The impact of outpatient supportive oncology on cancer care cost and utilization.

BACKGROUND: Supportive oncology (SO) care reduces symptom severity, admissions, and costs in patients with advanced cancer. This study examines the impact of SO care on utilization and costs. METHODS: Retrospective analysis of utilization and costs comparing patients enrolled in SO versus three comparison cohorts who did not receive SO. Using claims, the authors estimated differences in health care utilization and cost between the treatment group and comparison cohorts. The treatment group consisting of patients treated for cancer at an National Cancer Institute-designated cancer center who received SO between January 2018 and December 2019 were compared to an asynchronous cohort that received cancer care before January 2018 (n = 60), a contemporaneous cohort with palliative care receiving SO care from other providers in the Southeastern Pennsylvania region during the program period (n = 86), and a contemporaneous cohort without palliative care consisting of patients at other cancer centers who were eligible for but did not receive SO care (n = 393). RESULTS: At 30, 60, and 90 days post-enrollment into SO, the treatment group had between 27% and 70% fewer inpatient admissions and between 16% and 54% fewer emergency department visits (p < .05) compared to non-SO cohorts. At 90 days following enrollment in SO care, total medical costs were between 4.4% and 24.5% lower for the treatment group across all comparisons (p < .05). CONCLUSIONS: SO is associated with reduced admissions, emergency department visits, and total costs in advanced cancer patients. Developing innovative reimbursement models could be a cost-effective approach to improve care of patients with advanced cancer.

Barriers to Participation in a Structured Quality Improvement Initiative to Reduce Avoidable Emergency Department Visits-A Qualitative Study.

INTRODUCTION: Barriers to quality improvement (QI) initiatives in multi-institutional hospital settings are understudied. Here we describe a qualitative investigation of factors negatively affecting a QI initiative focused on reducing avoidable emergency department (ED) visits after bariatric surgery across 17 hospitals. Our goal was to explore participant perspectives and identify themes describing why the program was not effectively implemented or why the program may have been ineffective when correctly implemented. METHODS: We performed semistructured group interviews with 17 sites (42 interviews) participating in a statewide bariatric QI program. We used descriptive content analysis to identify challenges, facilitators, and barriers to implementation of the QI program. All analyses were conducted using MAXQDA software. RESULTS: Results revealed barriers across hospitals related to four themes: buy-in, provider accessibility, resources at participating hospitals, and patient barriers to care. In particular, the initiative faced difficulty if it was not well-matched to the factors driving increasing ED visits at a particular site, such as lack of patient access to outpatient or primary care. Additional challenges occurred if the initiative was not adapted and customized to the working systems in place at each site, involving employees, surgeons, support staff, and leadership. CONCLUSIONS: Overall, findings can direct future focused efforts aimed at site-specific interventions to reduce unnecessary postoperative ED visits. Results demonstrated a need for a nuanced approach that can be adapted based on facility needs and resources.

Global climate change: Effects of future temperatures on emergency department visits for mental disorders in Beijing, China.

Rising temperatures can increase the risk of mental disorders. As climate change intensifies, the future disease burden due to mental disorders may be underestimated. Using data on the number of daily emergency department visits for mental disorders at 30 hospitals in Beijing, China during 2016-2018, the relationship between daily mean temperature and such visits was assessed using a quasi-Poisson model integrated with a distributed lag nonlinear model. Emergency department visits for mental disorders attributed to temperature changes were projected using 26 general circulation models under four climate change scenarios. Stratification analyses were then conducted by disease subtype, sex, and age. The results indicate that the temperature-related health burden from mental disorders was projected to increase consistently throughout the 21st century, mainly driven by high temperatures. The future temperature-related health burden was higher for patients with mental disorders due to the use of psychoactive substances and schizophrenia as well as for women and those aged <65 years. These findings enhance our knowledge of how climate change could affect mental well-being and can be used to advance and refine targeted approaches to mitigating and adapting to climate change with a view on addressing mental disorders.

Pollen and viruses contribute to spatio-temporal variation in asthma-related emergency department visits.

