Sex and Age Differences in Atypical Chief Complaints for Acute Decompensated Heart Failure in Emergency Department Visits.

Objectives: Around one million United States emergency department (ED) visits annually are due to acute decompensated heart failure (ADHF) symptoms. Characterizing ED symptom presentation of ADHF patients may improve clinical care, yet sex and age differences in ED chief complaints have not been thoroughly investigated. This paper aims to describe differences in chief complaints and comorbid conditions for ED patients with a ADHF diagnosis, stratified by sex and age. Methods: Retrospective analysis of adults presenting to North Carolina EDs in NC DETECT, a statewide syndromic surveillance system, between 2010 and 2016 with a diagnosis of ADHF. Frequencies of chief complaint categories for ED visits and comorbid conditions, stratified by sex and age, were evaluated and standardized differences computed. Results: Top chief complaints were dyspnea (19.1%), chest pain (13.5%), and other respiratory complaints (13.4%). In the 18-44 age group, females when compared to males reported more nausea/vomiting (6.7% versus 4.1%) and headache (4.2% versus 2.0%). In those 45-64 and 65+ years old, complaints were similar by sex. When stratified by age group alone, the 18-44 and 45-64 age groups had more complaints of chest pain, whereas balance issues, weakness, and confusion were more common in the 65+ age group. Conclusion: Sex and age differences in atypical ADHF symptoms were seen in in ED patients with ADHF. Characterizing variation of ADHF symptoms in ED patients can inform the identification of ED patients with ADHF and the management of ADHF-related symptoms.

Determining the Educational Value of an Emergency Medicine Rotation for Non-Emergency Medicine Residents.

Background Residents from diverse specialties perform clinical rotations in the emergency department (ED). There is little research about the value of the ED rotation for them. Objectives We sought to determine the learning objectives of non-EM residents (NEMRs) in the ED, the effectiveness of the rotation, and the highest-yield components of their experience. Methods From 2017-2019, we surveyed NEMR on their pre-rotation learning objectives and their comfort level with 15 common ED presentations/procedures before and after the rotation. We assessed how well their objectives were met, the highest-yield components of their rotation, and opportunities for improvement. Results We collected responses from 56 (47%) pre-rotation and 61 (51%) post-rotation residents over a two-year period. The five most commonly cited learning goals were: management of acutely ill patients, triage skills, procedural competence, and ultrasound. Seventy-eight percent (78%) of residents reported their learning goals were moderately to very well met during their rotation. NEMRs' level of comfort improved in all the commonly encountered clinical experiences in the ED in a statistically significant manner. They cited on-shift teaching by attending physicians and senior EM residents as the most valuable learning resource. Conclusion NEMR from diverse medical and surgical specialties could identify specific learning objectives for their EM rotation with common themes, and the majority felt their educational goals were met. They gained comfort with the management and triage of all the assessed common ED conditions. By collecting and defining their specific needs and goals, we are better equipped to improve the quality and value of the rotation.

Psychosocial services provided by licensed cardiac rehabilitation programs.

Background: Professional health organizations recommend that outpatient cardiac rehabilitation programs include activities to optimize the physical, mental, and social well-being of patients. The study objectives were to describe among cardiac rehabilitation programs (1) mental health assessments performed; (2) psychosocial services offered; and (3) leadership's perception of barriers to psychosocial services offerings. Methods: A cross-sectional survey of North Carolina licensed outpatient cardiac rehabilitation programs on their 2018 services was conducted. Descriptive statistics were used to summarize survey responses. Thematic analysis of free text questions related to barriers to programmatic establishment or expansion of psychosocial services was performed by two team members until consensus was reached. Results: Sixty-eight programs (89%) responded to the survey. Forty-eight programs (70%) indicated offering psychosocial services; however, a majority (73%) of programs reported not directly billing for those services. At program enrollment, mental health was assessed in 94% of programs of which 92% repeated the assessment at discharge. Depression was assessed with the 9-item Patient Health Questionnaire by a majority (75%) of programs. Psychosocial services included individual counseling (59%), counseling referrals (49%), and educational classes (29%). Directors reported lack of internal resources (92%) and patient beliefs (45%) as the top barriers to including or expanding psychosocial services at their facilities. Conclusions: Cardiac rehabilitation programs routinely assess mental health but lack the resources to establish or expand psychosocial services. Interventions aimed at improving patient education and reducing stigma of mental health are important public health opportunities.

