Emergency department resource utilization among nursing home residents, a National Cross-Sectional Study.

OBJECTIVES: Persons 65 years and older (older persons), particularly residents of nursing homes (NHs), disproportionately access the emergency department (ED) and utilize more medical resources. The goal of this study is to provide a contemporary description of healthcare utilization patterns and disposition decisions for United States (US) NH residents presenting to EDs. METHODS: Older persons presenting to EDs in the US were identified in the National Hospital Ambulatory Medical Care Survey (NHAMCS) 2017, 2018 and 2019 datasets. We examined demographic, clinical, and resource use characteristics and outcomes. After survey weighting, we compared the frequency of different imaging, medications, clinical interventions, and outcomes in the ED between NH residents and those residing outside NHs. RESULTS: From 2017 to 2019, older persons made 24,441,285 annual visits to the ED, comprising 17.5% of all visits. Among these, 1,579,916 visits (6.5%) were by NH residents. Compared with non-NH residents, NH residents were older (mean age: 81.2 [95%CI 81.5-82.9] vs 76.1 [95%CI 75.8-76.4]), underwent more imaging (82.8% [95%CI 79.5-86.1] vs 71.6% [95%CI 69.9-73.3]), were administered fewer potentially inappropriate medications (PIMs) in the ED or upon discharge (9.5% [95%CI 6.2-2.7] vs 17.1% [95%CI 15.8-18.4]), and had a higher proportion of visits resulting in hospital admission (44.1% [95%CI 38.2-49.9] vs 26.0% [95%CI 23.3, 28.7]). CONCLUSIONS: Older NH residents presenting to the ED use more resources and are more likely to be hospitalized compared to older persons residing outside NHs. The resource-intensive nature of these visits highlights the importance of targeted, multi-disciplinary interventions that optimize ED care for this population.

Collecting verbal autopsies: improving and streamlining data collection processes using electronic tablets.

BACKGROUND: There is increasing interest in using verbal autopsy to produce nationally representative population-level estimates of causes of death. However, the burden of processing a large quantity of surveys collected with paper and pencil has been a barrier to scaling up verbal autopsy surveillance. Direct electronic data capture has been used in other large-scale surveys and can be used in verbal autopsy as well, to reduce time and cost of going from collected data to actionable information. METHODS: We collected verbal autopsy interviews using paper and pencil and using electronic tablets at two sites, and measured the cost and time required to process the surveys for analysis. From these cost and time data, we extrapolated costs associated with conducting large-scale surveillance with verbal autopsy. RESULTS: We found that the median time between data collection and data entry for surveys collected on paper and pencil was approximately 3 months. For surveys collected on electronic tablets, this was less than 2 days. For small-scale surveys, we found that the upfront costs of purchasing electronic tablets was the primary cost and resulted in a higher total cost. For large-scale surveys, the costs associated with data entry exceeded the cost of the tablets, so electronic data capture provides both a quicker and cheaper method of data collection. CONCLUSIONS: As countries increase verbal autopsy surveillance, it is important to consider the best way to design sustainable systems for data collection. Electronic data capture has the potential to greatly reduce the time and costs associated with data collection. For long-term, large-scale surveillance required by national vital statistical systems, electronic data capture reduces costs and allows data to be available sooner.

Measuring causes of death in populations: a new metric that corrects cause-specific mortality fractions for chance.