BACKGROUND: Asthma exacerbations are an important cause of emergency department visits but much remains unknown about the role of environmental triggers including viruses and allergenic pollen. A better understanding of spatio-temporal variation in exposure and risk posed by viruses and pollen types could help prioritize public health interventions. OBJECTIVE: Here we quantify the effects of regionally important Cupressaceae pollen, tree pollen, other pollen types, rhinovirus, seasonal coronavirus, respiratory syncytial virus, and influenza on asthma-related emergency department visits for people living near eight pollen monitoring stations in Texas. METHODS: We used age stratified Poisson regression analyses to quantify the effects of allergenic pollen and viruses on asthma-related emergency department visits. RESULTS: Young children (<5 years of age) had high asthma-related emergency department rates (24.1 visits/1,000,000 person-days), which were mainly attributed to viruses (51.2%). School-aged children also had high rates (20.7 visits/1,000,000 person-days), which were attributed to viruses (57.0%), Cupressaceae pollen (0.7%), and tree pollen (2.8%). Adults had lower rates (8.1 visits/1,000,000 person-days) which were attributed to viruses (25.4%), Cupressaceae pollen (0.8%), and tree pollen (2.3%). This risk was spread unevenly across space and time; for example, during peak Cuppressaceae season, this pollen accounted for 8.2% of adult emergency department visits near Austin where these plants are abundant, but 0.4% in cities like Houston where they are not; results for other age groups were similar. CONCLUSIONS: Although viruses are a major contributor to asthma-related emergency department visits, airborne pollen can explain a meaningful portion of visits during peak pollen season and this risk varies over both time and space because of differences in plant composition.

Disparities in the impact of heat wave definitions on emergency department visits during the first year of life among preterm and full-term infants in California.

INTRODUCTION: Heat waves will be aggravated due to climate change, making this a critical public health threat. However, heat wave definitions to activate alert systems can be ambiguous, highlighting the need to assess a range of definitions to identify those that contribute to the most adverse health outcomes. Additionally, children are highly susceptible to the impacts of heat waves, especially infants, despite the lack of focus on this subpopulation. We aimed to assess the relationship between 30 heat wave definitions and the first all-cause emergency department (ED) visits for California infants. We also examined modification of this relationship by preterm birth status and demographic characteristics to identify possible health disparities. METHODS: Live-born, singleton deliveries from the Study of Outcomes in Mothers and Infants born in 2014-2018 were included. Thirty heat wave definitions were assessed based on temperature metrics (minimum/maximum temperatures), thresholds (90th; 92.5th; 95th; 97.5th; 99th percentiles), and duration (1-; 2-; 3-days). A time-stratified case-crossover design assessed heat wave impacts on ED visits using infants with a warm season ED visit (May-October) within the first year of life (n = 228,250). Effect modification by preterm birth status, age, sex, race/ethnicity, education, and delivery payment type was also investigated. RESULTS: Infants demonstrated increased risk of an ED visit with exposure to all heat definitions. The 3-day minimum temperature 99th percentile definition had the highest adjusted odds ratio (AOR: 1.14; 95% CI: 1.05-1.23) for the total population. Term infants were more affected by some heat waves than preterm infants. Effect modification was additionally identified, such as by maternal education. DISCUSSION: This study provides insight on the heat wave definitions that lead to adverse health outcomes and the identification of the most susceptible infants to these impacts, which has implications on heat-related interventions.

Lag effect of ambient temperature on respiratory emergency department visits in Beijing: a time series and pooled analysis.

BACKGROUND: Although the association between ambient temperature and mortality of respiratory diseases was numerously documented, the association between various ambient temperature levels and respiratory emergency department (ED) visits has not been well studied. A recent investigation of the association between respiratory ED visits and various levels of ambient temperature was conducted in Beijing, China. METHODS: Daily meteorological data, air pollution data, and respiratory ED visits data from 2017 to 2018 were collected in Beijing. The relationship between ambient temperature and respiratory ED visits was explored using a distributed lagged nonlinear model (DLNM). Then we performed subgroup analysis based on age and gender. Finally, meta-analysis was utilized to aggregate the total influence of ambient temperature on respiratory ED visits across China. RESULTS: The single-day lag risk for extreme cold peaked at a relative risk (RR) of 1.048 [95% confidence interval (CI): 1.009, 1.088] at a lag of 21 days, with a long lag effect. As for the single-day lag risk for extreme hot, a short lag effect was shown at a lag of 7 days with an RR of 1.076 (95% CI: 1.038, 1.114). The cumulative lagged effects of both hot and cold effects peaked at lag 0-21 days, with a cumulative risk of the onset of 3.690 (95% CI: 2.133, 6.382) and 1.641 (95% CI: 1.284, 2.098), respectively, with stronger impact on the hot. Additionally, the elderly were more sensitive to ambient temperature. The males were more susceptible to hot weather than the females. A longer cold temperature lag effect was found in females. Compared with the meta-analysis, a pooled effect of ambient temperature was consistent in general. In the subgroup analysis, a significant difference was found by gender. CONCLUSIONS: Temperature level, age-specific, and gender-specific effects between ambient temperature and the number of ED visits provide information on early warning measures for the prevention and control of respiratory diseases.

