A systematic review of tools for predicting complications in patients with acute infectious diarrhea.

OBJECTIVE: To identify tools that predict the risk of complications in patients presenting to outpatient clinics or emergency departments (ED) with acute infectious diarrhea. METHODS: Medline, Embase, Cochrane Library, Web of Science and CINAHL were searched from inception to July 2021. Articles reporting on the derivation or validation of a score to stratify the risk of intravenous rehydration or hospitalization among patients with acute infectious diarrhea in the ED or outpatient clinic were retained for analysis. RESULTS: Five articles reporting on two different tools were identified. Developed to assess the risk of hospitalization of children, the EsVida scale has not been externally validated. Developed originally to assess the level of dehydration in children, the Clinical Dehydration Scale (CDS) was evaluated as a risk stratification tool. For predicting intravenous rehydration, a CDS score ≥ 1 showed a sensitivity between 0.73 and 0.88 and specificity between 0.38 and 0.69, whereas a CDS score ≥ 5 showed a sensitivity between 0.06 and 0.32 and specificity between 0.94 and 0.99. For predicting hospitalization, a CDS score ≥ 1 showed a sensitivity between 0.74 and 1.00 and specificity between 0.34 and 0.38, whereas a CDS score ≥ 5 showed a sensitivity between 0.26 and 0.62 and specificity between 0.66 and 0.96. High heterogeneity among studies and unclear risk of bias precluded meta-analysis. CONCLUSION: As a risk-stratification tool, the CDS has been validated only for children. Further research is needed to develop and validate a tool suitable for adults in the ED.

Parents' perspective on pediatric emergency department visits for low-acuity conditions before and during the COVID-19 pandemic: a cross-sectional bicentric study.

OBJECTIVES: The primary objective of this study was to describe and compare the motivation of parents/guardians to bring children with low-acuity conditions to a tertiary-care pediatric emergency department (ED) versus a clinic before and after the pandemic. The secondary objectives were to describe and compare the demographic and clinical characteristics of the population studied and the impact of the pandemic on their access to primary care services. METHODS: This is a cross-sectional study based on a survey administered to parents/guardians of patients presenting with low-acuity conditions at one of two EDs. RESULTS: The respondents numbered 659. Children were brought to a pediatric ED generally because of the perceived urgency of the condition, the presumed resource availability in the pediatric ED and the unavailability of the primary care physician. However, most respondents (n = 438, 66.5%) indicated preference for a clinic. More respondents before than during the pandemic reported they had been unable to find a doctor outside the ED (48.6% before COVID vs 26.8% during COVID, p < 0.001) but patients during the pandemic were less likely to seek care in a primary care practice or walk-in clinic (30.0% during COVID vs 48.6% before COVID, p < 0.001). In addition, the number of respondents presenting with symptoms of infection decreased by more than half after the pandemic began while the proportion of musculoskeletal and psychiatric complaints doubled. CONCLUSION: Although the pandemic has altered the landscape of presenting complaints and pediatric healthcare-seeking behaviors, most respondents indicated they would prefer to receive care in a clinic. This finding contradicts the view that most pediatric ED visits for low-acuity conditions are by choice rather than perceived necessity. Prioritizing improved access to primary care resources would better address the preferences and expectations of parents/guardians.

