Measuring concordance and discordance between selected individual characteristics and corresponding neighborhood-level social determinants of health.

Background: Individuals reside within communities influenced by various social determinants impacting health, which may harmonize or conflict at individual and neighborhood levels. While some experience concordant circumstances, discordance is prevalent, yet poorly understood due to the lack of a universally accepted method for quantifying it. This paper proposes a methodology to address this gap. Methods: We propose a systematic approach to operationalize concordance and discordance between individual and neighborhood social determinants, using household income (HHI) (continuous) and race/ethnicity (categorical) as examples for individual social determinants. We demonstrated our method with a small dataset that combines self-reported individual data with geocoded neighborhood level. We anticipate that the risk profiles created by either self-reported individual data or neighborhood-level data alone will differ from patterns demonstrated by typologies based on concordance and discordance. Results: In our cohort, it was revealed that 20% of patients experienced discordance between their HHIs and neighborhood characteristics. Additionally, 38% reside in racially/ethnically concordant neighborhoods, 23% in discordant ones, and 39% in neutral ones. Conclusion: Our study introduces an innovative approach to defining and quantifying the notions of concordance and discordance in individual attributes concerning neighborhood-level social determinants. It equips researchers with a valuable tool to conduct more comprehensive investigations into the intricate interplay between individuals and their environments. Ultimately, this methodology facilitates a more accurate modeling of the true impacts of social determinants on health, contributing to a deeper understanding of this complex relationship.

The Association of Racial Residential Segregation and Survival After Out-of-Hospital Cardiac Arrest in the United States.

Background: Residential segregation has been identified as drivers of disparities in health outcomes, but further work is needed to understand this association with clinical outcomes for out-of-hospital cardiac arrest (OHCA). We utilized Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine if there are differences in survival to discharge and survival with good neurological outcome, as well as likelihood of bystander CPR, using validated measures of racial, ethnic, and economic segregation. Methods: We conducted a retrospective observational study using data from the Cardiac Arrest Registry to Enhance Survival (CARES) dataset to examine associations among adult OHCA patients. The primary predictor was the Index of Concentration at the Extremes (ICE), a validated measure that includes race, ethnicity, and income across three measures at the census tract level. The primary outcomes were survival to discharge and survival with good neurological status. A multivariable modified Poisson regression modeling approach with random effects at the EMS agency and hospital level was utilized. Results: We identified 626,264 OHCA patients during the study period. The mean age was 62 years old (SD 17.2 years), and 35.7% (n =223,839) of the patients were female. In multivariable models, we observed an increased likelihood of survival to discharge and survival with good neurological outcome for those patients residing in predominately White population census tracts and higher income census tracts as compared to lower income Black and Hispanic/Latinx population census tracts (RR 1.24, CI 1.20-1.28) and a 32% increased likelihood of receiving bystander CPR in higher income census tracts as compared to reference (RR 1.32, CI 1.30-1.34). Conclusions: In this study examining the association of measures of residential segregation and OHCA outcomes, there was an increased likelihood of survival to discharge, survival with good neurological status, and likelihood of receiving B-CPR for those patients residing in predominately White population and higher income census tracts when compared to predominately Black and/or Hispanic Latinx populations and lower income census tracts. This research suggests that areas impacted by residential and economic segregation are important targets for both public policy interventions as well as addressing disparities in care across the chain of survival for OHCA.

Stage B Heart Failure Is Ubiquitous in Emergency Patients with Asymptomatic Hypertension.

