Characteristics and Health Care Utilization of Patients With Housing Insecurity in the ED.

Importance: Unstable housing and homelessness can exacerbate adverse health outcomes leading to increased risk of chronic disease, injury, and disability. However, emergency departments (EDs) have no universal method to identify those at risk of or currently experiencing homelessness. Objective: To describe the extent of housing insecurity among patients who seek care in an urban ED, including chief concerns, demographics, and patterns of health care utilization. Design, Setting, and Participants: This cross-sectional study included all adult patients presenting to the ED at Vanderbilt University Medical Center (VUMC), an urban tertiary care, level I trauma center in the Southeast US, from January 5 to May 16, 2023. Main Outcomes and Measures: The primary outcome was the proportion of ED visits at which patients screened positive for housing insecurity. Secondary outcomes included prevalence of insecurity by chief concerns, demographics, and patterns of health care utilization. Results: Of all 23 795 VUMC ED visits with screenings for housing insecurity (12 465 visits among women [52%]; median age, 47 years [IQR, 32-48 years]), in 1185 (5%), patients screened positive for current homelessness or housing insecurity (660 unique patients); at 22 610 visits (95%), the screening result was negative. Of visits with positive results, the median age of patients was 46 years (IQR, 36-55 years) and 829 (70%) were among male patients. Suicide and intoxication were more common chief concerns among visits at which patients screened positive (132 [11%] and 118 [10%], respectively) than among those at which patients screened negative (220 [1%] and 335 [2%], respectively). Visits with positive results were more likely to be among patients who were uninsured (395 [33%] vs 2272 [10%]) and had multiple visits during the study period. A higher proportion of positive screening results occurred between 8 pm and 6 am. The social work team assessed patients at 919 visits (78%) with positive screening results. Conclusions and Relevance: In this cross-sectional study of 23 795 ED visits, at 5% of visits, patients screened positive for housing insecurity and were more likely to present with a chief concern of suicide, to be uninsured, and to have multiple visits during the study period. This analysis provides a call for other institutions to introduce screening and create tailored care plans for patients experiencing housing insecurity to achieve equitable health care.

A Graduate Medical Orientation Intervention Focused on Local Health Inequities.

Background: Residents must understand the social drivers of health in the communities they serve to deliver quality care. While resident orientation provides an opportunity to introduce residents to social and structural drivers of health, inequity, and care delivery relevant to the patient population in their new communities, many graduate medical education orientation curricula do not include this content. Objective: To report the development and implementation of a novel, patient-centered health equity orientation curriculum, including initial feasibility and acceptability data as well as preliminary self-reported outcomes. Methods: The curriculum was developed by academic faculty in collaboration with institutional and local health equity champions. Content centered on the history of inequities and racism within the local communities and included didactic presentations, asynchronous video, and virtual site visits to community resource groups. The curriculum was administered to all 2021 incoming Vanderbilt University Medical Center medical and surgical residents (N=270) over 2 half-days, both in-person and via Zoom. Data were collected anonymously via pre- and post-surveys. Results: A total of 216 residents (80% response rate) provided pre-survey response data, but only 138 residents (51.1%) provided post-survey data, including self-reported demographics (eg, underrepresented in medicine status) and level of agreement with 10 competency-based statements coded as pertaining to knowledge, skills, behaviors, or attitudes (KSBAs). Primary outcomes included improvement in residents' KSBAs from pre- to post-survey. The greatest increases in percentages occurred with content that was specific to local history and population. Conclusions: In a class of incoming residents, this study demonstrated feasibility, acceptability, and pre-post curriculum improvement in self-reported KSBAs when addressing health equity issues.

Development of an Emergency Department-Based Intervention to Expand Access to Medications for Opioid Use Disorder in a Medicaid Nonexpansion Setting: Protocol for Engagement and Community Collaboration.