Brief Educational Video plus Telecare to Enhance Recovery for Older Emergency Department Patients with Acute Musculoskeletal Pain: an update to the study protocol for a randomized controlled trial.

BACKGROUND: This update describes changes to the Brief Educational Tool to Enhance Recovery (BETTER) trial in response to the COVID-19 pandemic. METHODS/DESIGN: The original protocol was published in Trials. Due to the COVID-19 pandemic, the BETTER trial converted to remote recruitment in April 2020. All recruitment, consent, enrollment, and randomization now occur by phone within 24 h of the acute care visit. Other changes to the original protocol include an expansion of inclusion criteria and addition of new recruitment sites. To increase recruitment numbers, eligibility criteria were expanded to include individuals with chronic pain, non-daily opioid use within 2 weeks of enrollment, presenting musculoskeletal pain (MSP) symptoms for more than 1 week, hospitalization in past 30 days, and not the first time seeking medical treatment for presenting MSP pain. In addition, recruitment sites were expanded to other emergency departments and an orthopedic urgent care clinic. CONCLUSIONS: Recruiting from an orthopedic urgent care clinic and transitioning to remote operations not only allowed for continued participant enrollment during the pandemic but also resulted in some favorable outcomes, including operational efficiencies, increased enrollment, and broader generalizability. TRIAL REGISTRATION: ClinicalTrials.gov NCT04118595 . Registered on October 8, 2019.

Outpatient Cardiac Rehabilitation Services, Participants and Workforce in North Carolina: Results of a 2019 Survey of Cardiac Rehabilitation Program Directors.

BACKGROUND Cardiac rehabilitation (CR) can improve quality of life and reduce subsequent hospitalizations for individuals with cardiovascular disease. Nevertheless, CR is underutilized, and less is known about the current content, patient population, and workforce of CR programs in North Carolina.OBJECTIVE To describe CR services, patient participation, and workforce in North Carolina in order to characterize CR infrastructure and identify opportunities to improve CR use.METHODS We distributed an electronic survey to all certified outpatient CR programs in North Carolina in spring 2019. Descriptive statistics were used to summarize program characteristics, participant characteristics, and current workforce. Data were analyzed overall and by region.RESULTS Responding programs (89.5% response rate, n=68) had been in operation for a mean of 24 (SD: 10.4) years. Programs have similar availability across the state, operating 4 days a week with 5 sessions per day. A majority of programs offered nutrition counseling (98.5%), stress management (94.1%), aerobic exercise (86.8%), and weight training (86.8%). Patients were majority male (65%), aged 65 or older (75%), and White (75%). Nearly half of patients referred to CR attended at least 1 session, though 25% discontinued early. Most programs were staffed by a median of 2 full-time nurses (97%) and by a median of 1.5 full-time exercise physiologists (96%). Mental health and administrative professionals were less frequent in CR settings.LIMITATIONS Since this survey was primarily completed by program directors, further research is needed to understand the challenges, experiences, and needs of the frontline CR workforce, as well as the direct experiences of patients who participate in CR.CONCLUSIONS CR programs in North Carolina offer a range of services. While half of patients referred to CR initiate services, interventions are needed to improve initiation and adherence to CR.

A 7 Year Summary of Emergency Department Visits by Patients With Mental Health Disorders.

OBJECTIVES: Emergency departments (EDs) have been increasingly utilized over time for psychiatric care. While multiple studies have assessed these trends in nationally representative data, few have evaluated these trends in state-level data. This investigation seeks to understand the mental health-related ED burden in North Carolina (NC) by describing trends in ED visits associated with a mental health diagnosis (MHD) over time. METHODS: Using data from NC DETECT, this investigation describes trends in NC ED visits from January 1, 2008 through December 31, 2014 by presence of a MHD code. A visit was classified by the first listed MHD ICD-9-CM code in the surveillance record and MHD codes were grouped into related categories for analysis. Visits were summarized by MHD status and by MHD category. RESULTS: Over 32 million ED visits were recorded from 2008 to 2014, of which 3,030,746 (9.4%) were MHD-related visits. The average age at presentation for MHD-related visits was 50 years (SD 23.5) and 63.9% of visits were from female patients. The proportion of ED visits with a MHD increased from 8.3 to 10.2% from 2008 to 2014. Annually and overall, the largest diagnostic category was stress/anxiety/depression. Hospital admissions resulting from MHD-related visits declined from 32.2 to 18.5% from 2008 to 2014 but remained consistently higher than the rate of admissions among non-MHD visits. CONCLUSION: Similar to national trends, the proportion of ED visits associated with a MHD in NC has increased over time. This indicates a need for continued surveillance, both stateside and nationally, in order to inform future efforts to mitigate the growing ED burden.