ABSTRAIT: OBJECTIFS: L'objectif principal de cette étude était de décrire et de comparer la motivation des parents/tuteurs à amener des enfants présentant des troubles de faible sévérité à un service d'urgence (SU) pédiatrique de soins tertiaires par rapport à une clinique avant et après la pandémie. Les objectifs secondaires étaient de décrire et de comparer les caractéristiques démographiques et cliniques de la population étudiée et l'impact de la pandémie sur leur accès aux services de soins primaires. MéTHODES: Il s'agit d'une étude transversale fondée sur une enquête menée auprès de parents/tuteurs de patients présentant des problèmes de faible sévérité à l'un des deux SU. RéSULTATS: Les répondants étaient au nombre de 659. Les enfants ont été amenés à un SU pédiatrique généralement en raison de l'urgence perçue de la condition, de la disponibilité présumée des ressources dans le SU pédiatrique et de l'indisponibilité du médecin de soins primaires. Cependant, la plupart des répondants (n = 438, 66,5%) ont indiqué une préférence pour une clinique. Plus de répondants avant que pendant la pandémie ont déclaré qu'ils avaient été incapables de trouver un médecin à l'extérieur de l'urgence (48,6% avant la COVID-19 contre 26,8% pendant la COVID-19, p < 0,001), mais les patients pendant la pandémie étaient moins susceptibles de solliciter des soins dans une clinique de soins primaires ou une clinique sans rendez-vous. (30,0% pendant la COVID-19 contre 48,6% avant la COVID-19, p < 0,001). De plus, le nombre de répondants présentant des symptômes d'infection a diminué de plus de la moitié après le début de la pandémie, tandis que la proportion de plaintes musculosquelettiques et psychiatriques a doublé. CONCLUSION: Bien que la pandémie ait modifié le portrait des raisons et des habitudes de consultation dans les urgences pédiatriques, la plupart des répondants ont indiqué qu'ils préféreraient recevoir des soins dans une clinique. Cette constatation contredit le point de vue selon lequel la plupart des visites aux urgences pédiatriques pour des problèmes de faible sévérité se font par choix plutôt que par nécessité perçue. Donner la priorité à l'amélioration de l'accès aux ressources de soins primaires permettrait de mieux répondre aux préférences et aux attentes des parents/tuteurs.

A systematic review of tools for predicting complications in patients with influenza-like illness.

Objective: To identify tools that predict the risk of complications for patients presenting to an outpatient clinic or an emergency department (ED) with influenza-like illness. Methods: We searched Medline, Embase, Cochrane Library and CINAHL from inception to July 2023. We included articles reporting on the derivation or validation of a score or algorithm used to stratify the risk of hospitalization or mortality among patients with influenza-like illness in the ED or outpatient clinic. Results: Twelve articles reporting on eight scores and six predictive models were identified. For predicting the need for hospitalization, the area under the curve (AUC) of the PMEWS and the CURB-65 ranged respectively from 0.76 to 0.94, and 0.65 to 0.88. The Community Assessment Tool had an AUC of 0.62. For predicting inpatient mortality, AUC was 0.66 for PMEWS and 0.79 for CURB-65, 0.79 for the SIRS criteria and 0.86 for the qSOFA score. Two scores were developed without external validation during the Covid-19 pandemic. The CovHos score and the Canadian Covid discharge score had an AUC ranged from 0.70 to 0.91. The predictive models performed adequately (AUC from 0.76 to 0.92) but will require external validation for clinical use. Tool diversity and study population heterogeneity precluded meta-analysis. Conclusion: Although the CURB, PMEWS and qSOFA scores appear to predict accurately the risk of complications of influenza-like illness, none were reliable enough to justify their widespread ED use. Refinement of an existing tool or development of a new tool to optimize the management of these patients is needed.

Value-based comparison of ambulatory children with respiratory diseases in an emergency department and a walk-in clinic: a retrospective cohort study in Québec, Canada.

OBJECTIVE: To compare health outcomes and costs given in the emergency department (ED) and walk-in clinics for ambulatory children presenting with acute respiratory diseases. DESIGN: A retrospective cohort study. SETTING: This study was conducted from April 2016 to March 2017 in one ED and one walk-in clinic. The ED is a paediatric tertiary care centre, and the clinic has access to lab tests and X-rays. PARTICIPANTS: Inclusion criteria were children: (1) aged from 2 to 17 years old and (2) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia or acute asthma. MAIN OUTCOME MEASURES: The primary outcome measure was the proportion of patients returning to any ED or clinic within 3 and 7 days of the index visit. The secondary outcome measures were the mean cost of care estimated using time-driven activity-based costing and the incidence of antibiotic prescription for URTI patients. RESULTS: We included 532 children seen in the ED and 201 seen in the walk-in clinic. The incidence of return visits at 3 and 7 days was 20.7% and 27.3% in the ED vs 6.5% and 11.4% in the clinic (adjusted relative risk at 3 days (aRR) (95% CI) 3.17 (1.77 to 5.66) and aRR at 7 days 2.24 (1.46 to 3.44)). The mean cost (95% CI) of care (CAD) at the index visit was $C96.68 (92.62 to 100.74) in the ED vs $C48.82 (45.47 to 52.16) in the clinic (mean difference (95% CI): 46.15 (41.29 to 51.02)). Antibiotic prescription for URTI was less common in the ED than in the clinic (1.5% vs 16.4%; aRR 0.10 (95% CI 0.03 to 0.32)). CONCLUSIONS: The incidence of return visits and cost of care were significantly higher in the ED, while antibiotic use for URTI was more frequent in the walk-in clinic. These data may help determine which setting offers the highest value to ambulatory children with acute respiratory conditions.