BACKGROUND: Verbal autopsy is gaining increasing acceptance as a method for determining the underlying cause of death when the cause of death given on death certificates is unavailable or unreliable, and there are now a number of alternative approaches for mapping from verbal autopsy interviews to the underlying cause of death. For public health applications, the population-level aggregates of the underlying causes are of primary interest, expressed as the cause-specific mortality fractions (CSMFs) for a mutually exclusive, collectively exhaustive cause list. Until now, CSMF Accuracy is the primary metric that has been used for measuring the quality of CSMF estimation methods. Although it allows for relative comparisons of alternative methods, CSMF Accuracy provides misleading numbers in absolute terms, because even random allocation of underlying causes yields relatively high CSMF accuracy. Therefore, the objective of this study was to develop and test a measure of CSMF that corrects this problem. METHODS: We developed a baseline approach of random allocation and measured its performance analytically and through Monte Carlo simulation. We used this to develop a new metric of population-level estimation accuracy, the Chance Corrected CSMF Accuracy (CCCSMF Accuracy), which has value near zero for random guessing, and negative quality values for estimation methods that are worse than random at the population level. RESULTS: The CCCSMF Accuracy formula was found to be CCSMF Accuracy = (CSMF Accuracy - 0.632) / (1 - 0.632), which indicates that, at the population-level, some existing and commonly used VA methods perform worse than random guessing. CONCLUSIONS: CCCSMF Accuracy should be used instead of CSMF Accuracy when assessing VA estimation methods because it provides a more easily interpreted measure of the quality of population-level estimates.

Emergency Department-Based Physical Function Measures for Falls in Older Adults and Outcomes: A Secondary Analysis of GAPcare.

BACKGROUND AND PURPOSE: Falls are the leading reason for injury-related emergency department (ED) visits for older adults. The Geriatric Acute and Post-acute Fall Prevention Intervention (GAPcare), an in-ED intervention combining a medication therapy management session delivered by a pharmacist and a fall risk assessment and plan by a physical therapist, reduced ED revisits at 6 months among older adults presenting after a fall. Our objective was to evaluate the relationship between measures of function obtained in the ED and clinical outcomes. METHODS: This was a secondary analysis of data from GAPcare, a randomized controlled trial conducted from January 2018 to October 2019 at 2 urban academic EDs. Standardized measures of function (Timed Up and Go [TUG] test, Barthel Activity of Daily Living [ADL], Activity Measure for Post Acute Care [AM-PAC] 6 clicks) were collected at the ED index visit. We performed a descriptive analysis and hypothesis testing (chi square test and analysis of variance) to assess the relationship of functional measures with outcomes (ED disposition, ED revisits for falls, and place of residence at 6 months). Emergency department disposition status refers to discharge location immediately after the ED evaluation is complete (eg, hospital admission, original residence, skilled nursing facility). RESULTS AND DISCUSSION: Among 110 participants, 55 were randomized to the GAPcare intervention and 55 received usual care. Of those randomized to the intervention, 46 received physical therapy consultation. Median age was 81 years; participants were predominantly women (67%) and White (94%). Seventy-three (66%) were discharged to their original residence, 14 (13%) were discharged to a skilled nursing facility and 22 (20%) were admitted. There was no difference in ED disposition status by index visit Barthel ADLs (P = .371); however, TUG times were faster (P = .016), and AM-PAC 6 clicks score was higher among participants discharged to their original residence (P ≤ .001). Participants with slower TUG times at the index ED visit were more likely to reside in nursing homes by six months (P = .002), while Barthel ADL and AM-PAC 6 clicks did not differ between those residing at home and other settings. CONCLUSIONS: Measures of function collected at the index ED visit, such as the AM-PAC 6 clicks and TUG time, may be helpful at predicting clinical outcomes for older adults presenting for a fall. Based on our study findings, we suggest a novel workflow to guide the use of these clinical measures for ED patients with falls.

Nursing Home to Emergency Care Transition Form Has Limited Uptake But Improves Documentation.

