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Objectives: Patients discharged from the emergency department (ED) are often referred for primary care, specialty, or other disease-specific follow-up appointments. Attendance at these scheduled followup appointments has been found to improve patient outcomes, decrease ED bounce-backs, and reduce malpractice risk. Reasons for missing follow-up visits are complex, but the most commonly reason cited by patients is simply forgetting. In this study the authors evaluated the ability of an automated text message reminder system to increase attendance at post-ED discharge follow-up appointments in a predominantly Hispanic safety-net population.Methods: This was a randomized controlled trial of ED patients with outpatient follow-up visits scheduled at the time of ED discharge. A total of 374 English-and Spanish-speaking patients with textcapable mobile phones were enrolled. Patients in the intervention arm received automated, personalized text message appointment reminders including date, time, and clinic location at 7, 3, and 1 day before scheduled visits. A t-test of proportions was used to compare outcomes between intervention and control groups. Both an intention-to-treat (ITT) and a per-protocol analysis of the data were performed. The ITT more accurately reflects real-world conditions where errors such as number entry errors are bound to occur. The per-protocol analysis adds value by isolating the effect of the intervention by comparing patients who actually received it compared with those who did not.Results: In the per-protocol analysis of the primary outcome, the overall appointment adherence rate was 72.6% in the intervention group compared with 62.1% in the control group (difference between groups = 10.5%, 95% confidence interval [CI] = 0.3% to 20.8%; p = 0.045; number needed to treat = 9.5). In the ITT analysis, the overall appointment attendance rate 70.2% in the intervention group compared with 62.1% in the control group (difference between groups = 8.2%; 95% CI = -1.6% to 17.7%; p = 0.100). In a secondary largely exploratory analysis, the intervention was found to have the most benefit in patients with the lowest baseline follow-up rate (English speakers with specialty care appointments).Conclusions: Automated text message appointment reminders resulted in improvement in attendance at scheduled post-ED discharge outpatient follow-up visits and represent a low-cost and highly scalable solution to increase attendance at post-ED follow-up appointments, which should be further explored in larger sample sizes and diverse patient populations.ACADEMIC EMERGENCY MEDICINE 2015;22:31-37

mHealth is a feasible, acceptable, and promising avenue to improve social support and diabetes outcomes.

BackgroundDespite a growing body of scientific literature exploring the nature of meditation there is limited information on the characteristics of individuals who use it. This is particularly true of comparative studies examining prevalence and predictors of use of various forms of meditation.MethodsA secondary analysis was conducted using data from the 2012 National Health Interview Survey (n = 34,525). Three popular forms of meditation were compared—mantra, mindfulness, and spiritual—to determine lifetime and 12-month use related to key sociodemographic, health behavior, health status, and healthcare access variables.ResultsThe 12-month prevalence for meditation practice was 3.1% for spiritual meditation, 1.9% for mindfulness meditation, and 1.6% for mantra meditation. This represents approximately 7.0, 4.3, and 3.6 million adults respectively. A comparison across the three meditation practices found many similarities in user characteristics, suggesting interest in meditation may be more related to the type of person meditating than to the type of practice selected. Across meditation styles use was more prevalent among respondents who were female, non-Hispanic White, college educated, physically active; who used other complementary health practices; and who reported depression. Higher utilization of conventional healthcare services was one of the strongest predictors of use of all three styles. In addition to similarities, important distinctions were observed. For example, spiritual meditation practice was more prevalent among former drinkers. This may reflect use of spiritual meditation practices in support of alcohol treatment and sobriety. Reasons for use of meditation were examined using the sample of respondents who practiced mindfulness meditation. Wellness and prevention (74%) was a more common reason than use to treat a specific health condition (30%). Common reasons for use included stress management (92%) and emotional well-being (91%), and to support other health behaviors. Meditation was viewed positively because it was self-care oriented (81%) and focused on the whole person (79%).ConclusionMeditation appears to provide an accessible, self-care resource that has potential value for mental health, behavioral self-regulation, and integrative medical care. Considering consumer preference for distinct types of meditation practices, understanding the underlying mechanisms, benefits, and applications of practice variations is important.

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We found high admission rates of patients on involuntary psychiatric holds to a pediatric medical unit with little psychiatric treatment in 1 hospital. Further research in other centers is required to determine the extent of the issue. Future studies of longer term outcomes (including readmission rates and assessments of functioning) are needed.

IntroductionPatients with mental health conditions frequently use emergency medical services. Many suffer from substance use and homelessness. If they use the emergency department (ED) as their primary source of care, potentially preventable frequent ED revisits and hospital readmissions can worsen an already crowded healthcare system. However, the magnitude to which homelessness affects health service utilization among patients with mental health conditions remains unclear in the medical community. This study assessed the impact of homelessness on 30-day ED revisits and hospital readmissions among patients presenting with mental health conditions in an urban, safety-net hospital.MethodsWe conducted a secondary analysis of administrative data on all adult ED visits in 2012 in an urban safety-net hospital. Patient demographics, mental health status, homelessness, insurance coverage, level of acuity, and ED disposition per ED visit were analyzed using multilevel modeling to control for multiple visits nested within patients. We performed multivariate logistic regressions to evaluate if homelessness moderated the likelihood of mental health patients’ 30-day ED revisits and hospital readmissions.ResultsStudy included 139,414 adult ED visits from 92,307 unique patients (43.5±15.1 years, 51.3% male, 68.2% Hispanic/Latino). Nearly 8% of patients presented with mental health conditions, while 4.6% were homeless at any time during the study period. Among patients with mental health conditions, being homeless contributed to an additional 28.0% increase in likelihood (4.28 to 5.48 odds) of 30-day ED revisits and 38.2% increase in likelihood (2.04 to 2.82 odds) of hospital readmission, compared to non-homeless, non-mental health (NHNM) patients as the base category. Adjusted predicted probabilities showed that homeless patients presenting with mental health conditions have a 31.1% chance of returning to the ED within 30-day post discharge and a 3.7% chance of hospital readmission, compared to non-homeless patients presenting with mental health conditions (25.2%, 2.6%) and NHNM (7.7%, 1.5%).ConclusionHomeless patients presenting with mental health conditions were more likely to return to the ED within 30 days and to be readmitted to the hospital. Interventions providing housing might improve their overall care management and have the potential to reduce ED revisits and hospital readmissions.

We report the first national estimates of EMTALA enforcement activities in more than a decade. Although EMTALA investigations and citations were common at the hospital level, they were rare at the ED-visit level. CMS actively pursued EMTALA investigations and issued citations throughout the study period, with half of hospitals subject to EMTALA investigations and a quarter receiving a citation for EMTALA violation, although there was a declining trend in enforcement. Further investigation is needed to determine the effect of EMTALA on access to or quality of emergency care.