Use of a Brief Negotiation Interview in the emergency department to reduce high-risk alcohol use among older adults: A randomized trial.

OBJECTIVE: To determine whether a Brief Negotiation Interview (BNI) performed in the emergency department (ED) can reduce future rates of alcohol use among older adults who are high-risk drinkers. METHODS: Adults aged 65 years and older in a single academic ED were screened for high-risk alcohol use based on the National Institute for Alcohol Abuse and Alcoholism definition of >7 drinks per week or >3 drinks per occasion. Eligible individuals who were high-risk drinkers who passed a cognitive impairment screener and who consented to enrollment were randomly assigned to receive the BNI versus usual care. Outcomes were assessed at 3, 6, and 12 months.  The primary outcome was the rate of high-risk alcohol use at 6 months. RESULTS:  Of 2250 ED patients who were screened, 183 (8%) met the criteria for high-risk alcohol use. Of those, 98 (53%) patients met full criteria and consented to participation. Of the participants, 67% were men and 83% were non-Hispanic White. There was no significant difference in the primary outcome of high-risk alcohol use at 6 months between the BNI at 59.1% (95% confidence interval [CI], 45.5%-76.8%) and the control at 49.1% (95% CI, 36.9%-65.2%). However, there was a significant time-effect reduction in alcohol consumption and rates of high-risk alcohol use for both groups. CONCLUSION: Among older adults who met the criteria for high-risk alcohol use, the BNI in the ED did not result in a reduction in high-risk alcohol use at 6 months, although both groups showed significant reductions after their ED visit. Further work is needed to determine the optimal setting and time to use the BNI to impact high-risk alcohol use in this population.

A hybrid model of acute unscheduled cancer care provided by a hospital-based acute care clinic and the emergency department: a descriptive study.

PURPOSE: Patients with cancer often experience medical events that require immediate evaluation. These evaluations typically occur in an emergency department (ED), but there is increasing interest in providing this care in other settings. We report on a novel care model whereby a nursing hotline is used to triage patients to the ED or to the North Carolina Cancer Hospital Infusion Center (NCCHIC). METHODS: A retrospective study of adult patients with a neoplasm diagnosis seeking acute care at a large academic hospital pre- and post-initiation of the novel care model in January of 2016. Patients were identified by querying the electronic medical record and clinic administrative data during matched 6 month pre- and post-periods. RESULTS: During the pre-initiation period, 1346 patients visited the ED on 1651 occasions (76.1% admission rate). In the post-initiation period, 1434 patients visited the ED on 1797 occasions (81.5% admission rate), and 246 patients visited the NCCHIC on 322 occasions (68.9% admission rate). The emergency severity index (ESI) in the pre-initiation ED group was primarily ESI 2 (30.6%) and ESI 3 (65.4%). In the post-initiation ED group, the ESI was similar (32.6% ESI 2 and 64.2% ESI 3). In contrast, the NCCHIC predominantly treated lower acuity patients (65.8% calculated ESI of 4/5). CONCLUSIONS: This model demonstrates a multidisciplinary partnership to providing acute unscheduled care for patients with cancer. In the early implementation phase of this model, approximately 15% of patients, generally of lower acuity, were seen in the NCCHIC.

Using malnutrition and food insecurity screening to identify broader health-related social needs amongst older adults receiving emergency department care in the Southeastern United States: A cross-sectional study.