Collaborative Integration of Community Health Workers in Hospitals and Health Centers to Reduce Pediatric Asthma Disparities: A Quality Improvement Program Evaluation.

To address pediatric asthma disparities on the South Side of Chicago, a community health worker (CHW) home visiting intervention was implemented collaboratively by academic institutions and community based health centers. This evaluation assessed the effectiveness of this longitudinal quality improvement CHW intervention in reducing asthma morbidity and healthcare utilization. All patients aged 2-18 who met the high-risk clinical criteria in outpatient settings or those who visited the ED due to asthma were offered the program. A within-subject study design analyzed asthma morbidity and healthcare utilization at baseline and follow-up. Multivariable mixed-effects regression models, adjusted for baseline demographic and asthma characteristics, were used to assess changes over time. Among 123 patients, the average age was 8.8 (4.4) years, and 89.3% were non-Hispanic black. Significant reductions were observed in the average daytime symptoms days (baseline 4.1 days and follow-up 1.6 days), night-time symptoms days (3.0 days and 1.2 days), and days requiring rescue medication (4.1 days and 1.6 days) in the past two weeks (all p < 0.001). The average number of emergency department visits decreased from 0.92 one year before to 0.44 one year after program participation, a 52% reduction (p < 0.001). No significant difference was found in hospital admissions. These results support the use of a collaborative approach to implement the CHW home visiting program as part of standard care for pediatric asthma patients in urban settings. This approach has the potential to reduce asthma disparities and underscores the valuable role of CHWs within the clinical care team.

Inpatient Hospital Costs, Emergency Department Visits, and Readmissions for Revision Hip and Knee Arthroplasty.

BACKGROUND: Revision total hip arthroplasty (THA) and total knee arthroplasty (TKA) tremendously burden hospital resources. This study evaluated factors influencing perioperative costs, including emergency department (ED) visits, readmissions, and total costs-of-care within 90 days following revision surgery. METHODS: A retrospective analysis of 772 revision TKAs and THAs performed on 630 subjects at a single center between January 2007 and December 2019 was conducted. Cost data were available from January 2015 to December 2019 for 277 patients. Factors examined included comorbidities, demographic information, preoperative Anesthesia Society of Anesthesiologists score, implant selection, and operative indication using mixed-effects linear regression models. RESULTS: Among 772 revisions (425 THAs and 347 TKAs), 213 patients required an ED visit, and 90 required hospital readmission within 90 days. There were 22.6% of patients who underwent a second procedure after their initial revision. Liver disease was a significant predictor of ED readmission for THA patients (multivariable odds ratio [OR]: 3.473, P = .001), while aseptic loosening, osteolysis, or instability significantly reduced the odds of readmission for TKA patients (OR: 0.368, P = .014). In terms of ED visits, liver disease increased the odds for THA patients (OR: 1.845, P = .100), and aseptic loosening, osteolysis, or instability decreased the odds for TKA patients (OR: 0.223, P < .001). Increased age was associated with increased costs in both THA and TKA patients, with significant cost factors including congestive heart failure for TKA patients (OR: $7,308.17, P = .004) and kidney disease for THA patients. Revision surgeries took longer than primary ones, with TKA averaging 3.0 hours (1.6 times longer) and THA 2.8 hours (1.5 times longer). CONCLUSIONS: Liver disease increases ED readmission risk in revision THA, while aseptic loosening, osteolysis, or instability decreases it in revision TKA. Increased age and congestive heart failure are associated with increased costs. These findings inform postoperative care and resource allocation in revision arthroplasty. LEVEL OF EVIDENCE: Economic and Decision Analysis, Level IV.

Assessing the Impact of the COVID-19 Pandemic on Pediatric Emergency Department Visits in Taiwan.

