Health care access problems of medically indigent emergency department walk-in patients

Pane, Gregg A; Farner, Michael C.; Salness, Kym A

doi:10.1016/s0196-0644(05)80832-7

Cited by 113 publications

(43 citation statements)

References 18 publications

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“…Prior studies of ED use in indigent communities have been cross-sectional rather than longitudinal or have relied on patient selfreport of use of services. 2,3,[7][8][9][10] These results are consistent with a study that interviewed ED patients in a large inner-city hospital and found that although most patients identified other clinics or private physicians where they received care, 63% identified the ED as their main source of outpatient care. 11 Another striking finding is that the majority of subsequent ED visits (65.5%) were accounted for by a minority (16.6%) of high-frequency ED users with a high prevalence of chronic medical conditions.…”

Section: Discussionsupporting

confidence: 80%

Ambulatory health care use by patients in a public hospital emergency department

et al. 1998

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OBJECTIVE:To describe primary care clinic use and emergency department (ED) use for a cohort of public hospital patients seen in the ED, identify predictors of frequent ED use, and ascertain the clinical diagnoses of those with high rates of ED use. DESIGN: Cohort observational study.SETTING: A public hospital in Atlanta, Georgia.PATIENTS: Random sample of 351 adults initially surveyed in the ED in May 1992 and followed for 2 years. MEASUREMENTS AND MAIN RESULTS:Of the 351 patients from the initial survey, 319 (91%) had at least one ambulatory visit in the public hospital system during the following 2 years and one third of the cohort was hospitalized. The median number of subsequent ED visits was 2 (mean 6.4), while the median number of visits to a primary care appointment clinic was 0 (mean 1. CONCLUSIONS:All subgroups of patients in this study relied heavily on the ED for ambulatory care, and high ED use was positively correlated with appointment clinic visits and inpatient hospitalization rates, suggesting that high resource utilization was related to a higher burden of illness among those patients. The prevalence of chronic medical conditions and substance abuse among these most frequent emergency department users points to a need for comprehensive primary care. Multidisciplinary case management strategies to identify frequent ED users and facilitate their use of alternative care sites will be particularly important as managed care strategies are applied to indigent populations who have traditionally received care in public hospital EDs.KEY WORDS: emergency department; public hospitals; ambulatory care; primary care clinic. J GEN INTERN MED 1998;13:614-620.T here are growing efforts to restrict access to emergency departments (EDs) on the premise that care can be more appropriately provided in alternative sites, such as primary care clinics. 1 These efforts may particularly affect indigent communities, in which many consider the ED to be their main health care provider. 2,3 A 1993 General Accounting Office report showed a 34% increase in ED visits by patients with Medicaid and a 15% increase in visits by uninsured patients between 1985 and 1990. 4 To reverse this trend, Medicaid managed care programs use gatekeepers, preauthorization, and payment denials to decrease ED use. Case management strategies have been limited to small groups of patients with a chronic disease, such as asthma.There is considerable evidence of the benefit of continuity care with a primary care provider; however, imposing financial and administrative barriers to ED use on indigent populations without workable alternatives may have undesirable outcomes. 5 Indigent patients receiving care in public hospital EDs represent a potentially highrisk population that is increasingly subject to managed care restrictions despite a paucity of clinical information about the type and necessity of care being received. The appropriate managed care strategy for this population, from case management to cost sharing, will depend on the prevalence of u...

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Section: Discussionsupporting

confidence: 80%

Ambulatory health care use by patients in a public hospital emergency department

et al. 1998

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“…In addition, the application of therapeutic 1 and monitoring 23,24 technologies once considered under the domain of the ICU has made the delivery of critical care more practical in the ED. Studies have quantitated that from 154 1 to 186 4 critical-patient-days per year are provided in the urban ED setting.…”

