneous coronary intervention facilities, however, Medicaid‐insured and uninsured patients had a 4.24– and 0.85–percentage point lower probability, respectively, in receiving percutaneous coronary intervention treatment compared with privately insured patients. They also had higher mortality and readmission rates relative to privately insured patients. Conclusions Although Medicaid‐insured and uninsured patients with acute myocardial infarction had better access to catheterization laboratories, they had significantly lower probabilities of receiving percutaneous coronary intervention treatment and a higher likelihood of death and readmission compared with privately insured patients. This provides empirical evidence that treatment received and health outcomes strongly vary between Medicaid‐insured, uninsured, and privately insured patients, with Medicaid‐insured patients most disproportionately affected, despite having better access to cardiac technology.

Objective The majority of paediatric ED visits result in discharge but little is known about what ED resources are deployed for these visits. The goal of this study was to understand the utilisation of diagnostic testing, procedures and hospital admission for paediatric ED visits triaged as ‘non-urgent’. Study design We examined US ED visits for children aged 0–17 years from 1 January 2009 to 31 December 2011 in the National Hospital Ambulatory Medical Care Survey. Visits triaged on arrival as ‘non-urgent’ (level 5) were compared with urgent visits (triage levels 1–4) for resource use and disposition. Sensitivity and specificity of triage for predicting resource use and disposition were assessed. Results Among 21 052 observations, representing 86 620 988 visits, 11.1% were triaged as ‘non-urgent’. Diagnostic services were provided during 37.6% (95% CI 33.9% to 41.4%) of non-urgent and 55.2% (95% CI 53.3% to 57.2%) of urgent visits. Procedures were performed in 23.9% (95% CI 20.4% to 27.3%) of non-urgent and 33.9% (95% CI 31.2% to 35.9%) of urgent visits. 1.7% (95% CI 0.09% to 2.6%) of the non-urgent visits resulted in admission, with 0.08% (95% CI 0% to 0.2%) to critical care units, compared with 4.4% (95% CI 3.6% to 5.2%) of the urgent visits, with 0.3% (95% CI 0.2% to 0.4%) to critical care. Despite some substantial differences in the rates of resource use, triage score had poor sensitivity for identifying patients who did not receive ED tests, procedures or admission. Conclusion A significant percentage of ED patients with non-urgent ED triage scores received ED testing and procedures. More work is needed to improve methods of prospectively identifying patients with low acuity complaints who do not need significant ED resources.

OBJECTIVES:Given increasing demand for emergency care, there is growing concern over the availability of emergency department (ED) and inpatient resources. Existing studies of ED bed supply are dated and often overlook hospital capacity beyond ED settings. We described recent statewide trends in the capacity of ED and inpatient hospital services from 2005 to 2014. DESIGN:Retrospective analysis. SETTING:Using California hospital data, we examined the absolute and per admission changes in ED beds and inpatient beds in all hospitals from 2005 to 2014. PARTICIPANTS:Our sample consisted of all patients inpatient and outpatient) from 501 hospital facilities over 10-year period. OUTCOME MEASURES:We analysed linear trends in the total annual ED visits, ED beds, licensed and staffed inpatient hospital beds and bed types, ED beds per ED visit, and inpatient beds per admission (ED and non-ED). RESULTS:Between 2005 and 2014, ED visits increased from 9.8 million to 13.2 million (an increase of 35.0%, p

BackgroundThere is substantial interest in identifying low-acuity visits to emergency departments (EDs) that could be treated more appropriately in other settings. Systematic differences in illness severity between ED patients and comparable patients elsewhere could make such strategies unsafe, but little evidence exists to guide policy makers.ObjectiveTo compare illness severity between patients visiting EDs and outpatient clinics, by comparing short-term mortality and hospitalization, controlling for patient demographics, comorbidity, and visit acuity.Research designCross-sectional study of outcomes after medical encounters.SubjectsNationally representative 20% sample of Medicare fee-for-service beneficiaries discharged home from ED or clinic visit in 2011, and enrolled continuously for 1 year before the visit.MeasuresAll-cause mortality and hospitalization in the 8, 15, and 30 days after discharge home from ED or clinic visits.ResultsAfter risk-adjusting for patient demographic, comorbidity, disability, and dual-eligibility status, as well as visit acuity as measured by a commonly used algorithm, we found that ED patients were more likely to die (risk-adjusted odds ratio=2.75; 95% confidence interval, 2.56-2.96) or be hospitalized (odds ratio=1.97; 95% confidence interval, 1.95-2.00) after discharge than clinic patients. Differences in short-term outcomes were observed even when comparing patients with the same discharge diagnoses after risk adjustment.ConclusionsPatients presenting to EDs have worse risk-adjusted short-term outcomes than those presenting to outpatient clinics, even after controlling for acuity level of visit or discharge diagnosis. Existing measures of acuity using administrative data may not adequately capture severity of illness, making judgments of the appropriate setting for care difficult.