Background and Objectives: The coronavirus disease 2019 (COVID-19) pandemic has profoundly impacted healthcare systems worldwide. To assess the effects of the pandemic on pediatric emergency department (ED) visits in Taiwan, we conducted a study to evaluate changes in pediatric ED visits during the COVID-19 pandemic. Materials and Methods: This retrospective study included pediatric patients (age ≤ 18) who visited the ED between 21 January 2019 and 30 April 2019, at three hospitals of the Cathay Health System, and compared them with a corresponding period in 2020. Basic information, including mode of arrival, triage level, disposition, chief complaints, and incidence rates, were analyzed before and during the pandemic. Results: A total of 10,116 patients, with 6009 in the pre-pandemic group and 4107 in the pandemic group, were included in this study. The mean number of daily pediatric ED visits decreased from 60.09 before the pandemic to 40.66 during the pandemic, while ambulance use increased significantly by 2.56%. The percentage of patients with high acuity triage levels (levels 1 and 2) was significantly lower during the pandemic period (0.63% and 10.18%, respectively) than the pre-pandemic period (0.7% and 10.9%, respectively). Additionally, a significantly higher proportion of patients were discharged during the pandemic period (89.36%) than during the pre-pandemic period (88.33%). The proportion of COVID-19-related complaints, such as fever and respiratory tract infections, as well as other complaints including gastrointestinal issues, trauma, and psychological problems, significantly increased during the pandemic. Conclusions: In preparation for future pandemics, we recommend increasing emergency medical service capacity, establishing a non-contagious route for obtaining chronic medication prescriptions, optimizing staff allocation in pediatric emergency departments, and increasing the number of hospital social workers for enhanced support.

Machine Learning-Based Early Warning Systems for Acute Care Utilization During Systemic Therapy for Cancer.

BACKGROUND: Emergency department visits and hospitalizations frequently occur during systemic therapy for cancer. We developed and evaluated a longitudinal warning system for acute care use. METHODS: Using a retrospective population-based cohort of patients who started intravenous systemic therapy for nonhematologic cancers between July 1, 2014, and June 30, 2020, we randomly separated patients into cohorts for model training, hyperparameter tuning and model selection, and system testing. Predictive features included static features, such as demographics, cancer type, and treatment regimens, and dynamic features, such as patient-reported symptoms and laboratory values. The longitudinal warning system predicted the probability of acute care utilization within 30 days after each treatment session. Machine learning systems were developed in the training and tuning cohorts and evaluated in the testing cohort. Sensitivity analyses considered feature importance, other acute care endpoints, and performance within subgroups. RESULTS: The cohort included 105,129 patients who received 1,216,385 treatment sessions. Acute care followed 182,444 (15.0%) treatments within 30 days. The ensemble model achieved an area under the receiver operating characteristic curve of 0.742 (95% CI, 0.739-0.745) and was well calibrated in the test cohort. Important predictive features included prior acute care use, treatment regimen, and laboratory tests. If the system was set to alarm approximately once every 15 treatments, 25.5% of acute care events would be preceded by an alarm, and 47.4% of patients would experience acute care after an alarm. The system underestimated risk for some treatment regimens and potentially underserved populations such as females and non-English speakers. CONCLUSIONS: Machine learning warning systems can detect patients at risk for acute care utilization, which can aid in preventive intervention and facilitate tailored treatment. Future research should address potential biases and prospectively evaluate impact after system deployment.

Migraine and air pollution: A systematic review.