Section: Discussionmentioning

confidence: 99%

Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

Nguyen

Rivers

Havstad

et al. 2000

Academic Emergency Medicine

151

102

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Abstract. Objectives:The changing landscape of health care in this country has seen an increase in the delivery of care to critically ill patients in the emergency department (ED). However, methodologies to assess care and outcomes similar to those used in the intensive care unit (ICU) are currently lacking in this setting. This study examined the impact of ED intervention on morbidity and mortality using the Acute Physiology and Chronic Health Evaluation (APACHE II), the Simplified Acute Physiology Score (SAPS II), and the Multiple Organ Dysfunction Score (MODS). Methods: This was a prospective, observational cohort study over a three-month period. Critically ill adult patients presenting to a large urban ED and requiring ICU admission were enrolled. APACHE II, SAPS II, and MODS scores and predicted mortality were obtained at ED admission, ED discharge, and 24, 48, and 72 hours in the ICU. In-hospital mortality was recorded. Results: Eighty-one patients aged 64 Ϯ 18 years were enrolled during the study period, with a 30.9% in-hospital mortality. The ED length of stay was 5.9 Ϯ 2.7 hours and the hospital length of stay was 12.2 Ϯ 16.6 days. Nine (11.1%) patients initially accepted for ICU admission were later admitted to the general ward after ED intervention. Septic shock was the predominant admitting diagnosis. At ED admission, there was a significantly higher APACHE II score in nonsurvivors (23.0 Ϯ 6.0) vs survivors (19.8 Ϯ 6.5, p = 0.04), while there was no significant difference in SAPS II or MODS scores. The APACHE II, SAPS II, and MODS scores were significantly lower in survivors than nonsurvivors throughout the hospital stay (p Յ 0.001). The hourly rates of change (decreases) in APACHE II, SAPS II, and MODS scores were significantly greater during the ED stay (Ϫ0.55 Ϯ 0.64, Ϫ1.02 Ϯ 1.10, and Ϫ0.16 Ϯ 0.43, respectively) than subsequent periods of hospitalization in survivors (p < 0.05). There was a significant decrease in APACHE II and SAPS II predicted mortality during the ED stay (Ϫ8.0 Ϯ 14.0% and Ϫ6.0 Ϯ 14.0%, respectively, p < 0.001) and equally at 24 hours in the ICU (Ϫ7.0 Ϯ 13.0% and Ϫ4.0 Ϯ 16.0%, respectively, p Յ 0.02). The APACHE II and SAPS II predicted mortality approached actual in-hospital mortality at approximately 12 hours and 36 hours after ED admission (in the ICU), respectively. Conclusions: The care provided during the ED stay for critically ill patients significantly impacts the progression of organ failure and mortality. Although this period is brief compared with the total length of hospitalization, physiologic determinants of outcome may be established before ICU admission. This study emphasizes the importance of ED intervention. It also suggests that unique physiologic assessment methodologies should be developed to examine the quality of patient care, improve the accuracy of prognostic decisions, and objectively measure the impact of clinical interventions and pathways in the ED setting.

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“…Data on hospitalizations and deaths from shigellosis during this period were obtained from the computerized provincial hospital discharge file and vital statistics registry, respectively, using International Classification of Diseases, ninth revision, Clinical Modification (ICD-9 CM) code 004. 16 Population figures from December 1993 were used to calculate and compare the rates of Indians and members of the general population.…”

Section: Methodsmentioning

confidence: 99%

“…[1][2][3][4][5][6][7][8][9] This resurgence has been most marked in our inner cities,1014 where patients at high risk for tuberculosis often use an emergency department as their initial or sole source of health care. [15][16][17][18] Effective and rapid isolation of patients with active tuberculosis in innercity emergency departments is essential because the presence of infectious patients in this crowded setting could contribute to outbreaks of tuberculosis. [19][20][21][22][23][24][25][26][27] The emergence of multidrugresistant strains has made the situation even more hazardous.…”

Section: Introductionmentioning

confidence: 99%

Controlling tuberculosis in an urban emergency department: a rapid decision instrument for patient isolation.

Redd¹,

Süsser²

1997

Am J Public Health

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OBJECTIVES: This study examined whether data routinely available in emergency departments could be used to improve isolation decisions for tuberculosis patients. METHODS: In a large emergency department in New York City, we compared the exposure histories of tuberculosis culture-positive and culture-negative patients and used these data to develop a rapid decision instrument to predict culture-positive tuberculosis. The screen used only data that are routinely available to emergency physicians. RESULTS: The method had high sensitivity (.96) and moderate specificity (.54). CONCLUSIONS: The method is easily adaptable for a broad range of settings and illustrates the potential benefits of applying basic epidemiologic methods in a clinical setting.

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Health care access problems of medically indigent emergency department walk-in patients

Cited by 113 publications

References 18 publications

Ambulatory health care use by patients in a public hospital emergency department

Ambulatory health care use by patients in a public hospital emergency department

Critical Care in the Emergency Department A Physiologic Assessment and Outcome Evaluation

Controlling tuberculosis in an urban emergency department: a rapid decision instrument for patient isolation.

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