Critical information gaps exist in nursing home-to-emergency department (NH-ED) transfer documentation. Standardization of forms may address these gaps. In a single state, a Continuity of Care Acute Care Transfer (CoC) Form was standardized and mandated to be used for all NH-ED transfers. The objective of this study was to evaluate adoption and effectiveness of the standardized CoC form. We used a random cross-sectional sample of 2019-2022 electronic health record encounter data to determine NH-ED documentation completeness after standardized CoC form implementation. Using patient characteristic adjusted linear and logistic regressions, we examined if CoC form standardization was associated with the number of key elements present on NH-ED transfer documentation and hospital admission, respectively. We then compared documentation completeness (out of 15 key data elements) to previously published pre-implementation data (2015-2016, n = 474). Of the 203 NH-ED transfer visits after CoC standardization (2019-2022), mean patient age was 81.8 years and 41.4% had dementia. Any NH-ED transfer form was present for 80.8% (n = 164) of encounters and 28.6% (n = 58) used the standardized CoC form. In comparison with the 2015-2016 data, there was an increase in documentation for functional baseline (20% to 30%), cognitive baseline (25% to 37%), and reason for transfer (25% to 82%). Post implementation, the use of the standardized CoC form was (1) associated with 2.55 (95% CI, 1.66-3.44) more key data elements documented and (2) not associated with a decreased odds of admission [odds ratio (OR), 1.06; 95% CI, 0.54-2.05] after controlling for confounders. Implementation of a statewide standardized CoC form for NH-ED transfers improved documentation of key elements, yet significant information gaps remain. Implementation evaluation is needed to identify how to achieve greater uptake of the form and improve the quality of information exchange between NHs and EDs.

Physician Views of Telehealth for Special Populations of Older Adults: Preliminary Findings.

This study's objective was to determine how frontline physicians perceived telehealth for older adults with sensory impairments, cognitive impairments, mobility challenges, or those receiving end-of-life care. We conducted a multiple-methods study of US emergency, geriatric, and primary care physicians. Phase 1 involved semi-structured interviews with 48 physicians on their experiences using telehealth with older adults. In phase 2, we used those qualitative findings to generate a web-based survey administered to 74 physicians. In phase 3, we reintegrated qualitative data to enrich survey results. We identified 3 key findings: (1) 50% of emergency physicians, 33% of geriatricians, and 18% of primary care physicians considered telehealth to be a poor substitute for providing end-of-life care (p = .68); (2) for hearing, vision, and cognitive impairments, 61%, 58%, and 54%, respectively, saw telehealth as a good or fair substitute for providing care (p = .14); and (3) 98% indicated that telehealth was a good or fair substitute for in-person care for those with mobility impairment (p < .001). Preferences and comfort using telehealth with older adults vary by clinical context, patient population, and physician specialty, requiring tailored adaptations.

Emergency department care transition barriers: A qualitative study of care partners of older adults with cognitive impairment.

INTRODUCTION: After emergency department (ED) discharge, persons living with cognitive impairment (PLWCI) and their care partners are particularly at risk for adverse outcomes. We sought to identify the barriers experienced by care partners of PLWCI during ED discharge care transitions. METHODS: We conducted a qualitative study of 25 care partners of PLWCI discharged from four EDs. We used the validated 4AT and care partner-completed AD8 screening tools, respectively, to exclude care partners of older adults with concern for delirium and include care partners of older adults with cognitive impairment. We conducted recorded, semi-structured interviews using a standardized guide, and two team members coded and analyzed all professional transcriptions to identify emerging themes and representative quotations. RESULTS: Care partners' mean age was 56.7 years, 80% were female, and 24% identified as African American. We identified four major barriers regarding ED discharge care transitions among care partners of PLWCI: (1) unique care considerations while in the ED setting impact the perceived success of the care transition, (2) poor communication and lack of care partner engagement was a commonplace during the ED discharge process, (3) care partners experienced challenges and additional responsibilities when aiding during acute illness and recovery phases, and (4) navigating the health care system after an ED encounter was perceived as difficult by care partners. DISCUSSION: Our findings demonstrate critical barriers faced during ED discharge care transitions among care partners of PLWCI. Findings from this work may inform the development of novel care partner-reported outcome measures as well as ED discharge care transition interventions targeting care partners.

Emergency department-to-community care transition barriers: A qualitative study of older adults.