OBJECTIVE: To systematically synthesize evidence from a broad range of studies on the association between air pollution and migraine. BACKGROUND: Air pollution is a ubiquitous exposure that may trigger migraine attacks. There has been no systematic review of this possible association. METHODS: We searched for empirical studies assessing outdoor air pollution and any quantified migraine outcomes. We included short- and long-term studies with quantified air pollution exposures. We excluded studies of indoor air pollution, perfume, or tobacco smoke. We assessed the risk of bias with the World Health Organization's bias assessment instrument for air quality guidelines. RESULTS: The final review included 12 studies with over 4,000,000 participants. Designs included case-crossover, case-control, time series, and non-randomized pre-post intervention. Outcomes included migraine-related diagnoses, diary records, medical visits, and prescriptions. Rather than pooling the wide variety of exposures and outcomes into a meta-analysis, we tabulated the results. Point estimates above 1.00 reflected associations of increased risk. In single-pollutant models, the percent of point estimates above 1.00 were carbon monoxide 5/5 (100%), nitrogen dioxide 10/13 (78%), ozone 7/8 (88%), PM2.5 13/15 (87%), PM10 2/2 (100%), black carbon 0/1 (0%), methane 4/6 (75%), sulfur dioxide 3/5 (60%), industrial toxic waste 1/1 (100%), and proximity to oil and gas wells 6/13 (46%). In two-pollutant models, 16/17 (94%) of associations with nitrogen dioxide were above 1.00; however, more than 75% of the confidence intervals included the null value. Most studies had low to moderate risks of bias. Where differences were observed, stronger quality articles generally reported weaker associations. CONCLUSIONS: Balancing the generally strong methodologies with the small number of studies, point estimates were mainly above 1.00 for associations of carbon monoxide, nitrogen dioxide, ozone, and particulate matter with migraine. These results were most consistent for nitrogen dioxide.

Trends in seasonal pollen and asthma-related morbidity among adults and children in a U.S. high-density urban center, 2001-2020.

OBJECTIVE: To analyze the long-term trends in pollen counts and asthma-related emergency department visits (AREDV) in adult and pediatric populations in the Bronx. METHODS: Daily values of adult and pediatric AREDV were retrospectively obtained from three major Bronx hospitals using ICD-10 codes and pollen counts were obtained from the Armonk station from 2001-2020. Wilcoxon Ranked Sum was applied to compare median values, while Spearman correlation was employed to examine the association between these variables, for both decades and each season. RESULTS: The median value of pediatric AREDV increased by 200% from the 1st to 2nd decade (p < 0.001) and AREDV peak shifted from predominantly the spring season in the 1st decade to the fall and winter seasons in the 2nd decade. Seasonal patterns were consistent over 20 years with summer AREDV lower than all other seasons (9 vs. 17 per day) (p < 0.001). Spring tree pollen peaks were correlated with AREDV peaks (rho = 0.34) (p < 0.001). Tree pollen exceeding 100 grains/m3 corresponded to a median of 19.0 AREDVs while all other tree pollen (0 - 99 grains/m3) corresponded to a median of 15.0 AREDVs (p < 0.001). AREDVs sharply declined in 2020, coinciding with the emergence of COVID-19. CONCLUSIONS: Pollen and AREDVs peak earlier in the spring and are more strongly interconnected, while asthma rates among children are rapidly rising, particularly in the fall and winter. These findings can advise targeted awareness campaigns for better management of asthma related morbidity.

Short-term associations between warm-season ambient temperature and emergency department visits for Alzheimer's disease and related dementia in five US states.

BACKGROUND: Ambient temperatures are projected to increase in the future due to climate change. Alzheimer's disease (AD) and Alzheimer's disease-related dementia (ADRD) affect millions of individuals and represent substantial health burdens in the US. High temperature may be a risk factor for AD/ADRD outcomes with several recent studies reporting associations between temperature and AD mortality. However, the link between heat and AD morbidity is poorly understood. METHODS: We examined short-term associations between warm-season daily ambient temperature and AD/ADRD emergency department (ED) visits for individuals aged 45 years or above during the warm season (May to October) for up to 14 years (2005-2018) in five US states: California, Missouri, North Carolina, New Jersey, and New York. Daily ZIP code-level maximum, average and minimum temperature exposures were derived from 1 km gridded Daymet products. Associations are assessed using a time-stratified case-crossover design using conditional logistic regression. RESULTS: We found consistent positive short-term effects of ambient temperature among 3.4 million AD/ADRD ED visits across five states. An increase of the 3-day cumulative temperature exposure of daily average temperature from the 50th to the 95th percentile was associated with a pooled odds ratio of 1.042 (95% CI: 1.034, 1.051) for AD/ADRD ED visits. We observed evidence of the association being stronger for patients 65-74 years of age and for ED visits that led to hospital admissions. Temperature associations were also stronger among AD/ADRD ED visits compared to ED visits for other reasons, particularly among patients aged 65-74 years. CONCLUSION: People with AD/ADRD may represent a vulnerable population affected by short-term exposure to high temperature. Our results support the development of targeted strategies to reduce heat-related AD/ADRD morbidity in the context of global warming.

Emergency department visits associated with wildfire smoke events in California, 2016-2019.