Unmet health-related social needs are common amongst older US adults and impact both quality of life and health outcomes. One of the ways that unmet health-related social needs impact health is through malnutrition, an imbalance in a person's intake of energy and/or nutrients. Lack of reliable access to a sufficient quantity of nutritious food is a specific health-related social need that can be assessed rapidly and, when unmet, is a direct risk factor for malnutrition and may be indicative of a broader range of unmet health-related social needs. We conducted a cross-sectional study to characterise malnutrition and food insecurity amongst older adults receiving emergency department (ED) care using brief, validated measures and to assess the burden of a broader range of health-related social needs amongst these patients. Patients were asked about their need for and willingness to receive a range of social services. The study was conducted in an academic ED serving a racially and socioeconomically diverse population in the Southeastern United States. A convenience sample of noncritically ill adults aged 60 years and older was approached between November 2018 and April 2019. Study patients (n = 127) were predominantly non-Hispanic white (67%), community dwelling (91%) and urban residents (66%) with 28% screening positive for malnutrition risk, 16% for food insecurity and 5% for both. Of those at risk for malnutrition, 25 (69%) reported ≥2 unmet health-related social needs and 14 (38%) were receptive to social services. Amongst food insecure patients, 18 (90%) reported additional unmet health-related social needs and 13 (65%) were receptive to receiving social services. In conclusion, a brief set of questions can identify subgroups of older ED patients who are food insecure or at risk for malnutrition. Individuals who screen positive for food insecurity have a high burden of unmet health-related social needs.

Brief educational video plus telecare to enhance recovery for older emergency department patients with acute musculoskeletal pain: study protocol for the BETTER randomized controlled trial.

BACKGROUND: Chronic musculoskeletal pain (MSP) affects more than 40% of adults aged 50 years and older and is the leading cause of disability in the USA. Older adults with chronic MSP are at risk for analgesic-related side effects, long-term opioid use, and functional decline. Recognizing the burden of chronic MSP, reducing the transition from acute to chronic pain is a public health priority. In this paper, we report the protocol for the Brief EducaTional Tool to Enhance Recovery (BETTER) trial. This trial compares two versions of an intervention to usual care for preventing the transition from acute to chronic MSP among older adults in the emergency department (ED). METHODS: Three hundred sixty patients from the ED will be randomized to one of three arms: full intervention (an interactive educational video about pain medications and recovery-promoting behaviors, a telecare phone call from a nurse 48 to 72 h after discharge from the ED, and an electronic communication containing clinical information to the patient's primary care provider); video-only intervention (the interactive educational video but no telecare or primary care provider communication); or usual care. Data collection will occur at baseline and at 1 week and 1, 3, 6, and 12 months after study enrollment. The primary outcome is a composite measure of pain severity and interference. Secondary outcomes include physical function, overall health, opioid use, healthcare utilization, and an assessment of the economic value of the intervention. DISCUSSION: This trial is the first patient-facing ED-based intervention aimed at helping older adults to better manage their MSP and reduce their risk of developing chronic pain. If effective, future studies will examine the effectiveness of implementation strategies. TRIAL REGISTRATION: ClinicalTrials.gov NCT04118595 . Registered on 8 October 2019.

Effect of Initiating Cardiac Rehabilitation After Myocardial Infarction on Subsequent Hospitalization in Older Adults.

PURPOSE: Outpatient cardiac rehabilitation (CR) participation after myocardial infarction (MI) reduces all-cause mortality; however, less is known about effects of CR on post-MI hospitalization. The study objective was to investigate effects of CR on hospitalization following acute MI among older adults. METHODS: Medicare beneficiaries aged 65 to 88 yr hospitalized in 2008 with acute MI, who survived at least 60 d post-discharge, had a revascularization procedure during index hospitalization, and did not have an MI in previous year were eligible for this study. CR initiation was assessed in the 60 d post-discharge. Competing risk survival analysis was used to estimate the proportion of discharged beneficiaries hospitalized between the end of 60-d exposure window and December 31, 2009, treating death as a competing event. RESULTS: The mean ± SD age of 32 851 Medicare beneficiaries meeting study criteria was 75 ± 6.0 yr, approximately half were male (52%), and the majority were white (88%). In this study, 21% of beneficiaries initiated CR within the exposure window. At 1 yr post-discharge, CR initiators had a lower risk of recurrent MI (4.2% [95% CI, 3.5-5.1]), cardiovascular (15.7% [95% CI, 14.3-17.2]), and all-cause (30.4% [95% CI, 28.8-32.1]) hospitalization than noninitiators (5.2% [95% CI, 5.0-5.5]; 18.0% [95% CI, 17.6-18.4]; and 33.2% [95% CI, 32.5-33.8], respectively). There was no difference in fracture risk (negative control outcome). CONCLUSIONS: This study provides evidence that CR can reduce the 1-yr risk of cardiovascular and all-cause hospital admissions in Medicare aged MI survivors.

