Assessment of respiratory rate monitoring in the emergency department.

Objectives: This study aimed to compare the different respiratory rate (RR) monitoring methods used in the emergency department (ED): manual documentation, telemetry, and capnography. Methods: This is a retrospective study using recorded patient monitoring data. The study population includes patients who presented to a tertiary care ED between January 2020 and December 2022. Inclusion and exclusion criteria were patients with simultaneous recorded RR data from all three methods and less than 10 min of recording, respectively. Linear regression and Bland-Altman analysis were performed between different methods. Results: A total of 351 patient encounters met study criteria. Linear regression yielded an R-value of 0.06 (95% confidence interval [CI] 0.00-0.12) between manual documentation and telemetry, 0.07 (95% CI 0.01-0.13) between manual documentation and capnography, and 0.82 (95% CI 0.79-0.85) between telemetry and capnography. The Bland-Altman analysis yielded a bias of -0.8 (95% limits of agreement [LOA] -12.2 to 10.6) between manual documentation and telemetry, bias of -0.6 (95% LOA -13.5 to 12.3) between manual documentation and capnography, and bias of 0.2 (95% LOA -6.2 to 6.6) between telemetry and capnography. Conclusion: There is a poor correlation between manual documentation and both automated methods, while there is relatively good agreement between the automated methods. This finding highlights the need to further investigate the methodology used by the ED staff in monitoring and documenting RR and ways to improve its reliability given that many important clinical decisions are made based on these assessments.

Trends in observation stays for Medicare beneficiaries with and without Alzheimer's disease and related dementias.

BACKGROUND: There has been a marked rise in the use of observation care for Medicare beneficiaries visiting the emergency department (ED) in recent years. Whether trends in observation use differ for people with Alzheimer's disease and Alzheimer's disease-related dementias (AD/ADRD) is unknown. METHODS: Using a national 20% sample of Medicare beneficiaries ages 68+ from 2012 to 2018, we compared trends in ED visits and observation stays by AD/ADRD status for beneficiaries visiting the ED. We then examined the degree to which trends differed by nursing home (NH) residency status, assigning beneficiaries to four groups: AD/ADRD residing in NH (AD/ADRD+ NH+), AD/ADRD not residing in NH (AD/ADRD+ NH-), no AD/ADRD residing in NH (AD/ADRD- NH+), and no AD/ADRD not residing in NH (AD/ADRD- NH-). RESULTS: Of 7,489,780 unique beneficiaries, 18.6% had an AD/ADRD diagnosis. Beneficiaries with AD/ADRD had more than double the number of ED visits per 1000 in all years compared to those without AD/ADRD and saw a faster adjusted increase over time (+26.7 vs. +8.2 visits/year; p < 0.001 for interaction). The annual increase in the adjusted proportion of ED visits ending in observation was also greater among people with AD/ADRD (+0.78%/year, 95% CI 0.77-0.80%) compared to those without AD/ADRD (+0.63%/year, 95% CI 0.59-0.66%; p < 0.001 for interaction). Observation utilization was greatest for the AD/ADRD+ NH+ population and lowest for the AD/ADRD- NH- population, but the AD/ADRD+ NH- group saw the greatest increase in observation stays over time (+15.4 stays per 1000 people per year, 95% CI 15.0-15.7). CONCLUSIONS: Medicare beneficiaries with AD/ADRD have seen a disproportionate increase in observation utilization in recent years, driven by both an increase in ED visits and an increase in the proportion of ED visits ending in observation.

Clinician Risk Tolerance and Rates of Admission From the Emergency Department.