Introduction: Hypertension is the leading risk factor for morbidity and mortality throughout the world and is pervasive in United States emergency departments (ED). This study documents the point prevalence of subclinical heart disease in emergency patients with asymptomatic hypertension. Method: This was a prospective observational study of ED patients with asymptomatic hypertension conducted at two urban academic EDs that belong to an eight-hospital healthcare organization in New York. Adult (≥18 years of age) English- or Spanish-speaking patients who had an initial blood pressure (BP) ≥160/100 millimeters of mercury (mmHg) and second BP ≥140/90 mm Hg, and pending discharge, were invited to participate in the study. We excluded patients with congestive heart failure, renal insufficiency, and atrial fibrillation, or who were pregnant, a prisoner, cognitively unable to provide informed consent, or experiencing symptoms of hypertension. We assessed echocardiographic evidence of subclinical heart disease (left ventricular hypertrophy, and diastolic and systolic dysfunction). Results: A total of 53 patients were included in the study; a majority were young (mean 49.5 years old, [SD 14-52]), self-identified as Black or Other (n = 39; 73.5%), and female (n = 30; 56.6%). Mean initial blood pressure was 172/100 mm Hg, and 24 patients (45.3%) self-reported a history of hypertension. Fifty patients completed an echocardiogram. All (100%) had evidence of subclinical heart disease, with 41 (77.4%) displaying left ventricular hypertrophy and 31 (58.5%) diastolic dysfunction. There was a significant relationship between diastolic dysfunction and female gender [x2 (1, n = 53) = 3.98; P = 0.046]; Black or other race [x2 (3, n = 53) = 9.138; P = 0.03] and Hispanic or other ethnicity [x2 (2, n = 53) = 8.03; P = 0.02]. Less than one third of patients demonstrated systolic dysfunction on echocardiogram, and this was more likely to occur in patients with diabetes mellitus [x2 (1, n = 51) = 4.84; P = 0.02]. Conclusion: There is a high probability that Black, Hispanic, and female patients with asymptomatic hypertension are on the continuum for developing overt heart failure. Emergency clinicians should provide individualized care that considers their unique health needs, cultural backgrounds, and social determinants of health.

"The project did not come to us with a solution": Perspectives of research teams on implementing a study about electronic health record-embedded individualized pain plans for emergency department treatment of vaso-occlusive episodes in adults with sickle cell disease.

BACKGROUND: This study aimed to capture the implementation process of the ALIGN Study, (An individualized Pain Plan with Patient and Provider Access for Emergency Department care of Sickle Cell Disease). ALIGN aimed to embed Individualized Pain Plans in the electronic health record (E-IPP) and provide access to the plan for both adult patients with sickle cell disease (SCD) and emergency department providers when a person with SCD comes to the emergency department in vaso-occlusive crises. METHODS: Semi-structured interviews were conducted with research teams from the 8 participating sites from the ALIGN study. Seventeen participants (principal investigators and study coordinators) shared their perspectives about the implementation of ALIGN in their sites. Data were analyzed in three phases using open coding steps adapted from grounded theory and qualitative content analysis. RESULTS: A total of seven overarching themes were identified: (1) the E-IPP structure (location and upkeep) and collaboration with the informatics team, (2) the role of ED champion, (3) the role of research coordinators, (4) research team communication, and communication between research team and clinical team, (5) challenges with the study protocol, (6) provider feedback: addressing over-utilizers, patient mistrust, and the positive feedback about the intervention, and (7) COVID-19 and its effects on study implementation. CONCLUSIONS: Findings from this study contribute to learning how to implement E-IPPs for adult patients with SCD in ED. The study findings highlight the importance of early engagement with different team members, a champion from the emergency department, study coordinators with different skills and enhancement of communication and trust among team members. Further recommendations are outlined for hospitals aiming to implement E-IPP for patients with SCD in ED.

Association of Racial Residential Segregation With Long-Term Outcomes and Readmissions After Out-of-Hospital Cardiac Arrest Among Medicare Beneficiaries.