Key Points Question What factors are associated with higher emergency department (ED) use among patients with and without mental health diagnoses? Findings This case-control study found that previous hospitalization and high rates of lagged ED visits were associated with higher future ED use. Mild, moderate, and severe mental health diagnoses were associated with increases of 2.9%, 12.1%, and 22.6%, respectively, in ED use. Meaning Prior patient visit patterns and patient illness severity associated with mental health diagnoses could be important contributors to increased ED use., This case-control study examines factors associated with higher emergency department (ED) use among US patients with vs without mental health diagnoses., Importance An association between frequent use of the emergency department (ED) and mental health diagnoses is frequently documented in the literature, but little has been done to more thoroughly understand why mental illness is associated with increased ED use. Objective To determine which factors were associated with higher ED use in the near future among patients with and without mental health diagnoses. Design, Setting, and Participants A retrospective case-control study of all patients presenting to the ED in California in 2013 using past ED data to predict future ED use. Data from January 1, 2012, through December 31, 2014, from California’s Office of Statewide Health Planning and Development were analyzed. Main Outcomes and Measures Factors associated with higher ED use in the year following an index visit for patients with vs without a mental health diagnosis. Results Among the 3 446 338 individuals in the study (accounting for 7 678 706 ED visits), 44.6% (1 537 067) were male; 31.6% (1 089 043) were between the ages of 18 and 30 years, 40.3% (1 338 874) were between the ages of 31 and 50 years, and 28.1% (968 421) were between the ages of 51 and 64 years. The mean (SD) number of ED visits per patient per year was 1.69 (2.56), and 29.1% of patients (1 002 884) had at least 1 mental health diagnosis. Previous hospitalization and high rates of lagged ED visits were associated with higher future ED use. The severity of the mental health diagnosis (mild, moderate, or severe) was associated with increased ED visits (incidence rate ratio [IRR], 1.029; 95% CI, 1.02-1.04 for mild; IRR, 1.121; 95% CI, 1.11-1.13 for moderate; and IRR, 1.226; 95% CI, 1.22-1.24 for severe). Little evidence was found for interaction effects between mental health diagnoses and other diagnoses in predicting increased future ED use. Conclusions and Relevance Certain classes of mental health diagnoses were associated with higher ED use. The presence of a mental illness diagnosis did not appear to interact with other patient-level factors in a way that meaningfully altered associations with future ED use.