Development of a Patient-Reported Experience Measure Tool for Ambulatory Patients With Acute Unexpected Needs: The APEX Questionnaire.

Background: The aim of this study was to develop a patient-reported experience measure (PREM) for comparing the experience of care received by ambulatory patients with acute unexpected needs presenting in emergency departments (EDs), walk-in clinics, and primary care practices. Methods: The Ambulatory Patient EXperience (APEX) questionnaire was developed using a 5-phase mixed-methods approach. The questionnaire was pretested by asking potential users to rate its clarity, usefulness, redundancy, content and face validities, and discrimination on a 9-point scale (1 = strongly disagree to 9 = strongly agree). The pre-final version was then tested in a pilot study. Results: The final questionnaire is composed of 61 questions divided into 7 sections. In the pretest (n = 25), median responses were 8 and above for all dimensions assessed. In the pilot study, 63 participants were enrolled. Adjusted results show that access, cleanliness, and feeling treated with respect and dignity by nurses and physicians were significantly better in the clinics than in the ED. Conclusion: We developed a questionnaire to assess and compare experience of ambulatory care in different clinical settings.

A value-based comparison of the management of respiratory diseases in walk-in clinics and emergency departments.

OBJECTIVES: Our aim was to compare some of the health outcomes and costs associated with value of care in emergency departments (ED) and walk-in clinics for ambulatory patients presenting with an acute respiratory disease. METHODS: A health records review was conducted from April 2016 through March 2017 in one ED and one walk-in clinic. Inclusion criteria were: (i) ambulatory patients at least 18 years old, (ii) discharged home with a diagnosis of upper respiratory tract infection (URTI), pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. Primary outcome was the proportion of patients returning to any ED or walk-in clinic within three and seven days of the index visit. Secondary outcomes were the mean cost of care and the incidence of antibiotic prescription for URTI patients. The cost of care was estimated from the Ministry of Health's perspectives using time-driven activity-based costing. RESULTS: The ED group included 170 patients and the walk-in clinic group 326 patients. The return visit incidences at three and seven days were, respectively, 25.9% and 38.2% in the ED vs. 4.9% and 14.7% in the walk-in clinic (adjusted relative risk (arr) of 4.7 (95% CI 2.6-8.6) and 2.7 (1.9-3.9)). The mean cost ($Cdn) of the index visit care was 116.0 (106.3-125.7) in the ED vs. 62.5 (57.7-67.3) in the walk-in clinic (mean difference of 56.4 (45.7-67.1)). Antibiotic prescription for URTI was 5.6% in the ED vs. 24.7% in the walk-in clinic (arr 0.2, 0.01-0.6). CONCLUSIONS: This study is the first in a larger research program to compare the value of care between walk-in clinics and the ED. The potential advantages of walk-in clinics over EDs (lower costs, lower incidence of return visits) for ambulatory patients with respiratory diseases should be considered in healthcare planning.