BACKGROUND: Over one-half of older adults are discharged to the community after emergency department (ED) visits, and studies have shown there is increased risk of adverse health outcomes in the immediate post-discharge period. Understanding the experiences of older adults during ED-to-community care transitions has the potential to improve geriatric emergency clinical care and inform intervention development. We therefore sought to assess barriers experienced by older adults during ED-to-community care transitions. METHODS: We conducted a qualitative analysis of community-dwelling cognitively intact patients aged 65 years and older receiving care in four diverse EDs from a single U.S. healthcare system. We constructed a conceptual framework a priori to guide the development and iterative revision of a codebook, used purposive sampling, and conducted recorded, semi-structured interviews using a standardized guide. Two researchers coded the professionally transcribed data using a combined deductive and inductive approach and analyzed transcripts to identify dominant themes and representative quotations. RESULTS: Among 25 participants, 20 (80%) were women and 17 (68%) were white. We identified four barriers during the ED-to-community care transition: (1) ED discharge process was abrupt with missing information regarding symptom explanation and performed testing, (2) navigating follow-up outpatient clinical care was challenging, (3) new physical limitations and fears hinder performance of baseline activities, and (4) major and minor ramifications for caregivers impact an older adult's willingness to request or accept assistance. CONCLUSIONS: Older adults identified barriers to successful ED-to-community care transitions that can inform the development of novel and effective interventions.

Perceptions of Signs of Addiction Among Opioid Naive Patients Prescribed Opioids in the Emergency Department.

OBJECTIVES: Patient knowledge deficits related to opioid risks, including lack of knowledge regarding addiction, are well documented. Our objective was to characterize patients' perceptions of signs of addiction. METHODS: This study utilized data obtained as part of a larger interventional trial. Consecutively discharged English-speaking patients, age >17 years, at an urban academic emergency department, with a new opioid prescription were enrolled from July 2015 to August 2017. During a follow-up phone interview 7 to 14 days after discharge, participants were asked a single question, "What are the signs of addiction to pain medicine?" Verbatim transcribed answers were analyzed using a directed content analysis approach and double coding. These codes were then grouped into themes. RESULTS: There were 325 respondents, 57% female, mean age 43.8 years, 70.1% privately insured. Ten de novo codes were added to the 11 DSM-V criteria codes. Six themes were identified: (1) effort spent acquiring opioids, (2) emotional and physical changes related to opioid use, (3) opioid use that is "not needed, (4) increasing opioid use, (5) an emotional relationship with opioids, and (6) the inability to stop opioid use. CONCLUSIONS: Signs of addiction identified by opioid naive patients were similar to concepts identified in medical definitions. However, participants' understanding also included misconceptions, omissions, and conflated misuse behaviors with signs of addiction. Identifying these differences will help inform patient-provider risk communication, providing an opportunity for counseling and prevention.

Effect of Standardized Handoff Curriculum on Improved Clinician Preparedness in the Intensive Care Unit: A Stepped-Wedge Cluster Randomized Clinical Trial.