Importance: Much remains unknown about the extent of and factors that influence clinician-level variation in rates of admission from the emergency department (ED). In particular, emergency clinician risk tolerance is a potentially important attribute, but it is not well defined in terms of its association with the decision to admit. Objective: To further characterize this variation in rates of admission from the ED and to determine whether clinician risk attitudes are associated with the propensity to admit. Design, Setting, and Participants: In this observational cohort study, data were analyzed from the Massachusetts All Payer Claims Database to identify all ED visits from October 2015 through December 2017 with any form of commercial insurance or Medicaid. ED visits were then linked to treating clinicians and their risk tolerance scores obtained in a separate statewide survey to examine the association between risk tolerance and the decision to admit. Statistical analysis was performed from 2022 to 2023. Main Outcomes and Measures: The ratio between observed and projected admission rates was computed, controlling for hospital, and then plotted against the projected admission rates to find the extent of variation. Pearson correlation coefficients were then used to examine the association between the mean projected rate of admission and the difference between actual and projected rates of admission. The consistency of clinician admission practices across a range of the most common conditions resulting in admission were then assessed to understand whether admission decisions were consistent across different conditions. Finally, an assessment was made as to whether the extent of deviation from the expected admission rates at an individual level was associated with clinician risk tolerance. Results: The study sample included 392 676 ED visits seen by 691 emergency clinicians. Among patients seen for ED visits, 221 077 (56.3%) were female, and 236 783 (60.3%) were 45 years of age or older; 178 890 visits (46.5%) were for patients insured by Medicaid, 96 947 (25.2%) were for those with commercial insurance, 71 171 (18.5%) were Medicare Part B or Medicare Advantage, and the remaining 37 702 (9.8%) were other insurance category. Of the 691 clinicians, 429 (62.6%) were male; mean (SD) age was 46.5 (9.8) years; and 72 (10.4%) were Asian, 13 (1.9%) were Black, 577 (83.5%) were White, and 29 (4.2%) were other race. Admission rates across the clinicians included ranged from 36.3% at the 25th percentile to 48.0% at the 75th percentile (median, 42.1%). Overall, there was substantial variation in admission rates across clinicians; physicians were just as likely to overadmit or underadmit across the range of projected rates of admission (Pearson correlation coefficient, 0.046 [P = .23]). There also was weak consistency in admission rates across the most common clinical conditions, with intraclass correlations ranging from 0.09 (95% CI, 0.02-0.17) for genitourinary/syncope to 0.48 (95% CI, 0.42-0.53) for cardiac/syncope. Greater clinician risk tolerance (as measured by the Risk Tolerance Scale) was associated with a statistically significant tendency to admit less than the projected admission rate (coefficient, -0.09 [P = .04]). The other scales studied revealed no significant associations. Conclusions and Relevance: In this cohort study of ED visits from Massachusetts, there was statistically significant variation between ED clinicians in admission rates and little consistency in admission tendencies across different conditions. Admission tendencies were minimally associated with clinician innate risk tolerance as assessed by this study's measures; further research relying on a broad range of measures of risk tolerance is needed to better understand the role of clinician attitudes toward risk in explaining practice patterns and to identify additional factors that may be associated with variation at the clinician level.

Frequency of Intubation for Medicare Beneficiaries With Acute Stroke and Association With Patient Outcomes.

BACKGROUND AND OBJECTIVES: Intubation for acute stroke is common in the United States, with few established guidelines. METHODS: This is a retrospective observational study of acute stroke admissions from 2011 to 2018 among fee-for-service Medicare beneficiaries aged 65-100 years. Patient demographics and chronic conditions as well as hospital characteristics were identified. We identified patient intubation, stroke subtype (ischemic vs intracerebral hemorrhage), and thrombectomy. Factors associated with intubation were identified by a linear probability model with intubation as the outcome and patient characteristics, stroke subtype, and thrombectomy as predictors, adjusting for within-hospital correlation. We compared hospital characteristics between adjusted intubation rate quartiles. We specified a linear probability model with 30-day mortality as the patient-level outcome and hospital intubation rate quartile as the categorical predictor, again adjusting for patient characteristics. We specified an analogous model for quartiles of hospital referral regions. RESULTS: There were 800,467 stroke hospitalizations at 3,581 hospitals. Among 2,588 hospitals with 25 or more stroke hospitalizations, the median intubation rate was 4.8%, while a quarter had intubation rates below 2.4% and 10% had rates above 12.5%. Ischemic strokes had a 21% lower adjusted intubation risk than intracerebral hemorrhages (risk difference [RD] -21.1%, 95% CI -21.3% to -20.9%; p < 0.001), whereas thrombectomy was associated with a 19.2% higher adjusted risk (95% CI RD 18.8%-19.6%; p < 0.001). Women and older patients had lower intubation rates. Large, urban hospitals and academic medical centers were overrepresented in the top quartile of hospital adjusted intubation rates. Even after adjusting for available characteristics, intubated patients had a 44% higher mortality risk than non-intubated patients (p < 0.001). Hospitals in the highest intubation quartile had higher adjusted 30-day mortality (19.3%) than hospitals in the lowest quartile (16.7%), a finding that was similar when restricting to major teaching hospitals (22.3% vs 18.1% in the 4th vs 1st quartiles, respectively). There was no association between market quartile of intubation and patient 30-day mortality. DISCUSSION: Intubation for acute stroke varied by patient and hospital characteristics. Hospitals with higher adjusted rates of intubation had higher patient-level 30-day mortality, but much of the difference may be due to unmeasured patient severity given that no such association was observed for health care markets.

