Clinical and longitudinal patterns of frequent presenters to emergency departments: A multi-centre data linkage analysis.

OBJECTIVE: To describe clinical characteristics and longitudinal patterns of representation in a cohort of patients who frequently present to EDs for care. METHODS: A retrospective data analysis linking routinely collected ED data across three hospitals. The study population consisted of patients who presented to any ED on 10 or more occasions in any continuous 365-day period from 1 July 2015 to 30 June 2021. Presenting complaints were divided into those with any mental health, drug and alcohol, or social presentations (MHDAS group) and those without (non-MHDAS group). Outcomes of interest were number of presentations as well as temporal and facility clustering of presentations. A per patient regression analysis was performed to identify independent risk factors for increased presentations. RESULTS: Presentations by 1640 frequent ED presenters in the study constituted 4.6% of total ED presentations. MHDAS study group were younger, predominantly English speaking, twice as likely to be married, had lower hospital admission rates and almost three times as many of them did not wait for treatment. Statistically significant differences were also found between these groups regarding presentation clustering, facility entropy, each of the four categories of the number of ED presentations, and Index of Relative Socio-Economic Advantage and Disadvantage. CONCLUSION: Representations associated with MHDAS have a different trajectory of representation episodes compared to non-MHDAS group. Escalating number of presentations and clustering are important predictors of future representation numbers. Those 'did not waits' who appear to be representing would be the highest risk of ongoing and persistent representations in the future and should be the target of early interventions to ensure they are accessing appropriate care before this happens.

Emergency clinician perceptions of patients who present frequently to the emergency department: a snapshot of current practice.

Objective This study aimed to assess emergency clinician perceptions of adult patients who present frequently to the emergency department (ED) in an Australian context and understand current practices. Methods ED clinicians including general practitioners, career medical officers and nurse unit managers working at New South Wales Australia level 3-6 hospitals were surveyed. Responses to open-ended questions were independently coded by two reviewers and the main themes were analysed. Results Almost all the 210 participants (99%) could identify a population of frequent ED presenters at their hospital. Participants suggested that 9-12 presentations per year was a useful benchmark to use to characterise frequent ED presentations. They also indicated the need to consider as criteria recurrent presentations, their complexity, disease category and timeframe. Participants believed that the cause for presentation, from a restricted list of clinical alternatives, was multifactorial but the single most common cause for presentation was thought to be mental health followed by drug and alcohol. A total of 73% of participants reported that their hospitals had interventions to address frequent ED presentations, most commonly case management, multidisciplinary meetings and staff specialist involvement. Lack of co-ordination between services and a lack of resources in ED were cited as barriers to improving outcomes for patients who frequently present. Conclusions ED clinicians surveyed offered suggestions on how to characterise frequent ED presentations beyond the number of visits to better identify this higher risk population. Additional services, as well as better coordination between patients, families, hospitals and outpatient services, appear needed in order to improve outcomes for this cohort of patients. Interventions should focus on increasing health outcomes, rather than a decrease in the number of presentations alone.

Understanding patient preferences for emergency care for lower triage acuity presentations during GP hours: a qualitative study in Australia.

BACKGROUND: Low acuity presentations to Australian emergency departments drive long wait times, higher costs and may be better treated in primary care settings. This study sought to understand factors leading these patients to present to emergency departments. METHODS: Semi-structured interviews were carried out with patients at two tertiary emergency departments in Sydney during general practitioner opening hours. Nvivo was used to code the interviews and a thematic analysis was carried out to capture the main themes from the interviews. RESULTS: Forty-four interviews were included in the analysis across the two sites. They represented a diverse population in terms of ethnicity, education and socioeconomic background. Patient preferences for emergency care were organised into four main themes: (i) patients were referred (either by another health service, work, friend, or family), (ii) emergency department factors (convenience of investigations and severity of symptoms requiring emergency care), (iii) GP factors (does not have a GP, cannot find an appointment with a GP or has previously had a negative experience with a GP) and (iv) personal factors such as their connection to the hospital. CONCLUSION: Multiple factors led patients to seek ED care for low acuity presentations during GP hours. Some of these factors could be addressed to meet patient needs in the community, however this is currently not the case. Addressing these factors to improve access to GP clinics and the availability of services outside the hospital setting could reduce ED presentations and likely improve patient experience.

Costs and effects of interventions targeting frequent presenters to the emergency department: a systematic and narrative review.