Background The national impact of racial residential segregation on out-of-hospital cardiac arrest outcomes after initial resuscitation remains poorly understood. We sought to characterize the association between measures of racial and economic residential segregation at the ZIP code level and long-term survival and readmissions after out-of-hospital cardiac arrest among Medicare beneficiaries. Methods and Results In this retrospective cohort study, using Medicare claims data, our primary predictor was the index of concentration at the extremes, a measure of racial and economic segregation. The primary outcomes were death up to 3 years and readmissions. We estimated hazard ratios (HRs) across all 3 types of index of concentration at the extremes measures for each outcome while adjusting for beneficiary demographics, treating hospital characteristics, and index hospital procedures. In fully adjusted models for long-term survival, we found a decreased hazard of death and risk of readmission for beneficiaries residing in the more segregated White communities  and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes across all 3 indices of concentration at the extremes measures (race: HR, 0.87 [95% CI, 0.81-0.93]; income: HR, 0.75 [95% CI, 0.69-0.78]; and race+income: HR, 0.77 [95% CI, 0.72-0.82]). Conclusions We found a decreased hazard of death and risk for readmission for those residing in the more segregated White communities  and higher-income ZIP codes compared with the more segregated Black communities and lower-income ZIP codes when using validated measures of racial and economic segregation. Although causal pathways and mechanisms remain unclear, disparities in outcomes after out-of-hospital cardiac arrest are associated with the structural components of race and wealth and persist up to 3 years after discharge.

Designing a Road Map for Action to Address Bias and Racism Within a Large Academic Medical Center.

ABSTRACT: The convergence of the COVID-19 pandemic, the Black Lives Matter Movement, and the public anguish and outrage resulting from the murder of George Floyd in 2020 intensified the commitment of many health care institutions to pursue racial and social justice and achieve health equity. The authors describe the Road Map for Action to Address Racism, which was developed to unify and systematize antiracism efforts across the Mount Sinai Health System. A 51-member Task Force to Address Racism, comprising faculty, staff, students, alumni, health system leaders, and trustees, developed recommendations to achieve the goal of becoming an antiracist and equitable health care and learning institution by intentionally addressing all forms of racism and promoting greater diversity, inclusion, and equity for its workforce and community. Grounded in the principles of Collective Impact, the Task Force developed a set of 11 key strategies to effect systemwide change. The strategies affected all aspects of the organization: business systems and financial operations, delivery of care, workforce development and training, leadership development, medical education, and community engagement. The authors describe Road Map implementation, currently in process, including the appointment of strategy leaders, evolution of a governance structure integrating stakeholders from across the health system, development of an evaluation framework, communication and engagement efforts, and process measures and progress to date. Lessons learned include the importance of recognizing the work of dismantling racism as integral to, not apart from, the institution's day-to-day work, and the need for specialized expertise and a significant investment of time to coordinate Road Map implementation. Going forward, rigorous assessment of quantitative and qualitative outcomes and a commitment to sharing successes and challenges will be critical to eradicating systems that have perpetuated inequities in the biomedical sciences and medicine and in the delivery of health care.

Emergency Physician Observations and Attitudes on Law Enforcement Activities in the Emergency Department.

INTRODUCTION: Law enforcement officers (LEO) interact with patients and clinicians in the emergency department (ED) for many reasons. There is no current consensus on what should comprise, or how to best enact, guidelines that ideally balance LEO activities in the service of public safety with patient health, autonomy, and privacy. The purpose of this study was to explore how a national sample of emergency physicians (EP) perceives activities of LEOs during the delivery of emergency medical care. METHODS: Members of the Emergency Medicine Practice Research Network (EMPRN) were recruited via an email-delivered, anonymous survey that elicited experiences, perceptions, and knowledge of policies that guide interactions with LEOs in the ED. The survey included multiple-choice items, which we analyzed descriptively, and open-ended questions, which we analyzed using qualitative content analysis. RESULTS: Of 765 EPs in the EMPRN, 141 (18.4%) completed the survey. Respondents represented diverse locations and years in practice. A total of 113 (82%) respondents were White, and 114 (81%) were male. Over a third reported LEO presence in the ED on a daily basis. A majority (62%) perceived LEO presence as helpful for clinicians and clinical practice. When asked about the factors deemed highly important in allowing LEOs to access patients during care, 75% reported patients' potential as a threat to public safety. A small minority of respondents (12%) considered the patients' consent or preference to interact with LEOs. While 86% of EPs felt that information-gathering by LEO was appropriate in the ED setting, only 13% were aware of policy to guide these decisions. Perceived barriers to implementation of policy in this area included: issues of enforcement; leadership; education; operational challenges; and potential negative consequences. CONCLUSION: Future research is warranted to explore how policies and practices that guide intersections between emergency medical care and law enforcement impact patients, clinicians, and the communities that health systems serve.