Trends in performance of hospital outpatient procedures and associated 30-day costs among Medicare beneficiaries from 2011 to 2018.

BACKGROUND: United States healthcare has increasingly transitioned to outpatient care delivery. The degree to which Academic Medical Centers (AMCs) have been able to shift surgical procedures from inpatient to outpatient settings despite higher patient complexity is unknown. METHODS: This observational study used a 20% sample of fee-for-service Medicare beneficiaries age 65 and older undergoing eight elective procedures from 2011 to 2018 to model trends in procedure site (hospital outpatient vs. inpatient) and 30-day standardized Medicare costs, overall and by hospital teaching status. RESULTS: Of the 1,222,845 procedures, 15.9% occurred at AMCs. There was a 2.42% per-year adjusted increase (95% CI 2.39%-2.45%; p < .001) in proportion of outpatient hospital procedures, from 68.9% in 2011 to 85.4% in 2018. Adjusted 30-day standardized costs declined from $18,122 to $14,353, (-$560/year, 95% CI -$573 to -$547; p < .001). Patients at AMCs had more chronic conditions and higher predicted annual mortality. AMCs had a lower proportion of outpatient procedures in all years compared to non-AMCs, a difference that was statistically significant but small in magnitude. AMCs had higher costs compared to non-AMCs and a lesser decline over time (p < .001 for the interaction). AMCs and non-AMCs saw a similar decline in 30-day mortality. CONCLUSIONS: There has been a substantial shift toward outpatient procedures among Medicare beneficiaries with a decrease in total 30-day Medicare spending as well as 30-day mortality. Despite a higher complexity population, AMCs shifted procedures to the outpatient hospital setting at a similar rate as non-AMCs. IMPLICATIONS: The trend toward outpatient procedural care and lower spending has been observed broadly across AMCs and non-AMCs, suggesting that Medicare beneficiaries have benefited from more efficient delivery of procedural care across academic and community hospitals.

Trends in healthy days at home for Medicare beneficiaries using the emergency department.

BACKGROUND: Older adults, particularly those with Alzheimer's Disease and Alzheimer's Disease Related Dementias (AD/ADRD), have high rates of emergency department (ED) visits and are at risk for poor outcomes. How best to measure quality of care for this population has been debated. Healthy Days at Home (HDAH) is a broad outcome measure reflecting mortality and time spent in facility-based healthcare settings versus home. We examined trends in 30-day HDAH for Medicare beneficiaries after visiting the ED and compared trends by AD/ADRD status. METHODS: We identified all ED visits among a national 20% sample of Medicare beneficiaries ages 68 and older from 2012 to 2018. For each visit, we calculated 30-day HDAH by subtracting mortality days and days spent in facility-based healthcare settings within 30 days of an ED visit. We calculated adjusted rates of HDAH using linear regression, accounting for hospital random effects, visit diagnosis, and patient characteristics. We compared rates of HDAH among beneficiaries with and without AD/ADRD, including accounting for nursing home (NH) residency status. RESULTS: We found fewer adjusted 30-day HDAH after ED visits among patients with AD/ADRD compared to those without AD/ADRD (21.6 vs. 23.0). This difference was driven by a greater number of mortality days, SNF days, and, to a lesser degree, hospital observation days, ED visits, and long-term hospital days. From 2012 to 2018, individuals living with AD/ADRD had fewer HDAH each year but a greater mean annual increase over time (p < 0.001 for the interaction between year and AD/ADRD status). Being a NH resident was associated with fewer adjusted 30-day HDAH for beneficiaries with and without AD/ADRD. CONCLUSIONS: Beneficiaries with AD/ADRD had fewer HDAH following an ED visit but saw moderately greater increases in HDAH over time compared to those without AD/ADRD. This trend was visit driven by declining mortality and utilization of inpatient and post-acute care.

Resident Attitudes Toward Performing Pelvic Examinations in the Emergency Department.