BACKGROUND: Previous systematic reviews have examined the effectiveness of interventions for frequent presenters to the Emergency Department (ED) but not the costs and cost-effectiveness of such interventions. METHOD: A systematic literature review was conducted which screened the following databases: Pubmed, Medline, Embase, Cochrane and Econlit. An inclusion and exclusion criteria were developed following PRISMA guidelines. A narrative review methodology was adopted due to the heterogeneity of the reporting of the costs across the studies. RESULTS: One thousand three hundred eighty-nine papers were found and 16 were included in the review. All of the interventions were variations of a case management approach. Apart from one study which had mixed results, all of the papers reported a decrease in ED use and costs. There were no cost effectiveness studies. CONCLUSION: The majority of interventions for frequent presenters to the ED were found to decrease ED use and cost. Future research should be undertaken to examine the cost effectiveness of these interventions.

Clinical pathways for suicidality in emergency settings: a public health priority.

Rates of self-harm in Australia are increasing and constitute a concerning public health issue. Although there are standard treatment pathways for physical complaints, such as headache, abdominal pain and chest pain, in Emergency Medicine, there is no national pathway for self-harm or other psychiatric conditions that present to the emergency department. Herein we outline the difference between clinical practice guidelines and clinical pathways, discuss pathways we have identified on self-harm in Australia and overseas and discuss their applicability to the Australian context and the next steps forward in addressing this public health issue.

Chemical agents for the sedation of agitated patients in the ED: a systematic review.

OBJECTIVE: Chemical agents commonly used to sedate agitated patients in the emergency department include benzodiazepines, antipsychotics, or a combination of the 2 classes. Our objective was to determine if a class or combination therapy is (1) more effective, as measured by the proportion sedated at 15-20 minutes and the need for repeat sedation, and (2) safer, as measured by the proportion of reported adverse events. METHODS: Systematic literature review and meta-analysis of studies comparing 2 or more chemical agents for sedation of agitated patients in the emergency department were carried out in PubMed, PsycINFO, Embase, and the Cochrane database. Meta-analyses for pairwise comparisons of drug class (benzodiazepine, antipsychotic, or combination) were carried out for each outcome: proportion sedated, need for repeat sedation, and adverse events. RESULTS: Seven studies with 1135 patients were included. At 15-20 minutes, the proportion of patients sedated was greater with combination therapy than benzodiazepines alone (risk ratio [RR] = 1.31, P < .0001). Antipsychotics and combination agents required significantly less repeat sedations than benzodiazepines alone (RR = 0.49, P < .0001 and RR = 0.64, P = .002). There was significant heterogeneity in adverse event data, with respiratory system adverse events (desaturation, and need for airway and ventilatory support) being the most commonly reported. Benzodiazepines were associated with a higher incidence of adverse events than antipsychotics or combination therapy. CONCLUSION: Combination therapy sedated a greater proportion of patients at 15-20 minutes than benzodiazepines alone. Antipsychotics and combination therapy were more effective, requiring less repeat doses for sedation than benzodiazepines. The risk of any adverse event was higher with benzodiazepines.

Long term sequelae from childhood pneumonia; systematic review and meta-analysis.

BACKGROUND: The risks of long term sequelae from childhood pneumonia have not been systematically assessed. The aims of this study were to: (i) estimate the risks of respiratory sequelae after pneumonia in children under five years; (ii) estimate the distribution of the different types of respiratory sequelae; and (iii) compare sequelae risk by hospitalisation status and pathogen. METHODS: We systematically reviewed published papers from 1970 to 2011. Standard global burden of disease categories (restrictive lung disease, obstructive lung disease, bronchiectasis) were labelled as major sequelae. 'Minor' sequelae (chronic bronchitis, asthma, other abnormal pulmonary function, other respiratory disease), and multiple impairments were also included. Thirteen papers were selected for inclusion. Synthesis was by random effects meta-analysis and meta-regression. RESULTS: Risk of at least one major sequelae was 5.5% (95% confidence interval [95% CI] 2.8-8.3%) in non hospitalised children and 13.6% [6.2-21.1%]) in hospitalised children. Adenovirus pneumonia was associated with the highest sequelae risk (54.8% [39.2-70.5%]) but children hospitalised with no pathogen isolated also had high risk (17.6% [10.9-24.3%]). The most common type of major sequela was restrictive lung disease (5.4% [2.5-10.2%]) . Potential confounders such as loss to follow up and median age at infection were not associated with sequelae risk in the final models. CONCLUSIONS: All children with pneumonia diagnosed by a health professional should be considered at risk of long term sequelae. Evaluation of childhood pneumonia interventions should include potential impact on long term respiratory sequelae.

Global and regional risk of disabling sequelae from bacterial meningitis: a systematic review and meta-analysis.