Importance: Clinician miscommunication contributes to an estimated 250 000 deaths in US hospitals per year. Efforts to standardize handoff communication may reduce errors and improve patient safety. Objective: To determine the effect of a standardized handoff curriculum, UW-IPASS, on interclinician communication and patient outcomes. Design, Setting, and Participants: This cluster randomized stepped-wedge randomized clinical trial was conducted from October 2015 to May 2016 at 8 medical and surgical intensive care units at 2 hospital systems within an academic tertiary referral center. Participants included residents, fellows, advance-practice clinicians, and attending physicians (n = 106 clinicians, with 1488 handoff events over 8 months) and data were collected from daily text message-based surveys and patient medical records. Exposures: The UW-IPASS standardized handoff curriculum. Main Outcomes and Measures: The primary aim was to assess the effect of the UW-IPASS handoff curriculum on perceived adequacy of interclinician communication. Patient days of mechanical ventilation, intensive care unit length of stay, reintubations within 24 hours, and order workflow patterns were also analyzed. Mixed-effects logistic regression was used to compute odds ratios and confidence intervals with adjustment for location, time period, and clinician. Results: A total of 63 residents and advance practice clinicians, 13 fellows, and 30 attending physicians participated in the study. During the control period, clinicians reported being unprepared for their shift because of a poor-quality handoff in 35 of 343 handoffs (10.2%), while UW-IPASS-period residents reported being unprepared in 53 of 740 handoffs (7.2%) (odds ratio, 0.19; 95% CI, 0.03-0.74; P = .03). Compared with the control phase, the perceived duration of handoffs among clinicians using UW-IPASS was unchanged (+5.5 minutes; 95% CI, 0.34-9.39; P = .30). Early morning order entry decreased from 106 per 100 patient-days in the control phase to 78 per 100 patient-days in the intervention period (-28 orders; 95% CI, -55 to -4; P = .04). Overall, UW-IPASS was not associated with any changes in intensive care unit length of stay, duration of mechanical ventilation, or the number of reintubations. Conclusions and Relevance: The UW-IPASS standardized handoff curriculum was perceived to improve intensive care provider preparedness and workflow. IPASS-based curricula represent an important step forward in communication standardization efforts and may help reduce communication errors and omissions. Trial Registration: isrctn.org Identifier: ISRCTN14209509.

Implementing the PHMRC shortened questionnaire: Survey duration of open and closed questions in three sites.

BACKGROUND: More countries are using verbal autopsy as a part of routine mortality surveillance. The length of time required to complete a verbal autopsy interview is a key logistical consideration for planning large-scale surveillance. METHODS: We use the PHMRC shortened questionnaire to conduct verbal autopsy interviews at three sites and collect data on the length of time required to complete the interview. This instrument uses a novel checklist of keywords to capture relevant information from the open response. The open response section is timed separately from the section consisting of closed questions. RESULTS: We found the median time to complete the entire interview was approximately 25 minutes and did not vary substantially by age-specific module. The median time for the open response section was approximately 4 minutes and 60% of interviewees mentioned at least one keyword within the open response section. CONCLUSIONS: The length of time required to complete the interview was short enough for large-scale routine use. The open-response section did not add a substantial amount of time and provided useful information which can be used to increase the accuracy of the predictions of the cause of death. The novel checklist approach further reduces the burden of transcribing and translating a large amount of free text. This makes the PHMRC instrument ideal for national mortality surveillance.

Use of Smartphone for Verbal Autopsy.

Traditionally, verbal autopsies (VA) are collected on paper-based questionnaires and reviewed by physicians for cause of death assignment, it is resource intensive and time consuming. The Population Health Metrics Research Consortium VA questionnaires was made available on an Android-based application and cause of death was derived using the Tariff method. Over one year, all adult deaths occurring in 48 villages in 4 counties were identified and a VA interview was conducted using the smartphone VA application. A total of 507 adult deaths were recorded and VA interviews were conducted. Cardiovascular disease was the leading cause of death (35.3%) followed by injury (14.6%) and neoplasms (13.5%). The total cost of the pilot study was USD28 835 (USD0.42 per capita). The interviewers found use of smartphones to conduct interviews to be easier. The study showed that using a smartphone application for VA interviews was feasible for implementation in rural China.

Global and National Burden of Diseases and Injuries Among Children and Adolescents Between 1990 and 2013: Findings From the Global Burden of Disease 2013 Study.