Patient health literacy and the receipt of opioids in the emergency department.

OBJECTIVE: Assess relationships between patient health literacy and formal education and use of opioids during and following an emergency department (ED) visit. DESIGN: Prospective, cross-sectional study. SETTING: Academic ED. PARTICIPANTS: Adults aged ≥ 60 years presenting to the ED with musculoskeletal pain. MAIN OUTCOME MEASURES: Opioid use during and after an ED visit. RESULTS: In a sample of 136 patients, patients with low health literacy were more likely to receive an opioid in the ED than patients with high health literacy (70 percent vs 52 percent; 18 percent difference, 95% confidence interval [CI]: -1 percent, 35 percent), receive an opioid prescription (63 percent vs 44 percent; 19 percent difference, 95% CI: 1 percent, 37 percent), and take opioids during the week following the ED visit (48 percent vs 29 percent; 18 percent difference, 95% CI: 0 percent, 36 percent). CONCLUSIONS: A greater proportion of older adults receiving ED care for musculoskeletal pain with low health literacy receive and use opioids during and following an ED visit.

Approaches to Address Premature Death of Patients When Assessing Patterns of Use of Health Care Services After an Index Event.

BACKGROUND: Studies of the use of health care after the onset of disease are important for assessing quality of care, treatment disparities, and guideline compliance. Cohort definition and analysis method are important considerations for the generalizability and validity of study results. We compared different approaches for cohort definition (restriction by survival time vs. comorbidity score) and analysis method [Kaplan-Meier (KM) vs. competing risk] when assessing patterns of guideline adoption in elderly patients. METHODS: Medicare beneficiaries aged 65-95 years old who had an acute myocardial infarction (AMI) in 2008 were eligible for this study. Beneficiaries with substantial frailty or an AMI in the prior year were excluded. We compared KM with competing risk estimates of guideline adoption during the first year post-AMI. RESULTS: At 1-year post-AMI, 14.2% [95% confidence interval (CI), 14.0%-14.5%) of beneficiaries overall initiated cardiac rehabilitation when using competing risk analysis and 15.1% (95% CI, 14.8%-15.3%) from the KM analysis. Guideline medication adoption was estimated as 52.3% (95% CI, 52.0%-52.7%) and 53.4% (95% CI, 53.1%-53.8%) for competing risk and KM methods, respectively. Mortality was 17.0% (95%CI, 16.8%-17.3%) at 1 year post-AMI. The difference in cardiac rehabilitation initiation at 1-year post-AMI from the overall population was 0.1%, 1.7%, and 1.9% compared with 30-day survivor, 1-year survivor, and comorbidity-score restricted populations, respectively. CONCLUSIONS: In this study, the KM method consistently overestimated the competing risk method. Competing risk approaches avoid unrealistic mortality assumptions and lead to interpretations of estimates that are more meaningful.

Position matters: Validation of medicare hospital claims for myocardial infarction against medical record review in the atherosclerosis risk in communities study.

PURPOSE: The objectives of this study were to investigate sensitivity and specificity of myocardial infarction (MI) case definitions using multiple discharge code positions and multiple diagnosis codes when comparing administrative data to hospital surveillance data. METHODS: Hospital surveillance data for ARIC Study cohort participants with matching participant ID and service dates to Centers for Medicare and Medicaid Services (CMS) hospitalization records for hospitalizations occurring between 2001 and 2013 were included in this study. Classification of Definite or Probable MI from ARIC medical record review defined "gold standard" comparison for validation measures. In primary analyses, an MI was defined with ICD9 code 410 from CMS records. Secondary analyses defined MI using code 410 in combination with additional codes. RESULTS: A total of 25 549 hospitalization records met study criteria. In primary analysis, specificity was at least 0.98 for all CMS definitions by discharge code position. Sensitivity ranged from 0.48 for primary position only to 0.63 when definition included any discharge code position. The sensitivity of definitions including codes 410 and 411.1 were higher than sensitivity observed when using code 410 alone. Specificity of these alternate definitions was higher for women (0.98) than for men (0.96). CONCLUSION: Algorithms that rely exclusively on primary discharge code position will miss approximately 50% of all MI cases due to low sensitivity of this definition. We recommend defining MI by code 410 in any of first 5 discharge code positions overall and by codes 410 and 411.1 in any of first 3 positions for sensitivity analyses of women.