Mounting evidence suggests that emergency physicians tend to avoid patients with gynecologic chief complaints, and that avoidance may be higher for male physicians compared to females. One underlying reason could be discomfort with performing pelvic examinations. The goal of this study was to assess whether male residents report greater discomfort with pelvic examinations than females. We performed a cross-sectional, Institutional Review Board-approved survey of residents at 6 academic emergency medicine programs. Of 100 residents who completed the survey, 63 self-identified as male, 36 female, and one selected "prefer not to say" and was excluded. Responses were compared between male and females using chi-square tests. In secondary analysis, t-tests were used to compare preferences for various chief complaints. Self-reported comfort with pelvic examinations did not differ significantly between males and females (p = 0.4249). Barriers for male respondents in performing pelvic examinations included lack of training, general dislike, and concern the patient would prefer female providers. Male residents had a statistically significant higher aversion ranking towards patients with vaginal bleeding than female residents (mean difference = 0.48, confidence interval = 0.11-0.87). Aversion ranking was the same between males and females on other chief complaints. There is a gender disparity among male and female residents in attitudes towards patients with vaginal bleeding. However, the results from this study do not demonstrate a significant difference in self-reported comfort amongst male and female residents in performing pelvic examinations. This disparity may be driven by other barriers, including self-reported lack of training and concern about patients' physician gender preferences.

Association of Academic Medical Center Presence With Clinical Outcomes at Neighboring Community Hospitals Among Medicare Beneficiaries.

Importance: Studies suggest that academic medical centers (AMCs) have better outcomes than nonteaching hospitals. However, whether AMCs have spillover benefits for patients treated at neighboring community hospitals is unknown. Objective: To examine whether market-level AMC presence is associated with outcomes for patients treated at nonteaching hospitals within the same markets. Design, Setting, and Participants: This retrospective, population-based cohort study assessed traditional Medicare beneficiaries aged 65 years and older discharged from US acute care hospitals between 2015 and 2017 (100% sample). Data were analyzed from August 2021 to December 2022. Exposures: The primary exposure was market-level AMC presence. Health care markets (ie, hospital referral regions) were categorized by AMC presence (percentage of hospitalizations at AMCs) as follows: no presence (0%), low presence (>0% to 20%), moderate presence (>20% to 35%), and high presence (>35%). Main Outcomes and Measures: The primary outcomes were 30-day and 90-day mortality and healthy days at home (HDAH), a composite outcome reflecting mortality and time spent in facility-based health care settings. Results: There were 22 509 824 total hospitalizations, with 18 865 229 (83.8%) at non-AMCs. The median (IQR) age of patients was 78 (71-85) years, and 12 568 230 hospitalizations (55.8%) were among women. Of 306 hospital referral regions, 191 (62.4%) had no AMCs, 61 (19.9%) had 1 AMC, and 55 (17.6%) had 2 or more AMCs. Markets characteristics differed significantly by category of AMC presence, including mean population, median income, proportion of White residents, and physicians per population. Compared with markets with no AMC presence, receiving care at a non-AMC in a market with greater AMC presence was associated with lower 30-day mortality (9.5% vs 10.1%; absolute difference, -0.7%; 95% CI, -1.0% to -0.4%; P < .001) and 90-day mortality (16.1% vs 16.9%; absolute difference, -0.8%; 95% CI, -1.2% to -0.4%; P < .001) and more HDAH at 30 days (16.49 vs 16.12 HDAH; absolute difference, 0.38 HDAH; 95% CI, 0.11 to 0.64 HDAH; P = .005) and 90 days (61.08 vs 59.83 HDAH; absolute difference, 1.25 HDAH; 95% CI, 0.58 to 1.92 HDAH; P < .001), after adjustment. There was no association between market-level AMC presence and mortality for patients treated at AMCs themselves. Conclusions and Relevance: AMCs may have spillover effects on outcomes for patients treated at non-AMCs, suggesting that they have a broader impact than is traditionally recognized. These associations are greatest in markets with the highest AMC presence and persist to 90 days.

Impact of a Mandatory Prescription Drug Monitoring Program Check on Emergency Department Opioid Prescribing Rates.