IMPORTANCE: The literature focuses on mortality among children younger than 5 years. Comparable information on nonfatal health outcomes among these children and the fatal and nonfatal burden of diseases and injuries among older children and adolescents is scarce. OBJECTIVE: To determine levels and trends in the fatal and nonfatal burden of diseases and injuries among younger children (aged <5 years), older children (aged 5-9 years), and adolescents (aged 10-19 years) between 1990 and 2013 in 188 countries from the Global Burden of Disease (GBD) 2013 study. EVIDENCE REVIEW: Data from vital registration, verbal autopsy studies, maternal and child death surveillance, and other sources covering 14,244 site-years (ie, years of cause of death data by geography) from 1980 through 2013 were used to estimate cause-specific mortality. Data from 35,620 epidemiological sources were used to estimate the prevalence of the diseases and sequelae in the GBD 2013 study. Cause-specific mortality for most causes was estimated using the Cause of Death Ensemble Model strategy. For some infectious diseases (eg, HIV infection/AIDS, measles, hepatitis B) where the disease process is complex or the cause of death data were insufficient or unavailable, we used natural history models. For most nonfatal health outcomes, DisMod-MR 2.0, a Bayesian metaregression tool, was used to meta-analyze the epidemiological data to generate prevalence estimates. FINDINGS: Of the 7.7 (95% uncertainty interval [UI], 7.4-8.1) million deaths among children and adolescents globally in 2013, 6.28 million occurred among younger children, 0.48 million among older children, and 0.97 million among adolescents. In 2013, the leading causes of death were lower respiratory tract infections among younger children (905.059 deaths; 95% UI, 810,304-998,125), diarrheal diseases among older children (38,325 deaths; 95% UI, 30,365-47,678), and road injuries among adolescents (115,186 deaths; 95% UI, 105,185-124,870). Iron deficiency anemia was the leading cause of years lived with disability among children and adolescents, affecting 619 (95% UI, 618-621) million in 2013. Large between-country variations exist in mortality from leading causes among children and adolescents. Countries with rapid declines in all-cause mortality between 1990 and 2013 also experienced large declines in most leading causes of death, whereas countries with the slowest declines had stagnant or increasing trends in the leading causes of death. In 2013, Nigeria had a 12% global share of deaths from lower respiratory tract infections and a 38% global share of deaths from malaria. India had 33% of the world's deaths from neonatal encephalopathy. Half of the world's diarrheal deaths among children and adolescents occurred in just 5 countries: India, Democratic Republic of the Congo, Pakistan, Nigeria, and Ethiopia. CONCLUSIONS AND RELEVANCE: Understanding the levels and trends of the leading causes of death and disability among children and adolescents is critical to guide investment and inform policies. Monitoring these trends over time is also key to understanding where interventions are having an impact. Proven interventions exist to prevent or treat the leading causes of unnecessary death and disability among children and adolescents. The findings presented here show that these are underused and give guidance to policy makers in countries where more attention is needed.

Identifying otolaryngology systematic review research gaps: comparing Global Burden of Disease 2010 results with Cochrane Database of Systematic Review content.

IMPORTANCE: Burden of disease should inform research prioritization. OBJECTIVE: To determine whether systematic reviews and protocols published in the Cochrane Database of Systematic Reviews (CDSR) appropriately reflect disease burden for otolaryngologic conditions as measured by the Global Burden of Disease (GBD) 2010 project. DESIGN: Two investigators independently assessed 10 otolaryngologic conditions in CDSR for systematic review and protocol representation from March to June 2014. The otolaryngologic diseases were matched to their respective GBD 2010 disability-adjusted life-years (DALYs) to assess their correlation. MAIN OUTCOMES AND MEASURES: Relationship of CDSR representation (based on systematic reviews and protocols) with percentage of total 2010 DALYs, 2010 DALY rank, and DALY percentage change from 1990 to 2010 for 10 otolaryngologic conditions. RESULTS: All 10 otolaryngologic conditions were represented by at least 1 systematic review in CDSR. The number of reviews and protocols in CDSR was well matched with GBD 2010 disability metrics for only 1 disease, mouth cancer. Upper respiratory infections, otitis media, thyroid cancer, and cleft lip and cleft palate were overrepresented in CDSR, and esophageal cancer, "other hearing loss," nasopharynx cancer, larynx cancer, and "cancer of other part of pharynx and oropharynx" were underrepresented. CONCLUSIONS AND RELEVANCE: The representation of otolaryngologic conditions in CDSR correlates poorly with DALY metrics. The results of this study may guide future research prioritization and allocation of funds.