National study of barriers to timely primary care and emergency department utilization among Medicaid beneficiaries.

STUDY OBJECTIVE: We compare the association between barriers to timely primary care and emergency department (ED) utilization among adults with Medicaid versus private insurance. METHODS: We analyzed 230,258 adult participants of the 1999 to 2009 National Health Interview Survey. We evaluated the association between 5 specific barriers to timely primary care (unable to get through on telephone, unable to obtain appointment soon enough, long wait in the physician's office, limited clinic hours, lack of transportation) and ED utilization (≥1 ED visit during the past year) for Medicaid and private insurance beneficiaries. Multivariable logistic regression models adjusted for demographics, socioeconomic status, health conditions, outpatient care utilization, and survey year. RESULTS: Overall, 16.3% of Medicaid and 8.9% of private insurance beneficiaries had greater than or equal to 1 barrier to timely primary care. Compared with individuals with private insurance, Medicaid beneficiaries had higher ED utilization overall (39.6% versus 17.7%), particularly among those with barriers (51.3% versus 24.6% for 1 barrier and 61.2% versus 28.9% for ≥2 barriers). After adjusting for covariates, Medicaid beneficiaries were more likely to have barriers (adjusted odds ratio [OR] 1.41; 95% confidence interval [CI] 1.30 to 1.52) and higher ED utilization (adjusted OR 1.48; 95% CI 1.41 to 1.56). ED utilization was even higher among Medicaid beneficiaries with 1 barrier (adjusted OR 1.66; 95% CI 1.44 to 1.92) or greater than or equal to 2 barriers (adjusted OR 2.01; 95% CI 1.72 to 2.35) compared with that for individuals with private insurance and barriers. CONCLUSION: Compared with individuals with private insurance, Medicaid beneficiaries were affected by more barriers to timely primary care and had higher associated ED utilization. Expansion of Medicaid eligibility alone may not be sufficient to improve health care access.

Emergency department control of blood pressure in intracerebral hemorrhage.

BACKGROUND: Early treatment of elevated blood pressure (BP) in patients presenting with spontaneous intracerebral hemorrhage (ICH) may decrease hematoma enlargement and lead to better neurologic outcome. STUDY OBJECTIVE: To determine whether early BP control in patients with spontaneous ICH is both feasible and tolerated when initiated in the Emergency Department (ED). METHODS: A single-center, prospective observational study in patients with spontaneous ICH was performed to evaluate a protocol to lower, and maintain for 24 h, the mean arterial pressure (MAP) to a range of 100-110 mm Hg within 120 min of arrival to the ED. An additional goal of placing a functional arterial line within 90 min was specified in our protocol. Hematoma volume, neurologic disability, adverse events, and in-hospital mortality were recorded. RESULTS: A total of 22 patients were enrolled over a 1-year study period. The average time to achieve our target MAP after implementation of our protocol was 123 min (range 19-297 min). The average time to arterial line placement was 84 min (range 36-160 min). Overall, 77% of the patients tolerated the 24-h protocol. The in-hospital mortality rate in this group of patients was 41%. CONCLUSIONS: Adopting a protocol to reduce and maintain the MAP to a target of 100-110 mm Hg within 120 min of ED arrival was safe and well tolerated in patients presenting with spontaneous ICH. If future trials demonstrate a clinical benefit of early BP control in spontaneous ICH, EDs should implement similar protocols.

A comparison of HIV testing in the emergency department and urgent care.

BACKGROUND: Although national guidelines recommend universal human immunodeficiency virus (HIV) testing, emergency departments (EDs) may choose to limit testing to certain patients, such as those triaged to urgent care (UC). OBJECTIVE: To compare the results of rapid HIV testing in an urban ED with an affiliated UC. METHODS: This was a retrospective analysis of an HIV testing program that included screening, which was initiated by triage nurses, and diagnostic testing, which was initiated by clinicians. Eligible patients were ≥ 12 years old and medically stable. RESULTS: From April 2005 through December 2006, HIV tests were completed in 6196 (8.3%) of the 74,331 ED visits and 3256 (8.8%) of the 37,169 UC visits. Screening accounted for 5009 (80.8%) of the ED tests and 2914 (89.5%) of the UC tests, and diagnostic testing accounted for the remainder. Eighty (1.3%) of the ED tests and 21 (0.6%) of the UC tests were positive (p = 0.0024). Compared with newly diagnosed HIV-positive ED patients, HIV-positive UC patients were less likely to have CD4 counts < 200 cells/µL (adjusted odds ratio 0.19, 95% confidence interval 0.05-0.65). CONCLUSION: Although the yield of HIV testing is greater among ED patients, UC patients are diagnosed at a less advanced stage of illness.

Is the ordering of imaging for suspected venous thromboembolism consistent with D-dimer result?

STUDY OBJECTIVE: We assessed whether the ordering of imaging studies in patients with suspected venous thromboembolism was consistent with the results of D-dimer testing. METHODS: We performed a retrospective chart review of consecutive cases in which a D-dimer assay was performed at an urban academic emergency department during a 13-month period. Measurements included D-dimer result and results of imaging for venous thromboembolism. The primary outcome measure was the percentage of patients in each D-dimer category (positive or negative result with a cutoff value of 500 ng fibrinogen equivalent units/dL) who underwent subsequent imaging within 48 hours. We also report the results of the imaging studies obtained. RESULTS: A total of 553 D-dimer tests were ordered, with 266 (48.1%) negative and 287 (51.9%) positive results. Of patients with a negative D-dimer result, 37 (14%; 95% confidence interval [CI] 10% to 19%) underwent at least 1 imaging study. Of patients with a positive D-dimer result, 137 (48%; 95% CI 42% to 54%) did not undergo imaging. CONCLUSION: Evaluation for venous thromboembolism occasionally proceeded despite a negative D-dimer result, whereas frequently no further evaluation occurred despite a positive result. These findings suggest that actual clinical practice differs from what is recommended by published algorithms that guide evaluation of patients with suspected venous thromboembolism.