A Quality Framework to Address Racial and Ethnic Disparities in Emergency Department Care.

The emergency department serves as a vital source of health care for residents in the United States, including as a safety net. However, patients from minoritized racial and ethnic groups have historically experienced disproportionate barriers to accessing health care services and lower quality of services than White patients. Quality measures and their application to quality improvement initiatives represent a critical opportunity to incentivize health care systems to advance health equity and reduce health disparities. Currently, there are no nationally recognized quality measures that track the quality of emergency care delivery by race and ethnicity and no published frameworks to guide the development and prioritization of quality measures to reduce health disparities in emergency care. To address these gaps, the American College of Emergency Physicians (ACEP) convened a working group of experts in quality measurement, health disparities, and health equity to develop guidance on establishing quality measures to address racial and ethnic disparities in the provision of emergency care. Based on iterative discussion over 3 working group meetings, we present a summary of existing emergency medicine quality measures that should be adapted to track racial and ethnic disparities, as well as a framework for developing new measures that focus on disparities in access to emergency care, care delivery, and transitions of care.

Cocaethylene cardiotoxicity in emergency department patients with acute drug overdose.

OBJECTIVES: Cocaine use results in over 500,000 emergency department (ED) visits annually across the United States and ethanol co-ingestion is reported in 34% of these. Commingling cocaine with ethanol results in the metabolite cocaethylene (CE), which is metabolically active for longer than cocaine alone. Current literature on the cardiotoxicity of CE compared to cocaine alone is limited and lacks consensus. This study aims to fill this gap in the literature and examine cardiovascular events in cocaine use as confirmed by urine toxicology versus CE exposure. METHODS: This was a secondary data analysis of a prospective cohort study of adult patients with acute drug overdose at two urban tertiary care hospital EDs over 4 years. Patients with positive urinary cocaine metabolites were analyzed, and outcomes were compared between patients with overdose and confirmed presence of cocaine on urine toxicology (cocaine group) and patients with cocaine and ethanol use (CE group). The primary outcome was cardiac arrest. Secondary outcomes included myocardial injury and hyperlactatemia. Data were analyzed using multivariable regression models. RESULTS: We enrolled a total of 199 patients (150 cocaine, 49 CE). Rates of cardiac arrest were significantly higher in the CE group compared to cocaine (6.1% vs. 0.67%, p = 0.048). Cocaine was significantly associated with myocardial injury compared to CE exposure (mean initial troponin 0.01 ng/ml vs. 0.16 ng/ml, p = 0.021), while hyperlactatemia was associated with CE exposure (mean initial lactate 4.1 mmol/L vs. 2.9 mmol/L, p = 0.038). CONCLUSIONS: When compared to cocaine exposure alone, CE exposure in ED patients with acute drug overdose was significantly associated with higher occurrence of cardiac arrest, higher mean lactate concentrations, and lower occurrence of myocardial injury.

Missed Opportunities for HIV and Hepatitis C Screening Among Emergency Department Patients With Untreated Opioid Use Disorder.

OBJECTIVE: We assessed the frequency of emergency department (ED) HIV and hepatitis C (HCV) screening in a high-risk cohort of ED patients with untreated opioid use disorder (OUD). METHODS: This analysis used data from a prospective, observational study of English-speaking adults with untreated OUD enrolled from April 2017 to December 2018 in 4 urban, academic EDs. Two cohorts were defined for this analysis by self-reported negative/unknown status for HIV (cohort 1) and HCV (cohort 2). Sites featured structured screening programs throughout the entire enrollment period for HIV and during at least part of the enrollment period for HCV. We calculated the proportion tested for HIV and HCV during the study enrollment ED visit. RESULTS: Among 394 evaluated ED patients, 328 of 394 (83.2%) were not tested for HIV or HCV and 244 of 393 (62.1%) lacked a usual medical care provider. In cohort 1, 375 reported negative or unknown HIV status; 59/375 (15.7%) overall and 33/218 (15.1%) of those reporting recent injection drug use were tested for HIV. In cohort 2, 231 reported negative of unknown HCV status; 22/231 (9.5%) overall and 9/98 (9.2%) of those reporting recent injection drug use were tested for HCV. The proportion tested by the ED ranged from 3% to 25% for HIV and 4% to 32% for HCV across study sites. CONCLUSIONS: Emergency department HIV and HCV screening remains infrequent among patients with untreated OUD, including those who inject drugs, even in EDs committed to screening. Targeted HIV/HCV screening should be considered as an adjunct strategy until the ideal of universal screening is more fully achieved.