Randomized controlled pilot study of an educational video plus telecare for the early outpatient management of musculoskeletal pain among older emergency department patients.

BACKGROUND: Musculoskeletal pain is a common reason for emergency department (ED) visits. Following discharge from the ED, patients, particularly older patients, often have difficulty controlling their pain and managing analgesic side effects. We conducted a pilot study of an educational video about pain management with and without follow-up telephone support for older adults presenting to the ED with musculoskeletal pain. METHODS: ED patients aged 50 years and older with musculoskeletal pain were randomized to: (1) usual care, (2) a brief educational video only, or (3) a brief educational video plus a protocol-guided follow-up telephone call from a physician 48-72 hours after discharge (telecare). The primary outcome was the change from the average pain severity before the ED visit to the average pain severity during the past week assessed one month after the ED visit. Pain was assessed using a 0-10 numerical rating scale. RESULTS: Of 75 patients randomized (mean age 64 years), 57 (76%) completed follow up at one month. Of the 18 patients lost to follow up, 12 (67%) had non-working phone numbers. Among patients randomized to the video (arms 2 and 3), 46/50 viewed the entire video; among the 25 patients randomized to the video plus telecare (arm 3), 23 were reached for telecare. Baseline pain scores for the usual care, video, and video plus telecare groups were 7.3, 7.1, and 7.5. At one month, pain scores were 5.8, 4.9, and 4.5, corresponding to average decreases in pain of -1.5, -2.2, and -3.0, respectively. In the pairwise comparison between intervention groups, the video plus telecare group had a 1.7-point (95% CI 1.2, 2.1) greater decrease in pain compared to usual care, and the video group had a 1.1-point (95% CI 0.6, 1.6) greater decrease in pain compared to usual care after adjustment for baseline pain, age, and gender. At one month, clinically important differences were also observed between the video plus telecare and usual care groups for analgesic side effects, ongoing opioid use, and physical function. CONCLUSION: Results of this pilot trial suggest the potential value of an educational video plus telecare to improve outcomes for older adults presenting to the ED with musculoskeletal pain. Changes to the protocol are identified to increase retention for assessment of outcomes. TRIALS REGISTRATION: ClinicalTrials.gov, NCT02438384 . Registered on 5 May 2015.

Variation in the use of 12-lead electrocardiography for patients with chest pain by emergency medical services in North Carolina.

BACKGROUND: Prehospital 12-lead electrocardiography (ECG) is critical to timely STEMI care although its use remains inconsistent. Previous studies to identify reasons for failure to obtain a prehospital ECG have generally only focused on individual emergency medical service (EMS) systems in urban areas. Our study objective was to identify patient, geographic, and EMS agency-related factors associated with failure to perform a prehospital ECG across a statewide geography. METHODS AND RESULTS: We analyzed data from the Prehospital Medical Information System (PreMIS) in North Carolina from January 2008 to November 2010 for patients >30 years of age who used EMS and had a prehospital chief complaint of chest pain. Among 3.1 million EMS encounters, 134 350 patients met study criteria. From 2008-2010, 82 311 (61%) persons with chest pain received a prehospital ECG; utilization increased from 55% in 2008 to 65% in 2010 (trend P<0.001). Utilization by health referral region ranged from 22.9% to 74.2% and was lowest in rural areas. Men were more likely than women to have an ECG performed (63.0% vs 61.3%, adjusted RR 1.02, 95% CI 1.01 to 1.04). The certification-level of the EMS provider (paramedic vsbasic/intermediate) and system-level ECG equipment availability were the strongest predictors of ECG utilization. Persons in an ambulance with a certified paramedic were significantly more likely to receive a prehospital ECG than nonparamedics (RR 2.15, 95% CI 1.55, 2.99). CONCLUSIONS: Across a large geographic area prehospital ECG use increased significantly, although important quality improvement opportunities remain. Increasing ECG availability and improving EMS certification and training levels are needed to improve overall care and reduce rural-urban treatment differences.