ObjectiveTo examine current trends in the characteristics of patients visiting California emergency departments (EDs) in order to better direct the allocation of acute care resources.DesignA retrospective study.SettingWe analysed ED utilisation trends between 2005 and 2015 in California using non-public patient data from California’s Office of Statewide Health Planning and Development.ParticipantsWe included all ED visits in California from 2005 to 2015.Primary and secondary outcome measuresWe analysed ED visits and visit rates by age, sex, race/ethnicity, payer and urban/rural trends. We further examined age, sex, race/ethnicity and urban/rural trends within each payer group for a more granular picture of the patient population. Additionally, we looked at the proportion of patients admitted from the ED and distribution of diagnoses.ResultsBetween 2005 and 2015, the annual number of ED visits increased from 10.2 to 14.2 million in California. ED visit rates increased by 27.8% (pConclusionsOur findings reveal an increasing demand for emergency care and may reflect current limitations in accessing care in other parts of the healthcare system. Policymakers may need to recognise the increasingly vital role that EDs are playing in the provision of care and consider ways to incorporate this changing reality into the delivery of health services.

Letters Obtained funding: Both authors. Administrative, technical, or material support: Prather. Study supervision: Prather. Conflict of Interest Disclosures: Dr Prather is a paid consultant for Posit Science on an unrelated project. No other disclosures were reported. Funding/Support: Dr Prather's involvement was supported by grant K08HL112961 from the National Heart, Lung, and Blood Institute. Dr Leung’s involvement was supported by grant K99HD084758 from the Eunice Kennedy Shriver National Institute of Child Health and Human Development. Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication. 1. Extent and health consequences of chronic sleep loss and sleep disorders. In: Colten HR, Altevogt BM, eds. Sleep Disorders and Sleep Deprivation: An Unmet Public Health Problem. Washington, DC; National Academies Press; 2006:55-136. 2. Prather AA, Janicki-Deverts D, Hall MH, Cohen S. Behaviorally assessed sleep and susceptibility to the common cold. Sleep. 2015;38(9):1353-1359. 3. Cohen S, Doyle WJ, Alper CM, Janicki-Deverts D, Turner RB. Sleep habits and susceptibility to the common cold. Arch Intern Med. 2009;169(1):62-67. 4. Patel SR, Malhotra A, Gao X, Hu FB, Neuman MI, Fawzi WW. A prospective study of sleep duration and pneumonia risk in women. Sleep. 2012;35(1):97-101. 5. Bryant PA, Trinder J, Curtis N. Sick and tired: does sleep have a vital role in the immune system? Nat Rev Immunol. 2004;4(6):457-467. 6. Buysse DJ. Sleep health: can we define it? does it matter? Sleep. 2014;37(1): Urgent Care Needs Among Nonurgent Visits to the Emergency Department The goal of triage is to prioritize patients who need to be seen most urgently; it is essential for providing the highest quality of care to the sickest patients. 1 We sought to determine whether a triage determination of non- urgent status in the emer- Editor's Note page 854 gency department (ED) effec- tively ruled out the possibility of serious pathologic conditions, as indicated by visits result- ing in diagnostic screening, procedures, hospitalization, or death, and compared these findings with visits deemed as urgent from triage. Methods | The National Hospital Ambulatory Medical Care Survey is a national multistage probability sample survey of patient visits to the ED. These data contain triage scores for each ED visit as assessed by a triage nurse on arrival based on a scale of 1 to 5, with 1 being immediate, 2 emergent, 3 urgent, 4 semi- urgent, and 5 nonurgent. 