BACKGROUND: Prescription drug monitoring programs (PDMPs) exist in 49 states to guide opioid prescribing. In 40 states, clinicians must check the PDMP prior to prescribing an opioid. Data on mandated PDMP checks show mixed results on opioid prescribing. OBJECTIVES: This study sought to examine the impact of the Massachusetts mandatory PDMP check on opioid prescribing for discharges from an urban tertiary emergency department (ED). METHODS: This was a retrospective cohort study of discharges from one ED from 7/1/2010-10/15/2018. The primary outcome was the monthly percentage of patients discharged from the ED with an opioid prescription. The intervention was Massachusetts mandating a PDMP check for all opioid prescriptions. Prescribing was compared pre- and post-mandate. Interrupted time series (ITS) analysis accounted for known declining trends in opioid prescribing. RESULTS: Of 273,512 ED discharges, 35,050 (12.8%) received opioid prescriptions. Mean monthly opioid prescribing decreased post-intervention from 15.1% (SD ± 3.5%) to 5.1% (SD ± 0.9%; p < 0.001). ITS showed equal pre and post-intervention slopes (-0.002, p = 0.819). A small immediate decrease occurred in prescribing around the mandated check: a 3-month level effect decrease of 0.018 (p = 0.039), 6-month level effect 0.019 (p = 0.023), and a 12-month level effect of 0.020 (p = 0.019). The 24-month level effect was not decreased. CONCLUSION: Prior to the mandated PDMP check, ED opioid prescribing was declining. The mandate did not change the rate of decline but was associated with a non-sustained drop in opioid prescribing immediately following enactment.

Trends in Costs of Care for Medicare Beneficiaries Treated in the Emergency Department From 2011 to 2016.

Importance: There is little evidence regarding how total costs of care associated with an emergency department (ED) visit have changed, despite increasing policy focus on the value of acute care. Objective: To examine trends in total standardized 30-day costs of care associated with an ED visit. Design, Setting, and Participants: This cross-sectional study of 14 113 088 ED visits at 4730 EDs from 2011 to 2016 included a 20% national sample of traditional Medicare beneficiaries aged 65 years and older. Data analysis was conducted from August 2018 to April 2020. Exposures: Time (year) as a continuous variable. Main Outcomes and Measures: Trends in disposition from the ED and 30-day total standardized costs for all ED visits as well as the following spending components: index visit cost, physician costs, subsequent ED visit costs, subsequent inpatient costs, subsequent observation costs, non-ED outpatient care, postacute care, and aggregated total spending after the index ED visit. Results: The analytic sample consisted of 14 113 088 ED visits at 4730 EDs. The mean (SD) beneficiary age was 78.6 (8.6) years, 8 573 652 visits (60.7%) were among women, and 11 908 691 visits (84.7%) were among white patients. The proportion of patients discharged from the ED rose from 1 233 701 of 2 309 563 visits (53.4%) in 2011 to 1 279 701 of 2 268 363 visits (56.4%) in 2016. Total adjusted 30-day standardized costs of care declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016 (-$126/y; 95% CI, -$130 to -$121; P < .001) for all ED visits. This decrease was primarily associated with a decline in total spending on the index ED visit (-$48/y; 95% CI, -$50 to -$47; P < .001) as well as lower spending on postacute care (-$42/y; 95% CI, -$44 to -$41; P < .001) and subsequent inpatient care (-$34/y; 95% CI, -$36 to -$32; P < .001). There was an increase in spending after the index visit on downstream observation care ($3.6/y; 95% CI, $3.5 to $3.7; P < .001), outpatient ED care ($4.6/y; 95% CI, $4.4 to $4.8; P < .001), and other outpatient care ($15/y; 95% CI, $12 to $18; P < .001). Conclusions and Relevance: In this study, total 30-day standardized costs of ED care for Medicare beneficiaries decreased in recent years. It may be that more intensive ED spending up front is associated with reductions in total costs of an acute episode.

The Effect of a Rapid Assessment Zone on Emergency Department Operations and Throughput.