RéSUMé: OBJECTIFS: Notre objectif était de comparer certains des résultats sanitaires et des coûts associés à la valeur des soins dans les services d'urgence et les cliniques sans rendez-vous pour les patients ambulatoires souffrant d'une maladie respiratoire aiguë. MéTHODES: Une revue des dossiers médicaux a été réalisée d'avril 2016 à mars 2017 dans un service d'urgence et une clinique sans rendez-vous. Les critères d'inclusion étaient les suivants : (i) patients ambulatoires âgés d'au moins 18 ans, (ii) renvoyés chez eux avec un diagnostic d'infection des voies respiratoires supérieures (IVRS), de pneumonie, d'asthme aigu ou d'exacerbation aiguë de la maladie pulmonaire obstructive chronique. Le résultat primaire était la proportion de patients retournant à un service d'urgence ou à une clinique sans rendez-vous dans les trois et sept jours suivant la visite de référence. Les résultats secondaires étaient le coût moyen des soins et l'incidence de la prescription d'antibiotiques pour les patients atteints d'IVRS. Le coût des soins a été estimé à partir des perspectives du ministère de la santé, en utilisant la méthode de calcul des coûts par activité en fonction du temps. RéSULTATS: Le groupe des urgences comprenait 170 patients et le groupe des cliniques sans rendez-vous 326 patients. Les incidences des visites de retour à trois et sept jours étaient respectivement de 25,9 % et 38,2 % dans le service des urgences contre 4,9 % et 14,7 % à la clinique sans rendez-vous (risque relatif ajusté (arr) de 4,7 (IC à 95 % 2,6 à 8,6) et 2,7 (1,9-3,9)). Le coût moyen ($CAN) de la visite de référence était de 116,0 (106,3-125,7) aux urgences contre 62,5 (57,7-67,3) dans la clinique sans rendez-vous (différence moyenne de 56,4 (45,7-67,1)). La prescription d'antibiotiques pour l'IVRS était de 5,6 % aux urgences contre 24,7 % dans la clinique sans rendez-vous (arr 0,2, 0,01-0,6). CONCLUSIONS: Cette étude est la première d'un programme de recherche plus vaste visant à comparer la valeur des soins entre les cliniques sans rendez-vous et les urgences. Les avantages potentiels des cliniques sans rendez-vous par rapport aux services d'urgence (coûts moindres, incidence plus faible des visites de retour) pour les patients ambulatoires souffrant de maladies respiratoires devraient être pris en compte dans la planification des soins de santé.

Adaptation of time-driven activity-based costing to the evaluation of the efficiency of ambulatory care provided in the emergency department.

Objectives: The aim of this study was: (1) to adapt the time-driven activity-based costing (TDABC) method to emergency department (ED) ambulatory care; (2) to estimate the cost of care associated with frequently encountered ambulatory conditions; and (3) to compare costs calculated using estimated time and objectively measured time. Methods: TDABC was applied to a retrospective cohort of patients with upper respiratory tract infections, urinary tract infections, unspecified abdominal pain, lower back pain and limb lacerations who visited an ED in Québec City (Canada) during fiscal year 2015-2016. The calculated cost of care was the product of the time required to complete each care procedure and the cost per minute of each human resource or equipment involved. Costing based on durations estimated by care professionals were compared to those based on objective measurements in the field. Results: Overall, 220 care episodes were included and 3080 time measurements of 75 different processes were collected. Differences between costs calculated using estimated and measured times were statistically significant for all conditions except lower back pain and ranged from $4.30 to $55.20 (US) per episode. Differences were larger for conditions requiring more advanced procedures, such as imaging or the attention of ED professionals. Conclusions: The greater the use of advanced procedures or the involvement of ED professionals in the care, the greater is the discrepancy between estimated-time-based and measured-time-based costing. TDABC should be applied using objective measurement of the time per procedure.

Identification of Predictors of Abnormal Calcium, Magnesium and Phosphorus Blood Levels in the Emergency Department: A Retrospective Cohort Study.

