Let Their Voices Be Seen.

STUDY OBJECTIVE: The mutual distrust, in part caused by misunderstanding and bias, between sickle cell disease (SCD) patients and their emergency department (ED) providers has been widely documented in the SCD literature. This study seeks to illustrate the perceptions and experiences of adult sickle cell patients who have had at least 1 ED experience in the last 2 years. METHODS: Qsource, a nonprofit health care consultancy based in Tennessee, used photovoice, a qualitative research method, to facilitate the representation of patients' experiences in living with SCD. Photovoice has participants document their experiences through photography and then, as a group, discuss and analyze the emotional state behind the photographs. Eight participants with SCD took 25 photographs during 4 weeks. Then, in a 2-hour critical dialogue, participants identified recurring themes through consensus. RESULTS: Participants identified 6 themes that emerged from their discussion: unpredictability of SCD, fickleness of time, coping with pain, proximity to death, avoidance of the ED, and need for improved communication. They expressed their wish to be active participants in their care, and many described a fear of death, which is exacerbated by a lack of control in the ED setting. CONCLUSION: Factors such as poor patient experience and misunderstanding may contribute to delays in seeking care for SCD patients. This may, in turn, escalate pain crises and increase the likelihood of hospital admission. We believe that photovoice may be a new means to educate ED providers on SCD patient perceptions, ultimately resulting in better ED care.

The burden of acute heart failure on U.S. emergency departments.

OBJECTIVES: The goal of this study was to examine 2006 to 2010 emergency department (ED) admission rates, hospital procedures, lengths of stay, and costs for acute heart failure (AHF). BACKGROUND: Patients with AHF are often admitted and are associated with high readmissions and cost. METHODS: We utilized Nationwide Emergency Department Sample AHF data from 2006 to 2010 to describe admission proportion, hospital length of stay (LOS), and ED charges as a surrogate for resource utilization. Results were compared across U.S. regions, patient insurance status, and hospital characteristics. RESULTS: There were 958,167 mean yearly ED visits for AHF in the United States. Fifty-one percent of the patients were female, and the median age was 75.1 years (interquartile range [IQR]: 62.5 to 83.7 years). Overall, 83.7% (95% confidence interval: 83.1% to 84.2%) were admitted; the median LOS was 3.4 days (IQR: 1.9 to 5.8 days). Comparing 2006 with 2010, there was a small decrease in median LOS (0.09 days), but the proportion admitted did not change. Odds of admission, adjusting for age, sex, hospital characteristic (academic and safety net status), and insurance (Medicare, Medicaid, private, self-pay/no charge) were highest in the Northeast. Median ED charges were $1,075 (IQR: $679 to $1,665) in 2006 and $1,558 (IQR: $1,018 to $2,335) in 2010. Patients without insurance were more likely to be discharged from the ED, but when admitted, were more likely to receive a major diagnostic or therapeutic procedure. CONCLUSIONS: A very high proportion of ED patients with AHF are admitted nationally, with significant variation in disposition and procedural decisions based on region of the country and type of insurance, even after adjusting for potential confounding.

Predictors of regional variations in hospitalizations following emergency department visits for atrial fibrillation.

The emergency department (ED) is often where atrial fibrillation (AF) is first detected and acutely treated and affected patients dispositioned. We used the Nationwide Emergency Department Sample to estimate the percentage of visits resulting in hospitalization and investigate associations between patient and hospital characteristics with hospitalization at the national and regional levels. We conducted a cross-sectional study of adults with AF listed as the primary ED diagnosis in the 2007 to 2009 Nationwide Emergency Department Sample. We performed multivariate logistic regression analyses investigating the associations between prespecified patient and hospital characteristics with hospitalization. From 2007 to 2009, there were 1,320,123 weighted ED visits for AF, with 69% hospitalized nationally. Mean regional hospitalization proportions were: Northeast (74%), Midwest (68%), South (74%), and West (57%). The highest odds ratios for predicting hospitalization were heart failure (3.85, 95% confidence interval [CI] 3.66 to 4.02), chronic obstructive pulmonary disease (2.47, 95% CI 2.34 to 2.61), and coronary artery disease (1.65, 95% CI 1.58 to 1.73). After adjusting for age, privately insured (0.77, 95% CI 0.73 to 0.81) and self-pay (0.77 95% CI 0.66 to 0.90) patients had lower odds compared with Medicare recipients, whereas Medicaid (1.21, 95% CI 1.11 to 1.32) patients tended to have higher odds. Patients living in low-income zip codes (1.18, 95% CI 1.12 to 1.25) and patients treated at large metropolitan hospitals (1.75, 95% CI 1.59 to 1.93) had higher odds. In conclusion, our analysis showed considerable regional variation in the management of patients with AF in the ED and in associations between patient socioeconomic and hospital characteristics with ED disposition; adapting best practices from among these variations in management could reduce hospitalizations and health-care expenses.