Survival After Out-of-Hospital Cardiac Arrest: The Role of Racial Residential Segregation.

Racial and racialized economic residential segregation has been empirically associated with outcomes across multiple health conditions but not yet explored in relation to out-of-hospital cardiac arrest (OHCA). We sought to examine if measures of racial and economic residential segregation are associated with differences in survival to discharge after OHCA for Black and White Medicare beneficiaries. Utilizing age-eligible Medicare fee-for-service claims data from 2013 to 2015, we identified OHCA claims and determined survival to discharge. The primary predictor, residential segregation, was calculated using the index of concentration at the extremes (ICE) for the beneficiary residential ZIP code. Multilevel modified Poisson regression models were used to determine the association of OHCA outcomes and ZIP code level ICE measures. In total, 194,263 OHCA cases were identified among beneficiaries residing in 75% of US ZIP codes. Black beneficiaries exhibited 12.1% survival to discharge, compared with 12.5% of White beneficiaries. In fully adjusted models of the three ICE measures accounting for differences in treating hospital characteristics, there was as high as a 28% (RR 1.28, CI 1.23-1.26) higher relative likelihood of survival to discharge in the most segregated White ZIP codes (Q5) as compared to the most segregated Black ZIP codes (Q1). Racial residential segregation is independently associated with disparities in OHCA outcomes; among Medicare beneficiaries who generated a claim after suffering an OHCA, ICE measures of racial segregation are associated with a lower likelihood of survival to discharge for those living in the most segregated Black and lower income quintiles compared to higher quintiles.

Cost variation and revisit rate for adult patients with asthma presenting to the emergency department.

BACKGROUND: Asthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care. STUDY OBJECTIVE: We sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation. METHODS: We used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering. RESULTS: In 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371-980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18-1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00-1.00). CONCLUSION: Hospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.

Feasibility of the Transport PLUS intervention to improve the transitions of care for patients transported home by ambulance: a non-randomized pilot study.

BACKGROUND: The growing population of patients over the age of 65 faces particular vulnerability following discharge after hospitalization or an emergency room visit. Specific areas of concern include a high risk for falls and poor comprehension of discharge instructions. Emergency medical technicians (EMTs), who frequently transport these patients home from the hospital, are uniquely positioned to aid in mitigating transition of care risks and are both trained and utilized to do so using the Transport PLUS intervention. METHODS: Existing literature and focus groups of various stakeholders were utilized to develop two checklists: the fall safety assessment (FSA) and the discharge comprehension assessment (DCA). EMTs were trained to administer the intervention to eligible patients in the geriatric population. Using data from the checklists, follow-up phone calls, and electronic health records, we measured the presence of hazards, removal of hazards, the presence of discharge comprehension issues, and correction or reinforcement of comprehension. These results were validated during home visits by community health workers (CHWs). Feasibility outcomes included patient acceptance of the Transport PLUS intervention and accuracy of the EMT assessment. Qualitative feedback via focus groups was also obtained. Clinical outcomes measured included 3-day and 30-day readmission or ED revisit. RESULTS: One-hundred three EMTs were trained to administer the intervention and participated in 439 patient encounters. The intervention was determined to be feasible, and patients were highly amenable to the intervention, as evidenced by a 92% and 74% acceptance rate of the DCA and FSA, respectively. The majority of patients also reported that they found the intervention helpful (90%) and self-reported removing 40% of fall hazards; 85% of such changes were validated by CHWs. Readmission/revisit rates are also reported. CONCLUSIONS: The Transport PLUS intervention is a feasible, easily implemented tool in preventative community paramedicine with high levels of patient acceptance. Further study is merited to determine the effectiveness of the intervention in reducing rates of readmission or revisit. A randomized control trial has since begun utilizing the knowledge gained within this study.