STUDY OBJECTIVE: We examine the effects of a front-end flow model designated the rapid assessment zone on multiple emergency department (ED) operational metrics. METHODS: This was a retrospective, before-after study of consecutive patient visits at an urban community ED. Six-month periods were compared before and after an intervention in 2017 that changed patient flow and the intake process. A lead nurse role splits patient flow immediately on patient arrival according to only age and chief complaint, allowing direct bedding without the bottlenecks of vital sign measurement, full triage assessment, or Emergency Severity Index assignment. A new patient care area (designated rapid assessment zone) preferentially expedites treatment of patients likely to remain ambulatory and serves as flexible acute care space when needed by individual cases and the ED. The outcomes measured were ED length of stay, arrival-to-provider time, the rate of leaving before treatment completion, and the rate of leaving before being seen. Data were analyzed with nonparametric testing, χ2 analysis, and multiple linear regression, controlling for patient visit characteristics, ED daily census volumes, and measurements of boarding patients. RESULTS: We analyzed 43,847 visits in the preintervention and 44,792 visits in the postintervention periods. The intervention was associated with the following changes: median ED length of stay from 203 to 171 minutes (-15.8%), median arrival-to-provider time from 28 to 13 minutes (-53.6%), leaving before treatment completion from 1.0% to 0.8% (-20%), and leaving before being seen from 3.1% to 0.5% (-84%). Regression analysis accounting for multiple confounders demonstrated that the reduced length of stay after rapid assessment zone implementation persisted across Emergency Severity Index levels 2 to 5 and all ED daily census levels. CONCLUSION: The rapid assessment zone model aims to decrease front-end bottlenecks and minimize serial intake assessments at a high-volume, urban ED. It was associated with improved patient throughput and decreased early patient departure. It may represent a useful model for similar centers.

Trends in Mortality for Medicare Beneficiaries Treated in the Emergency Department From 2009 to 2016.

Importance: Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date. Objective: To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older. Design, Setting, and Participants: This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15 416 385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older. Exposures: Time (year) as a continuous variable. Main Outcomes and Measures: The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined. Results: The sample included 15 416 385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P < .001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P < .001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P < .001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P < .001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P < .001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P < .001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P < .001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals). Conclusions and Relevance: Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.

Clinical differences between visits to adult freestanding and hospital-based emergency departments.

OBJECTIVE: Compare clinical characteristics for adult visits to freestanding emergency departments (FEDs) and a hospital-based ED (HBED). METHODS: Electronic health records were collected on adult ED visits from 7/1/14 to 6/30/15 from three FEDs and one level 1 trauma tertiary care HBED. RESULTS: There were 55,909 HBED visits; 44,108 FED visits. The FED population was slightly more female (61% vs 57%), younger (48 vs 46 years), white (86% vs 60%), and employed (67% vs 49%). A higher percent of FED visits had private insurance (43% vs 20%); a lower percent had Medicaid (25% vs 42%) and Medicare (23% vs 30%). The top three presenting problems were the same at the HBED and FEDs, but the order differed: gastrointestinal (HBED 19% vs FED 18%), cardiorespiratory (18% vs 16%), injury-pain-swelling of extremity (14% vs 17%). Differences were seen in primary ICD9 codes. One quarter of FED visits and only 18% of HBED visits were for injury/poisoning. A higher percent of FED visits were for respiratory diseases (12% vs 9%) but a lower percent were for circulatory system diseases (7% vs 11%) and visits for mental illness (2% vs 6%). Nearly 30% of HBED visits resulted in admission, compared to 8% of FED visits. ESI level differed significantly, with a lower percent of high acuity cases at FEDs (level 1: 0.1% vs 1.6%; level 2: 5% vs 26%). CONCLUSION: Differences were observed in clinical characteristics of adult HBED visits versus FEDs. Results of this study can help communities plan their emergency care system.

Use of Fine-scale Geospatial Units and Population Data to Evaluate Access to Emergency Care.

INTRODUCTION: Time to facility is a crucial element in emergency medicine (EM). Fine-scale geospatial units such as census block groups (CBG) and publicly available population datasets offer a low-cost and accurate approach to modeling geographic access to and utilization of emergency departments (ED). These methods are relevant to the emergency physician in evaluating patient utilization patterns, emergency medical services protocols, and opportunities for improved patient outcomes and cost utilization. We describe the practical application of geographic information system (GIS) and fine-scale analysis for EM using Ohio ED access as a case study. METHODS: Ohio ED locations (n=198), CBGs (n=9,238) and 2015 United States Census five-year American Community Survey (ACS) socioeconomic data were collected July-August 2016. We estimated drive time and distance between population-weighted CBGs and nearest ED using ArcGIS and 2010 CBG shapefiles. We examined drive times vs. ACS characteristics using multinomial regression and mapping. RESULTS: We categorized CBGs by centroid-ED travel time in minutes: <10 (73.4%; n=6,774), 10-30 (25.1%; n=2,315), and >30 (1.5%; n=141). CBGs with increased median age, Hispanic and non-Hispanic Black population, and college graduation rates had significantly decreased travel time. CBGs with increased low-income populations (adjusted odds ratio [AOR] [1.03], 95% confidence interval [CI] [1.01-1.04]) and vacant housing (AOR [1.06], 95% CI [1.05-1.08]) had increased odds of >30 minute travel time. CONCLUSION: Use of fine-scale geographic analysis and population data can be used to evaluate geographic accessibility and utilization of EDs. Methods described offer guidance to approaching questions of geographic accessibility and have numerous ED and pre-hospital applications.