An evaluation of statewide emergency department utilization following Tennessee Medicaid disenrollment.

OBJECTIVES: During a series of reforms to the Tennessee Medicaid expansion program (TennCare) in 2005, approximately 171,000 adults were disenrolled from Medicaid. The objective of this study was to examine the statewide effect of such a disenrollment on Tennessee emergency department (ED) utilization. METHODS: Administrative data on all ED visits in Tennessee from 2004 through 2006 were obtained from the State Emergency Department Database and State Inpatient Database under the Healthcare Utilization Project. Population statistics and uninsured estimates were obtained from the U.S. Census Bureau, and TennCare enrollment data were obtained from the State of Tennessee Department of TennCare. The proportion and rate of ED visits, assessed separately by payer type, were compared across a predisenrollment period from January 1, 2004, through July 31, 2005, and across a postdisenrollment period from August 1, 2005, through December 31, 2006. The proportion and rate of ED visits resulting in hospital admission, again assessed separately by payer type, were compared across the same disenrollment periods in a similar way. We fitted a series of linear models for the total number of ED visits and each proportion and rate, with various degrees of adjustment for seasonality and time trend. RESULTS: The mean number of ED visits was 45,662 per week during the predisenrollment period and 44,463 per week during the postdisenrollment period (mean difference = -1,199; 95% confidence interval [CI] -1,722 to -676). By payer category, there was a decrease of 3,119 visits per week by TennCare beneficiaries and an increase of 2,203 per week by the uninsured. After disenrollment, the absolute proportion of ED visits by TennCare beneficiaries significantly decreased by 6.2% (95% CI = -6.6% to -5.8%), and the absolute proportion of uninsured ED visits increased by 5.3% (95% CI = 4.9% to 5.7%). The rate of ED visits by TennCare beneficiaries decreased by -0.091 ED visits/person/year (95% CI = -0.136 to -0.046) in the disenrollment period when controlling for time and seasonality. The rate of ED visits among the uninsured increased by 0.038 ED visits/person/year (95% CI = 0.011 to 0.065) in the postdisenrollment period when controlling for cubic time trend. The proportion of all TennCare ED visits that resulted in hospital admission did not change significantly between the two periods after adjusting for time trend and seasonality. The proportion of uninsured ED visits resulting in hospital admission, however, significantly increased after disenrollment by 2.0% (95% CI = 1.8% to 2.2%) and by 0.6% (95% CI = 0.0% to 1.2%) after adjusting for time and seasonality. CONCLUSIONS: The TennCare disenrollment of 2005 was associated with a modest decrease in the number of total ED visits in Tennessee. However, the payer mix among the Tennessee ED population shifted abruptly. The increased rate of ED visits by Tennessee's uninsured and the increased proportion of uninsured ED visits leading to hospital admission suggest an increased burden of illness in this highly vulnerable population.

Those who can, do and they teach too: faculty clinical productivity and teaching.