Outcomes of the National Heart, Lung, and Blood Institute K12 program in emergency care research: 7-year follow-up.

BACKGROUND: Long-term follow-up for clinician-scientist training programs is sparse. We describe the outcomes of clinician-scientist scholars in the National Heart Lung and Blood Institute (NHLBI) K12 program in emergency care research up to 8.7 years after matriculation in the program. METHODS: This was a cohort study of faculty clinician-scientist scholars enrolled in a NHLBI K12 research training program at 6 sites across the US, with median follow-up 7.7 years (range 5.7-8.7 years) from the date of matriculation. Scholars completed electronic surveys in 2017 and 2019, with the 2019 survey collecting information for their current work setting, percent time for research, and grant funding from all sources. We used NIH RePorter and online resources to verify federal grants through March 2021. The primary outcome was a funded career development award (CDA) or research project grant (RPG) where the scholar was principal investigator. We included funding from all federal sources and national foundations. RESULTS: There were 43 scholars, including 16 (37%) women. Over the follow-up period, 32 (74%) received an individual CDA or RPG, with a median of 36 months (range 9-83 months) after entering the program. Of the 43 scholars, 23 (54%) received a CDA and 22 (51%) received an RPG, 7 (16%) of which were R01s. Of the 23 scholars who received a CDA, 13 (56%) subsequently had an RPG funded. Time to CDA or RPG did not differ by sex (women vs. men log-rank test p = 0.27) or specialty training (emergency medicine versus other specialties, p = 0.59). CONCLUSIONS: After 7 years of follow-up for this NHLBI K12 emergency care research training program, three quarters of clinician-scientist scholars had obtained CDA or RPG funding, with no notable differences by sex or clinical training.

Decline in U.S. Emergency Department admission rates driven by critical pathway conditions, 2006-2014.

OBJECTIVES: Despite increasing ED visits, evidence suggests overall hospitalization rates have decreased; however, it is unknown what clinical conditions account for these changes. We aim to describe condition-specific trends and hospital-level variation in hospitalization rates after ED visits from 2006 to 2014. METHODS: Retrospective observational study of adult ED visits to U.S. acute care hospitals using nationally weighted data from the 2006-2014 National Emergency Department Survey. Our primary outcome was ED admission rate, defined as the number of admissions originating in the ED divided by the number of ED visits. We report admission rates overall and for each condition, including changes over time. We used logistic regression to compare the odds of ED admission from 2006 to 2014, adjusting for patient and hospital characteristics. We also measured hospital-level variation by calculating hospital-level median ED admission rates and interquartile ranges. RESULTS: After adjusting for patient and hospital characteristics, the odds of ED admission for any condition were 0.49 (CI 0.45, 0.52) in 2014 compared to 2006. The conditions with the greatest relative change in ED admission rates were chest pain (21.7 to 7.5%) and syncope (28.9 to 13.8%). The decline in ED admission rates were accompanied by increased variation in hospital-level ED admission rates. CONCLUSIONS: Recent reductions in ED admissions are largely attributable to decreased admissions for conditions amenable to outpatient critical pathways. Focusing on hospitals with persistently above-average ED admission rates may be a promising approach to improve the value of acute care.

Provider-Referred Versus Self-Referred Emergency Department Visit After Urgent Care Center Visit.