Few data sources are available to assess the global and regional risk of sequelae from bacterial meningitis. We aimed to estimate the risks of major and minor sequelae caused by bacterial meningitis, estimate the distribution of the different types of sequelae, and compare risk by region and income. We systematically reviewed published papers from 1980 to 2008. Standard global burden of disease categories (cognitive deficit, bilateral hearing loss, motor deficit, seizures, visual impairment, hydrocephalus) were labelled as major sequelae. Less severe, minor sequelae (behavioural problems, learning difficulties, unilateral hearing loss, hypotonia, diplopia), and multiple impairments were also included. 132 papers were selected for inclusion. The median (IQR) risk of at least one major or minor sequela after hospital discharge was 19.9% (12.3-35.3%). The risk of at least one major sequela was 12.8% (7.2-21.1%) and of at least one minor sequela was 8.6% (4.4-15.3%). The median (IQR) risk of at least one major sequela was 24.7% (16.2-35.3%) in pneumococcal meningitis; 9.5% (7.1-15.3%) in Haemophilus influenzae type b (Hib), and 7.2% (4.3-11.2%) in meningococcal meningitis. The most common major sequela was hearing loss (33.9%), and 19.7% had multiple impairments. In the random-effects meta-analysis, all-cause risk of a major sequela was twice as high in the African (pooled risk estimate 25.1% [95% CI 18.9-32.0%]) and southeast Asian regions (21.6% [95% CI 13.1-31.5%]) as in the European region (9.4% [95% CI 7.0-12.3%]; overall I(2)=89.5%, p<0.0001). Risks of long-term disabling sequelae were highest in low-income countries, where the burden of bacterial meningitis is greatest. Most reported sequelae could have been averted by vaccination with Hib, pneumococcal, and meningococcal vaccines.

Incremental system costs of introducing combined DTwP-hepatitis B-Hib vaccine into national immunization services in Ethiopia.

OBJECTIVE: With support from the GAVI Alliance a fully liquid combined DTwP-HepB-Hib (pentavalent) vaccine in a single dose vial was introduced into Ethiopia's routine immunization services in March 2007. This vaccine was substituted with DTwP in a 10-dose vial. We aimed to estimate the incremental system costs of pentavalent vaccine delivery. METHODS: Data on cold storage expansion and increased vaccine transport frequency were collected in four regions of Ethiopia over a 2-week period, as part of a Post-Introduction Evaluation of the new vaccine. Interviews were conducted with individuals at all levels of the health system. Information on the costs of training and communication to facilitate the introduction was collected from the Ministry of Health, UNICEF and WHO in Addis Ababa. RESULTS: The switch from a 10-dose DTwP to a single dose pentavalent vaccine increased refrigeration storage volume per fully vaccinated child by 106% at national and regional levels and by 71% at the three lower levels of vaccine distribution. Cold storage equipment were purchased at all levels and the frequency of vaccine collection more than doubled in many places. Incremental capital costs of cold storage equipment, training and communication amounted to US$ 4.8 million, or US$ 1.53 per child in the 2007 birth cohort. After annualizing capital costs and adding recurrent costs, system costs came to US$ 0.80 per child in the 2007 birth cohort. With a vaccination coverage rate of 78% this is equivalent to US$ 1.13 per fully vaccinated child. The most important system cost item is cold storage, amounting to US$ 0.62 per child in the birth cohort and US$ 0.03 per additional cm(3) of cold storage. CONCLUSION: In Ethiopia introduction of pentavalent vaccine necessitated considerable investments in additional cold storage equipment as well as an increase in vaccine transport frequency. A GAVI Alliance introduction grant of US$ 0.30 per child in the birth cohort would cover approximately 20% of the capital investments undertaken to facilitate introduction.

Commercialism, choice and consumer protection: regulation of complementary medicines in Australia.

Controls on the supply and promotion of complementary medicines in Australia are weak. We used weight-loss products as an example to compare the regulation in Australia of listed complementary medicines and registered pharmaceutical products. Complementary medicines are listed without evaluation for efficacy, while conventional pharmaceutical products are registered after evaluation for quality, safety and efficacy. From 1996 to 2006, over 1000 "weight-loss" products were listed on the Australian Register of Therapeutic Goods; most contained multiple unevaluated ingredients (herbs, vitamins, minerals) of dubious efficacy. Over the same period, 10 conventional medicines were registered; each contained one evaluated ingredient of proven efficacy. The number of listed weight-loss products (and complaints about their promotion) is increasing. These appear to be a direct consequence of the decision not to evaluate listed products for efficacy and the lower fees for listing a product, compared with registration. Complaint procedures (now overloaded) are no substitute for adequate regulation at the time of market entry. Regulatory reform of listed and homoeopathic products is required.

Community consultation and engagement in health care reform.

In advocating for significant reform of the health care system, the Australian Health Care Reform Alliance (AHCRA) supports a process of citizen engagement that will allow the wider community to have a say in the future direction of their health care system. Models that have engaged community opinions have been successful overseas, and this article calls for similar processes in Australia.