OBJECTIVE: Academic emergency physicians (EPs) often feel that the demands of clinical productivity, income generation, and patient satisfaction conflict with educational objectives. The objective of this study was to explore whether the quality of faculty bedside teaching of residents correlated with high clinical productivity, measured by relative value units (RVUs). We also explored the strategies of high-performing faculty for optimal RVU generation and teaching performance. METHODS: We performed a mixed method study using quantitative and qualitative methods to analyze the relationship between RVUs, patient satisfaction, and teaching performance. We examined the relationship between teaching performance ratings, patient satisfaction, and RVUs per hour using correlations. Following this initial analysis, we conducted semi-structured interviews with the eight faculty members who have the highest clinical (RVU) and educational productivity ratings to learn more about their strategies for success. Our Institutional Review Board approved this study. RESULTS: We correlated resident evaluations of faculty with RVUs billed per hour. We conducted semi-structured interviews of faculty who led in both RVU productivity and resident evaluations. From these interviews, several themes emerged. When asked about how they excel in billing, most said that they pay attention to dictating a thorough chart on every patient and try to "stay busy" throughout their entire shift. When asked how they excel at resident education, most leading faculty said that they try to find a "teaching moment" and find small "clinical pearls" to pass along. Nevertheless, all eight leading faculty members believe that as the emphasis on billing productivity increases, resident and student education will suffer. CONCLUSION: Contrary to the opinion of some physicians, faculty can excel at both clinical productivity and resident education. This study found that highly efficient clinical productivity correlated with excellent resident teaching. This high level of performance did not appear to be at the expense of other important measures such as patient satisfaction or student teaching.

Surgeons' and emergency physicians' perceptions of trauma management and training.

OBJECTIVE: The study objective was to determine whether surgeons and emergency medicine physicians (EMPs) have differing opinions on trauma residency training and trauma management in clinical practice. METHODS: A survey was mailed to 250 EMPs and 250 surgeons randomly selected. RESULTS: Fifty percent of surgeons perceived that surgery exclusively managed trauma compared to 27% of EMPs. Surgeons were more likely to feel that only surgeons should manage trauma on presentation to the ED. However, only 60% of surgeons currently felt comfortable with caring for the trauma patient, compared to 84% of EMPs. Compared to EMPs, surgeons are less likely to feel that EMPs can initially manage the trauma patient (71% of surgeons vs. 92% of EMPs). CONCLUSION: EMPs are comfortable managing trauma while many surgeons do not feel comfortable with the complex trauma patient although the majority of surgeons responded that surgeons should manage the trauma.

Ovarian vein thrombosis: a rare cause of abdominal pain outside the peripartum period.

Ovarian vein thrombosis (OVT) is a rare cause of abdominal pain that may mimic a surgical abdomen. The differential diagnosis of OVT includes acute appendicitis, endometritis, pelvic inflammatory disease, pyelonephritis, nephrolithiasis, tubo-ovarian abscess, and ovarian torsion. The complications of OVT, including sepsis and pulmonary embolism, are significant. Diagnosis relies on a careful examination of the radiographic findings. This diagnosis should be considered not only in postpartum patients but also in women with pelvic inflammatory disease, recent abdominal surgery, malignancy, or known hypercoagulable state. In this report we present a case of OVT in a 29-year-old woman presenting with 3 days of sharp left-sided abdominal pain, nausea, and vomiting after bilateral salpingectomy. We then discuss the epidemiology, pathophysiology, and clinical management of OVT.

The changing epidemiology of HIV/AIDS in Tennessee.

BACKGROUND: We describe the changing epidemiology of HIV/AIDS in Tennessee to identify opportunities for improved response to the epidemic. METHODS: Health department records of all new cases of HIV/AIDS in Tennessee from January 1992 through December 2001 were examined. Cases were defined according to CDC criteria and classified as HIV or AIDS based on diagnosis in the initial report. RESULTS: During the ten-year study period, 14,278 new cases were reported; 67% were HIV and 33% were AIDS. Incidence in males was three times higher than females. The rate among blacks was seven times higher than whites. From 1992-1996, 17% of cases had a primary risk factor of heterosexual contact, increasing to 26% in 1997-2001 (P<0.01). The proportion of new cases with a diagnosis of AIDS was higher in non-metropolitan than metropolitan areas (35% vs. 21%, P<0.01). CONCLUSIONS: Intervention efforts should include targeting to blacks, females, heterosexual exposure, and persons in non-urban communities.