BACKGROUND: Urgent care centers (UCCs) provide an alternative to emergency departments (EDs) for low-acuity acute care, as they are convenient with shorter wait time, but little is known about the quality of care at UCCs. OBJECTIVE: We described and determined the differences in characteristics of patients who were sent to the ED by UCC physicians (provider-referred) with those of patients who went to the ED on their own (self-referred) within 72 h of discharge after a UCC visit. Our primary objective was to investigate whether observation unit use or hospital admission rates were different between the two groups. Our secondary objective was to identify whether their follow-up ED visits were avoidable. METHODS: We conducted this prospective cohort study between March 22, 2017 and September 30, 2018 in a closed health system. A total of 53,178 UCC visits resulted in 582 provider-referred and 263 self-referred ED visits. We compared the characteristics of the two groups and measured the outcomes of observation unit or hospital admissions. RESULTS: Patients with self-referred ED visits were younger; mean (standard deviation) age was 47.9 (24.5) years. Provider-referred patients appeared to be significantly associated with observation unit or hospital admission (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.24-2.46). Among the predictors for observation unit or hospital admission, consultation with a specialist in the ED was the strongest (adjusted OR 9.09; 95% CI 6.24-13.24); other significant predictors were Medicaid or no insurance. CONCLUSIONS: We found that after an urgent care visit, patients who were sent to the ED by a UCC provider were not more likely than self-referred patients to be admitted to an observation unit or hospital from the ED. Significant predictors for observation unit or hospital admission after UCC discharge were specialist consultation and type of insurance.

Improving Patient Race and Ethnicity Data Capture to Address Health Disparities: A Case Study From a Large Urban Health System.

While research and efforts to promote health equity abound, the persistence of disparities by race and ethnicity underscores the limitations of fragmented interventions and the need for systematic, multipronged approaches to health equity. The foundational step towards reducing health disparities is the establishment of the basic information needed to identify and measure those differences, i.e., the accurate capture of race and ethnicity information of all patients. To that end, we present a case study outlining a multifaceted approach for improving the capture of race and ethnicity data in an outpatient setting culminating in a 76% improvement in the completeness of this information. The effectiveness of this plan and its scalability within a large urban health system may benefit similar institutions seeking to improve the collection of race and ethnicity information and the reliability of their data. To this aim, we present an approach relying on the assessment and evaluation of system needs, modification of data infrastructure to align with goals, training, and education of relevant stakeholders, implementation and responsive action to results, and acknowledging limitations and lessons learned. We emphasize that cross-departmental collaboration, stakeholder engagement, institutional support, and culture of anti-racism were essential to the success of this initiative.

Perspectives About Emergency Department Care Encounters Among Adults With Opioid Use Disorder.

Importance: Emergency departments (EDs) are increasingly initiating treatment for patients with untreated opioid use disorder (OUD) and linking them to ongoing addiction care. To our knowledge, patient perspectives related to their ED visit have not been characterized and may influence their access to and interest in OUD treatment. Objective: To assess the experiences and perspectives regarding ED-initiated health care and OUD treatment among US patients with untreated OUD seen in the ED. Design, Setting, and Participants: This qualitative study, conducted as part of 2 studies (Project ED Health and ED-CONNECT), included individuals with untreated OUD who were recruited during an ED visit in EDs at 4 urban academic centers, 1 public safety net hospital, and 1 rural critical access hospital in 5 disparate US regions. Focus groups were conducted between June 2018 and January 2019. Main Outcomes and Measures: Data collection and thematic analysis were grounded in the Promoting Action on Research Implementation in Health Services (PARIHS) implementation science framework with evidence (perspectives on ED care), context (ED), and facilitation (what is needed to promote change) elements. Results: A total of 31 individuals (mean [SD] age, 43.4 [11.0] years) participated in 6 focus groups. Twenty participants (64.5%) identified as male and most 13 (41.9%) as White; 17 (54.8%) reported being unemployed. Themes related to evidence included patients' experience of stigma and perceived minimization of their pain and medical problems by ED staff. Themes about context included the ED not being seen as a source of OUD treatment initiation and patient readiness to initiate treatment being multifaceted, time sensitive, and related to internal and external patient factors. Themes related to facilitation of improved care of patients with OUD seen in the ED included a need for on-demand treatment and ED staff training. Conclusions and Relevance: In this qualitative study, patients with OUD reported feeling stigmatized and minimized when accessing care in the ED and identified several opportunities to improve care. The findings suggest that strategies to address stigma, acknowledge and treat pain, and provide ED staff training should be implemented to improve ED care for patients with OUD and enhance access to life-saving treatment.