Wildfire smoke has been associated with adverse respiratory outcomes, but the impacts of wildfire on other health outcomes and sensitive subpopulations are not fully understood. We examined associations between smoke events and emergency department visits (EDVs) for respiratory, cardiovascular, diabetes, and mental health outcomes in California during the wildfire season June-December 2016-2019. Daily, zip code tabulation area-level wildfire-specific fine particulate matter (PM2.5) concentrations were aggregated to air basins. A "smoke event" was defined as an air basin-day with a wildfire-specific PM2.5 concentration at or above the 98th percentile across all air basin-days (threshold = 13.5 µg/m3). We conducted a two-stage time-series analysis using quasi-Poisson regression considering lag effects and random effects meta-analysis. We also conducted analyses stratified by race/ethnicity, age, and sex to assess potential effect modification. Smoke events were associated with an increased risk of EDVs for all respiratory diseases at lag 1 [14.4%, 95% confidence interval (CI): (6.8, 22.5)], asthma at lag 0 [57.1% (44.5, 70.8)], and chronic lower respiratory disease at lag 0 [12.7% (6.2, 19.6)]. We also found positive associations with EDVs for all cardiovascular diseases at lag 10. Mixed results were observed for mental health outcomes. Stratified results revealed potential disparities by race/ethnicity. Short-term exposure to smoke events was associated with increased respiratory and schizophrenia EDVs. Cardiovascular impacts may be delayed compared to respiratory outcomes.

Mental health status as a predictor of emergency department visits and hospital readmissions post bariatric surgery: a retrospective cohort study.

BACKGROUND: This retrospective cohort study aims to investigate emergency department (ED) visits and readmission after bariatric surgery among patients with a history of anxiety and/or depression. We predict that patients with a reported history of anxiety and/or depression will have more ED visits in the year following surgery than patients without a history of mental illness. METHODS: Data were collected from the charts of all consecutive patients who underwent sleeve gastrectomy or gastric bypass surgery between March 2012 and December 2019. Data on baseline body mass index, mental health diagnosis and treatment and emergency department visits and hospital readmissions were retrospectively reviewed over the first year following surgery. RESULTS: One thousand two hundred ninety-seven patients were originally included in this study and 1113 patients were included in the final analysis. Patients with a history of depression (OR 1.23; 95% CI 0.87-1.73), anxiety (OR 1.14; 95% CI 0.81-1.60), or both (OR 1.17; 95% CI 0.83-1.65) did not have a statistically significant increase in ED visits compared to patients without these disorders. Patients with a history of depression (OR 1.49; 95% CI 0.86-2.61), anxiety (OR 1.45; 95% CI 0.80-2.65) or both (OR 1.47; 95% CI 0.94-2.29) did not have a statistically significant increase in hospital readmissions in the first year after surgery compared to patients without these disorders. Patients treated with a sleeve gastrectomy were readmitted due to postoperative complications less frequently than those treated with other surgeries (OR 0.20; 95% CI 0.05-0.83). CONCLUSION: Patients with a history of anxiety, depression or both did not have an increased rate of emergency department visits and hospital readmissions within the first year following bariatric surgery. This contradicts current literature and may be due to the multidisciplinary program patients undergo at this study's home institution.

Mobile integrated health-community paramedicine programs' effect on emergency department visits: An exploratory meta-analysis.

INTRODUCTION: Mobile Integrated Health Community Paramedicine (MIH-CP) programs are designed to increase access to care and reduce Emergency Department (ED) and Emergency Medical Services (EMS) usage. Previous MIH-CP systematic reviews reported varied interventions, effect sizes, and a high prevalence of biased methods. We aimed to perform a meta-analysis on MIH-CP effect on ED visits, and to evaluate study designs' effect on reported effect sizes. We hypothesized biased methods would produce larger reported effect sizes. METHODS: We searched Pubmed, Embase, CINAHL, and Scopus databases for peer-reviewed MIH-CP literature from January 1, 2000, to July 24, 2021. We included all full-text English studies whose program met the National Associations of Emergency Medical Technicians definition, reported ED visits, and had an MIH-CP related intervention and outcome. We established risk ratios for each included study through interpreting the reported data. We performed a random-effects and cumulative meta-analysis of ED visit data, tests of heterogeneity, and a moderator analysis to assess for factors influencing the magnitude of observed effect. RESULTS: We identified 16 studies that reported ED visit data and included 12 in our meta-analysis. All studies were observational; 3 used matched controls, 6 pre-post controls, and 3 without controls. 7 studies' intervention were diversion/triage while 5 studies intervened with health education/home primary care services. Pooled risk ratio for our data set was 0.56 (95% confidence interval 0.42-0.74). Cumulative meta-analysis revealed that as of 2018 MIH-CP programs began to show consistent reductions in ED visits. Significant heterogeneity was seen among studies, with I-squared >90%. Moderator analysis showed reduced heterogeneity for matched-control studies. CONCLUSION: Our data revealed MIH-CP programs were associated with a reduced risk of ED visits. Study design did not have a statistically significant influence on effect size, though it did influence heterogeneity. We would recommend future studies continue to use high levels of control to produce reliable data with lower heterogeneity.