2 We compared characteristics and outcomes of visits from January 1, 2009, to December 31, 2011, labeled as nonurgent (category 5) with characteristics and out- comes of visits with all other labels (categories 1-4), which we labeled as urgent visits. We focused on nonelderly adults aged 18 to 64 years and excluded visits for which triage scores were missing or where the patient left before triage or medical screening. This study was deemed exempt from human subjects review at the University of California San Francisco. Results | We analyzed 59 293 observations from 2009 to 2011, representing 240 million visits. A total of 218.49 million vis- its (92.5%) were deemed urgent at triage and 17.76 million vis- its (7.5%) as nonurgent. A total of 33.82 million visits (15.5%) deemed urgent arrived by ambulance, compared with 1.19 million visits (6.7%) considered nonurgent. Diagnostic ser- vices, such as blood tests, electrocardiograms, and imaging, were provided in 8.45 million nonurgent visits (47.6%) (any blood tests: weighted, 18.8% [95% CI, 15.5%-22.1%]; electro- cardiograms: 5.8% [95% CI, 4.3%-7.2%]; and any imaging: 28.5% [95% CI, 24.9%-32.0%]), and procedures, such as in- travenous fluids, casting, and splinting, were performed in 5.76 million nonurgent visits (32.4%) (intravenous fluids: weighted, 12.6% [95% CI, 9.7%-15.6%]; casting: 0.6% [95% CI, 0.2%- 1.0%]; and splinting: 6.2% [95% CI, 5.2%-7.3%]). In compari- son, diagnostic services were provided in 163.49 million ur- gent visits (74.8%) (any blood tests: weighted, 46.2% [95% CI, 44.7%-47.6%]; electrocardiograms: 18.7% [95% CI, 17.8%- 19.6%]; and any imaging: 49.0% [95% CI, 47.7%-50.3%]), and procedures were performed in 107.89 million urgent visits (49.4%) (intravenous fluids: weighted, 31.7% [95% CI, 30.2%- 33.3%]; casting: 0.3% [95% CI, 0.2%-0.3%]; and splinting: 5.6% [95% CI, 5.3%-5.9%]) (P < .001 for all comparisons) (Table 1). A total of 776 000 nonurgent visits (weighted, 4.4% [95% CI, 3.1%-5.7%]) resulted in admissions and of these, 126 000 (16.2%; weighted, 0.7% (95% CI, 0.1%-1.3%]) were admis- sions to critical care units. A total of 27.86 million urgent vis- its (weighted, 12.8% [95% CI, 11.7%-13.8%]) resulted in admis- sions (P < .001), of which only 2.91 million (10.5%; weighted, 1.3% (95% CI, 1.2%-1.5%]) (P = .32) were admissions to criti- cal care units. Overall, 1.01 million nonurgent visits (weighted, 5.7% [95% CI, 4.2%-7.1%]) resulted in admission or transfer, compared with 32.49 million urgent visits (weighted, 14.9% [95% CI, 13.8%-15.9%]) (P < .001) (Table 2). When we examined the chief symptoms reported at non- urgent visits, 6 of the top 10 reasons—back symptoms, ab- dominal pain, sore throat, headache, chest pain, and low back pain—were also in the top 10 symptoms reported at urgent vis- its. In addition, when the top 10 diagnoses from nonurgent visits were analyzed, 5 were identical to those at urgent visits (backache, lumbago, acute upper respiratory infection, cellulitis, and acute pharyngitis). Discussion | Our study found that a nontrivial proportion of ED visits that were deemed nonurgent arrived by ambu- lance, received diagnostic services, had procedures per- formed, and were admitted to the hospital, including to criti- cal care units. Certainly, not all of these data necessarily indicate that these services were required, and they could signal overuse or a lack of availability of primary care physicians. 3 However, to some degree, our findings indicate that either patients or health care professionals do entertain a degree of uncertainty that requires further evaluation before diagnosis. That half of the top 10 diagnoses, among over 14 000 International Classification of Diseases, Ninth Revision codes, are found in both nonurgent and urgent vis- its shows that 50% of these visits are virtually indistinguish- able from each other. There are certain limitations to this study. Specifically, while the National Hospital Ambulatory Medical Care Survey uses a 5-level triage score, not all hospitals do. The National Hospital Ambulatory Medical Care Survey therefore rescales visits to hospitals that do not use a 5-level triage score, and also JAMA Internal Medicine June 2016 Volume 176, Number 6 (Reprinted) Copyright 2016 American Medical Association. All rights reserved. Downloaded From: http://jamanetwork.com/ by a UCSF LIBRARY User on 11/18/2016 jamainternalmedicine.com