Associations between Difficulty Paying Medical Bills and Forgone Medical and Prescription Drug Care.

Problems paying medical bills have been reported to be associated with increased stress, bankruptcy, and forgone medical care. Using the Behavioral Model for Vulnerable Populations developed by Gelberg et al as a framework, as well as data from the 2010 Ohio Family Health Survey, this study examined the relationships between difficulty paying medical bills and forgone medical and prescription drug care. Logistic regression was used to examine associations between difficulty paying medical bills and predisposing, enabling, need (health status), and health behaviors (forgoing medical care). Difficulty paying medical bills increased the effect of lack of health insurance in predicting forgone medical care and had a conditional effect on the association between education and forgone prescription drug care. Those who had less than a bachelor's degree were more likely to forgo prescription drug care than those with a bachelor's degree, but only if they had difficulty paying medical bills. Difficulty paying medical bills also accounted for the relationships between several population characteristics (eg, age, income, home ownership, health status) in predicting forgone medical and prescription drug care. Policies to cap out-of-pocket medical expenses may mitigate health disparities by addressing the impact of difficulty paying medical bills on forgone care.

NYC condom use and satisfaction and demand for alternative condom products in New York City sexually transmitted disease clinics.

In 2007, via a high-profile media campaign, the New York City Department of Health and Mental Hygiene (NYC DOHMH) introduced the "NYC Condom," the first specially packaged condom unique to a municipality. We conducted a survey to measure NYC Condom awareness of and experience with NYC Condoms and demand for alternative male condoms to be distributed by the DOHMH. Trained interviewers administered short, in-person surveys at five DOHMH-operated sexually transmitted disease (STD) clinics in Spring 2008. We systematically sampled eligible patients: NYC residents aged ≥18 years waiting to see a physician. We approached 539; 532 agreed to be screened (98.7% response rate); 462 completed the survey and provided NYC zip codes. Most respondents were male (56%), non-Hispanic black (64%), aged 18-24 years (43%) or 25-44 years (45%), employed (65%), and had a high school degree/general equivalency diploma or less (53%). Of those surveyed, 86% were aware of the NYC Condom, and 81% of those who obtained the condoms used them. NYC Condom users were more likely to have four or more sexual partners in the past 12 months (adjusted odds ratio [AOR] = 2.0, 95% confidence interval [CI] = 1.0-3.8), use condoms frequently (AOR = 2.1, 95% CI = 1.3-3.6), and name an alternative condom for distribution (AOR = 2.2, 95% CI = 1.3-3.9). The most frequently requested condom types respondents wanted DOHMH to provide were larger size (28%), ultra thin/extra sensitive (21%), and extra strength (16%). We found high rates of NYC Condom use. NYC Condom users reported more sexual partners than others, suggesting the condom initiative successfully reached higher-risk persons within the STD clinic population. Study results document the condom social marketing campaign's success.

Seeing the forest and the trees: using network analysis to develop an organizational blueprint of state tobacco control systems.

In the United States, tobacco control activities are organized primarily in state tobacco control programs. These programs are comprised of public and private agencies working together to reduce tobacco use. The human, financial, and informational resources that go into state tobacco control programs are documented, and the outcomes of these programs have been studied in terms of health and health behavior. However, little is known about the organizational infrastructure that transforms the human, financial, and informational resources into positive health outcomes. This study examined the inter-organizational relationships among key partner agencies in eight state tobacco control programs. The state programs varied in terms of funding level, funding stability, and region of the country. Using a network analytic approach we asked an average of 14 agencies in each state program about their contacts and partnerships with the other key tobacco control agencies in their state program. Using network visualization and statistics we determined that the state networks shared some common features such as a highly central lead agency, but also had differences in network structure in terms of density and centralization. Using blockmodeling we found that, despite differences in state and program characteristics, there was a common organizational structure among the eight state programs. Understanding the inter-organizational relationships and the common organizational structures of state programs can aid researchers and practitioners in enhancing program capacity and in developing strategies for organizing effective public health systems.