PURPOSE: With rising healthcare costs limiting access to care, the judicious use of diagnostic tests has become a critical issue for many jurisdictions. Calcium, magnesium and phosphorus serum levels are regularly performed tests in the emergency department, but their clinical relevance have come into question. Authors sought to determine risk factors that could predict abnormal calcium, magnesium and phosphorus serum levels, as well as identify patients who may need corrective interventions. METHODS: A retrospective cohort study was conducted in two academic hospitals in Québec City. Demographic and clinical characteristics of 1008 patients who had serum calcium and/or magnesium and/or phosphorus levels drawn by an emergency physician were collected. Multivariate logistic regression models were fitted to obtain adjusted odds ratios for each risk factor for abnormal calcium or magnesium or phosphorus blood levels, and for a required intervention. RESULTS: Among patients for whom calcium, magnesium and phosphorus were tested in the Emergency Department, the most significant risk factors (OR>2) for electrolytic abnormality were as follows: hypocalcemia - respiratory distress, diuretics (excluding loop and thiazide), anti-neoplastic medication, long QTc, chronic kidney disease (CKD); hypercalcemia - bone pain, vitamin D, hallucinations; hypomagnesemia - diabetes, corticosteroids; hypermagnesemia - poor extremity perfusion, CKD, furosemide; hypophosphatemia - seizure; hyperphosphatemia - phosphate-binders, CKD, peripheral vascular atherosclerotic disease. Of all patients tested, 3.4% received a corrective intervention initiated by the emergency physician. Predictors of intervention on an electrolyte abnormality include poor peripheral perfusion, nausea and chronic obstructive pulmonary disease (COPD). CONCLUSION: Emergency physicians can potentially reduce the unnecessary testing of calcium, magnesium and phosphorus blood levels by targeting patients with high-acuity conditions or chronic comorbidities such as CKD, diabetes and COPD.

A Value-Based Comparison of the Management of Ambulatory Respiratory Diseases in Walk-in Clinics, Primary Care Practices, and Emergency Departments: Protocol for a Multicenter Prospective Cohort Study.

BACKGROUND: In Canada, 30%-60% of patients presenting to emergency departments are ambulatory. This category has been labeled as a source of emergency department overuse. Acting on the presumption that primary care practices and walk-in clinics offer equivalent care at a lower cost, governments have invested massively in improving access to these alternative settings in the hope that patients would present there instead when possible, thereby reducing the load on emergency departments. Data in support of this approach remain scarce and equivocal. OBJECTIVE: The aim of this study is to compare the value of care received in emergency departments, walk-in clinics, and primary care practices by ambulatory patients with upper respiratory tract infection, sinusitis, otitis media, tonsillitis, pharyngitis, bronchitis, influenza-like illness, pneumonia, acute asthma, or acute exacerbation of chronic obstructive pulmonary disease. METHODS: A multicenter prospective cohort study will be performed in Ontario and Québec. In phase 1, a time-driven activity-based costing method will be applied at each of the 15 study sites. This method uses time as a cost driver to allocate direct costs (eg, medication), consumable expenditures (eg, needles), overhead costs (eg, building maintenance), and physician charges to patient care. Thus, the cost of a care episode will be proportional to the time spent receiving the care. At the end of this phase, a list of care process costs will be generated and used to calculate the cost of each consultation during phase 2, in which a prospective cohort of patients will be monitored to compare the care received in each setting. Patients aged 18 years and older, ambulatory throughout the care episode, and discharged to home with one of the aforementioned targeted diagnoses will be considered. The estimated sample size is 1485 patients. The 3 types of care settings will be compared on the basis of primary outcomes in terms of the proportion of return visits to any site 3 and 7 days after the initial visit and the mean cost of care. The secondary outcomes measured will include scores on patient-reported outcome and experience measures and mean costs borne wholly by patients. We will use multilevel generalized linear models to compare the care settings and an overlap weights approach to adjust for confounding factors related to age, sex, gender, ethnicity, comorbidities, registration with a family physician, socioeconomic status, and severity of illness. RESULTS: Phase 1 will begin in 2021 and phase 2, in 2023. The results will be available in 2025. CONCLUSIONS: The end point of our program will be for deciders, patients, and care providers to be able to determine the most appropriate care setting for the management of ambulatory emergency respiratory conditions, based on the quality and cost of care associated with each alternative. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/25619.