BACKGROUND: The opioid epidemic has disproportionately impacted areas in the Appalachian region of the United States. Characterized by persistent Medicaid nonexpansion, higher poverty rates, and health care access challenges, populations residing in these areas of the United States have experienced higher opioid overdose death rates than those in other parts of the country. Jefferson County, Alabama, located in Southern Appalachia, has been especially affected, with overdose rates over 2 times greater than the statewide average (48.8 vs 19.9 overdoses per 10,000 persons). Emergency departments (EDs) have been recognized as a major health care source for persons with opioid use disorder (OUD). A program to initiate medications for OUD in the ED has been shown to be effective in treatment retention. Likewise, continued patient engagement in a recovery or treatment program after ED discharge has been shown to be efficient for long-term treatment success. OBJECTIVE: This protocol outlines a framework for ED-initiated medications for OUD in a resource-limited region of the United States; the study will be made possible through community partnerships with referral resources for definitive OUD care. METHODS: When a patient presents to the ED with symptoms of opioid withdrawal, nonfatal opioid overdose, or requesting opioid detoxification, clinicians will consider the diagnosis of OUD using the Diagnostic and Statistical Manual of Mental Disorders (fifth edition) criteria. All patients meeting the diagnostic criteria for moderate to severe OUD will be further engaged and assessed for study eligibility. Recruited subjects will be evaluated for signs and symptoms of withdrawal, treated with buprenorphine-naloxone as appropriate, and given a prescription for take-home induction along with an intranasal naloxone kit. At the time of ED discharge, a peer navigator from a local substance use coordinating center will be engaged to facilitate patient referral to a regional substance abuse coordinating center for longitudinal addiction treatment. RESULTS: This project is currently ongoing; it received funding in February 2019 and was approved by the institutional review board of the University of Alabama at Birmingham in June 2019. Data collection began on July 7, 2019, with a projected end date in February 2022. In total, 79 subjects have been enrolled to date. Results will be published in the summer of 2022. CONCLUSIONS: ED recognition of OUD accompanied by buprenorphine-naloxone induction and referral for subsequent long-term treatment engagement have been shown to be components of an effective strategy for addressing the ongoing opioid crisis. Establishing community and local partnerships, particularly in resource-limited areas, is crucial for the continuity of addiction care and rehabilitation outcomes. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/18734.

Pilot Study of Kano "Attractive Quality" Techniques to Identify Change in Emergency Department Patient Experience.

STUDY OBJECTIVE: We describe the use of the Kano Attractive Quality analytic tool to improve an identified patient experience gap in perceived compassion by emergency department (ED) providers. METHODS: In phase 1, point-of-service surveying assessed baseline patient perception of ED provider compassion. Phase 2 deployed Kano surveys to predict the effect of 4 proposed interventions on patient perception. Finally, phase 3 compared patients receiving standard care versus the Kano-identified intervention to assess the actual effect on patient experience. RESULTS: In phase 1, 193 of 200 surveys (97%) were completed, showing a baseline median score of 4 out of 5 (interquartile range [IQR] 3 to 5), with top box percentage of 33% for patients' perception of receiving compassionate care. In phase 2, 158 of 180 surveys (88%) using Kano-formatted questions were completed, and the data predicted that increasing shared decisionmaking would cause the greatest improvement in the patient experience. Finally, in phase 3, 45 of 49 surveys (92%) were returned and demonstrated a significant improvement in perceived concern and sensitivity, 5 (IQR 5 to 5) versus 4 (IQR 3 to 5) with a difference of 1 (95% CI 0.1-1.9) and a top box rating of 79% versus 35% with a difference of 44% (95% CI 12-66) by patients who received dedicated shared decisionmaking interventions versus those receiving standard of care. CONCLUSION: Kano analysis is likely predictive of change in patient experience. Kano methods may prove as useful in changing management of the health care industry as it has been in other industries.

Risk stratification of patients in an emergency department chest pain unit: prognostic value of exercise treadmill testing using the Duke score.

BACKGROUND: Exercise treadmill testing (ETT) has been standard for evaluating outpatients at risk for cardiovascular events. Few studies have demonstrated its prognostic usefulness in emergency department chest pain units or have used the Duke score [(exercise duration in minutes) - (5 x ST-segment deviation in millimeters) - (4 x treadmill angina index)] to grade its performance. AIMS: Our objective was to assess the usefulness of this score in a chest pain unit to predict cardiovascular events. METHODS: From November 2000 to October 2001, we retrospectively studied consecutive patients in the chest pain unit. Those undergoing ETT were stratified into "low" (Duke score > or = 5) and "moderate/high" risk groups (< 5). Cardiovascular events defined as death, myocardial infarction > 24 h after presentation, revascularization, acute congestive heart failure, stroke or arrhythmia were identified within 1 year after presentation. Differences in risk of having a cardiovascular event among low-risk and moderate/high-risk groups are presented. RESULTS: During the study period, 1,048 patients entered the chest pain unit; 800 met inclusion criteria. Of these, 599 received ETT and 201 had contraindications or a positive finding in the chest pain unit protocol before ETT. Cardiovascular event rates were 0.7% (3/454), 15.2% (22/145) and 14.9% (30/201) after 1 month of follow-up for low-risk, moderate/high-risk and no-ETT groups, respectively. CONCLUSIONS: According to the Duke score, the low-risk group developed minimal cardiovascular events compared with the moderate/high-risk group. The Duke score appears effective for risk stratification of chest pain patients in chest pain units.