An interrupted time series analysis of trends in opioid-related emergency department visits from pre-COVID-19 pandemic to pandemic, from the Canadian Hospitals Injury Reporting and Prevention Program.

BACKGROUND: Opioid-related emergency department (ED) visits in Canada increased during the COVID-19 pandemic, but how trends in volume and case severity changed from pre-pandemic times through the pandemic is not known. Trends in ED visits related to specific types of opioids also remain unclear. Our objective was to describe pre-pandemic trends and how they changed with the onset of COVID-19 and thereafter. METHODS: Based on data from the Canadian Hospitals Injury Reporting and Prevention Program, we identified opioid-related ED visits and constructed a time series from March 12, 2018 through March 7, 2021-two pre-COVID periods and one COVID period. We used an interrupted time series (ITS) analysis to examine trends in volume and case severity. We compared medians and means of monthly counts and percentages of severe cases between the periods, by sex, age, and opioid type. RESULTS: Before the pandemic, there was an increasing trend in fentanyl-related visits for males, females and 25- to 64-year-olds, and a decreasing trend in heroin-related visits for males and 18- to 64-year-olds. Fentanyl-related visits for 18- to 24-year-olds showed an immediate increase at the start of the pandemic and a decreasing trend during the pandemic. Heroin-related visits for 12- to 17-year-olds had an immediate increase at the start of the pandemic; for 18- to 24-year-olds and 45- to 64-year-olds, the prior decreasing pre-pandemic trend ceased. For pooled opioid-related visits, no significant trend in the percentage of severe cases was observed throughout the entire study period. CONCLUSION: This study shows that an ITS approach in trend analysis is a valuable supplement to comparisons of before and after measures (with or without controlling seasonal effects). The findings provide evidence on how ED presentations for opioid use evolved in Canada from 2018 to 2021. The results can inform policies designed to reduce opioid-related harm in the context of a public health emergency.

Predictors of frequent emergency department visits among hospitalized cancer patients: a comparative cohort study using integrated clinical and administrative data to improve care delivery.

BACKGROUND: Frequent emergency department (FED) visits by cancer patients represent a significant burden to the health system. This study identified determinants of FED in recently hospitalized cancer patients, with a particular focus on opioid use. METHODS: A prospective cohort discharged from surgical/medical units of the McGill University Health Centre was assembled. The outcome was FED use (≥ 4 ED visits) within one year of discharge. Data retrieved from the universal health insurance system was analyzed using Cox Proportional Hazards (PH) model, adopting the Lunn-McNeil approach for competing risk of death. RESULTS: Of 1253 patients, 14.5% became FED users. FED use was associated with chemotherapy one-year pre-admission (adjusted hazard ratio (aHR) 2.60, 95% CI: 1.80-3.70), ≥1 ED visit in the previous year (aHR: 1.80, 95% CI 1.20-2.80), ≥15 pre-admission ambulatory visits (aHR 1.54, 95% CI 1.06-2.34), previous opioid and benzodiazepine use (aHR: 1.40, 95% CI: 1.10-1.90 and aHR: 1.70, 95% CI: 1.10-2.40), Charlson Comorbidity Index ≥ 3 (aHR: 2.0, 95% CI: 1.2-3.4), diabetes (aHR: 1.60, 95% CI: 1.10-2.20), heart disease (aHR: 1.50, 95% CI: 1.10-2.20) and lung cancer (aHR: 1.70, 95% CI: 1.10-2.40). Surgery (cardiac (aHR: 0.33, 95% CI: 0.16-0.66), gastrointestinal (aHR: 0.34, 95% CI: 0.14-0.82) and thoracic (aHR: 0.45, 95% CI: 0.30-0.67) led to a decreased risk of FED use. CONCLUSIONS: Cancer patients with higher co-morbidity, frequent use of the healthcare system, and opioid use were at increased risk of FED use. High-risk patients should be flagged for preventive intervention.

Use telehealth as needed: telehealth substitutes in-person primary care and associates with the changes in unplanned events and follow-up visits.

BACKGROUND: Telehealth rapidly expanded since the outbreak of the COVID-19 pandemic. This study aims to understand how telehealth can substitute in-person services by 1) estimating the changes in non-COVID emergency department (ED) visits, hospitalizations, and care costs among US Medicare beneficiaries by visit modality (telehealth vs. in-person) during the COVID-19 pandemic relative to the previous year; 2) comparing the follow-up time and patterns between telehealth and in-person care. METHODS: A retrospective and longitudinal study design using US Medicare patients 65 years or older from an Accountable Care Organization (ACO). The study period was April-December 2020, and the baseline period was March 2019 - February 2020. The sample included 16,222 patients, 338,872 patient-month records and 134,375 outpatient encounters. Patients were categorized as non-users, telehealth only, in-person care only and users of both types. Outcomes included the number of unplanned events and costs per month at the patient level; number of days until the next visit and whether the next visit happened within 3-, 7-, 14- and 30-days at the encounter level. All analyses were adjusted for patient characteristics and seasonal trends. RESULTS: Beneficiaries who used only telehealth or in-person care had comparable baseline health conditions but were healthier than those who used both types of services. During the study period, the telehealth only group had significantly fewer ED visits/hospitalizations and lower Medicare payments than the baseline (ED 13.2, 95% CI [11.6, 14.7] vs. 24.6 per 1,000 patients per month and hospitalization 8.1 [6.7, 9.4] vs. 12.7); the in-person only group had significantly fewer ED visits (21.9 [20.3, 23.5] vs. 26.1) and lower Medicare payments, but not hospitalizations; the both-types group had significantly more hospitalizations (23.0 [21.4, 24.6] vs. 17.8). Telehealth was not significantly different from in-person encounters in number of days until the next visit (33.4 vs. 31.2 days) or the probabilities of 3- and 7-day follow-up visits (9.2 vs. 9.3% and 21.8 vs.23.5%). CONCLUSIONS: Patients and providers treated telehealth and in-person visits as substitutes and used either depending on medical needs and availability. Telehealth did not lead to sooner or more follow-up visits than in-person services.

Outcomes of an integrated practice unit for vulnerable emergency department patients.

BACKGROUND: An integrated practice unit (IPU) that provides a multidisciplinary approach to patient care, typically involving a primary care provider, registered nurse, social worker, and pharmacist has been shown to reduce healthcare utilization among high-cost super-utilizer (SU) patients or multi-visit patients (MVP). However, less is known about differences in the impact of these interventions on insured vs. uninsured SU patients and super high frequency SUs ([Formula: see text]8 ED visits per 6 months) vs. high frequency SUs (4-7 ED visits per 6 months). METHODS: We assessed the percent reduction in ED visits, ED cost, hospitalizations, hospital days, and hospitalization costs following implementation of an IPU for SUs located in an academic tertiary care facility. We compared outcomes for publicly insured with uninsured patients, and super high frequency SUs with high frequency SUs 6 months before vs. 6 months after enrollment in the IPU. RESULTS: There was an overall 25% reduction in hospitalizations (p < 0.001), and 23% reduction in hospital days (p = 0.0045), when comparing 6 months before vs. 6 months after enrollment in the program. There was a 26% reduction in average total direct hospitalization costs per patient (p = 0.002). Further analysis revealed a greater reduction in health care utilization for uninsured SU patients compared with publicly insured patients. The program reduced hospitalizations for super high frequency SUs. However, there was no statistically significant impact on overall health care utilization of super high frequency SUs when compared with high frequency SUs. CONCLUSIONS: Our study supports existing evidence that dedicated IPUs for SUs can achieve significant reductions in acute care utilization, particularly for uninsured and high frequency SU patients. TRIAL REGISTRATION: IRB201500212. Retrospectively registered.