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1.
Pamela Barbadoro Elena Di Tondo Vincenzo Giannicola Menditto Lucia Pennacchietti Februa Regnicoli Francesco Di Stanislao Marcello Mario D’Errico Emilia Prospero 《PloS one》2015,10(6)
Objective
The aim of this paper was to evaluate socio-economic factors associated to poor primary care utilization by studying two specific subjects: the hospital readmission rate, and the use of the Emergency Department (ED) for non-urgent visits.Methods
The study was carried out by the analysis of administrative database for hospital readmission and with a specific survey for non-urgent ED use.Results
Among the 416,698 sampled admissions, 6.39% (95% CI, 6.32–6.47) of re-admissions have been registered; the distribution shows a high frequency of events in the age 65–84 years group, and in the intermediate care hospitals (51.97%; 95%CI 51.37–52.57). The regression model has shown the significant role played by age, type of structure (geriatric acute care), and deprivation index of the area of residence on the readmission, however, after adjusting for the intensity of primary care, the role of deprivation was no more significant. Non-urgent ED visits accounted for the 12.10%, (95%CI 9.38–15.27) of the total number of respondents to the questionnaire (N = 504). The likelihood of performing a non-urgent ED visit was higher among patients aged <65 years (OR 3.2, 95%CI 1.3–7.8 p = 0.008), while it was lower among those perceiving as urgent their health problem (OR 0.50, 95%CI 0.30–0.90).Conclusions
In the Italian context repeated readmissions and ED utilization are linked to different trajectories, besides the increasing age and comorbidity of patients are the factors that are related to repeated admissions, the self-perceived trust in diagnostic technologies is an important risk factor in determining ED visits. Better use of public national health care service is mandatory, since its correct utilization is associated to increasing equity and better health care utilization. 相似文献2.
Matthew O. Wiens Heng Gan Celestine Barigye Guohai Zhou Elias Kumbakumba Jerome Kabakyenga Niranjan Kissoon J. Mark Ansermino Walter Karlen Charles P. Larson Stuart M. MacLeod 《PloS one》2015,10(1)
Background
Children discharged from hospitals in developing countries are at high risk of morbidity and mortality. However, few data describe these outcomes among children seen and discharged from rural outpatient centers.Objective
The objective of this exploratory study was to identify predictors of immediate and follow-up morbidity and mortality among children visiting a rural health center in Uganda.Methods
Subjects 0–12 years of age seeking care with a caregiver were consecutively enrolled from a single rural health center in Southwestern Uganda. Baseline variables were collected by research nurses and outcomes of referral, admission or death were recorded (immediate events). Death, hospital admission and health seeking occurring during the 30 days following the clinic visit were also determined (follow-up events). Univariate logistic regression was performed to identify baseline variables associated with immediate outcome and follow-up outcomes.Results
Over the four-month recruitment period 717 subjects were enrolled. There were 85 (11.9%) immediate events (10.1% were admitted, 2.2% were referred, none died). Forty-seven (7.8%) events occurred within 30 days after the visit (7.3% sought care from a health provider, 1.5% were admitted and 0.5% died). Variables associated with immediate events included living more than 30 minutes from the health center, age older than 5 years, having received an antimalarial prior to the visit, having seen a community health worker prior to the visit, elevated respiratory rate or temperature, and depressed weight-for-age z score or decreased oxygen saturation. These variables were not associated with follow-up events.Conclusions
Sick-child visits at a rural health center in South Western Uganda were associated with rates of mortality and subsequent admission of less than 2% in the period following the sick child visits. Other types of health seeking behavior occurred in approximately 7% of subjects during this same period. Several variables were associated with immediate events but there were no reliable predictors of follow-up events, possibly due to low statistical power. 相似文献3.
Background
Despite concerns about hypoglycemia events from overly aggressive glycemic reduction, population trends in hypoglycemia and hyperglycemic crisis incidence are unclear. To address this gap, we examined changes in emergency department (ED) visit rates for hypoglycemia and hyperglycemic crisis 2006–2011.Methods
Using data from the Nationwide Emergency Department Sample, we estimated the number of ED visits for hypoglycemia and hyperglycemic crisis via ICD-9-CM among adults with diabetes. Using data from the National Health Interview Survey, we estimated the population of adults with diabetes and calculated ED visit rates.Results
From 2006 to 2011, ED visit rates for hypoglycemia declined by 22% from 1.8 to 1.4 per 100 adults (p = 0.003). The rates decreased in all age groups (all P<0.05) except those aged 18 to 44 years (P = 0.31). Hypoglycemia rates displayed a J-shaped curve across age, with the highest rates among adults aged 75 years or older (P <0.001). ED visit rates for hyperglycemic crisis did not change overall but increased 17% for adults aged 65 to 74 years (P = 0.02) and 29% for women (P = 0.01). Hyperglycemic crisis rates were highest among adults aged 18 to 44 years (P <0.001).Conclusions
Hypoglycemia rates have declined for all adults but persons aged 18–44 years while rates for hyperglycemic crisis remained stable. Future preventive efforts should target on the susceptible population of adults aged 18 to 44 years and those aged 75 years or older. 相似文献4.
Kohei Hasegawa Yusuke Tsugawa Chu-Lin Tsai David FM Brown Carlos A Camargo Jr 《Respiratory research》2014,15(1):40
Background
Little is known about patients who frequently visit the emergency department (ED) for acute exacerbation of chronic obstructive pulmonary disease (AECOPD). We aimed to quantify the proportion and characteristics of patients with frequent ED visits for AECOPD and associated healthcare utilization.Methods
We conducted a retrospective cohort study of adults aged ≥40 years with at least one ED visit for AECOPD between 2010 and 2011, derived from population-based all-payer data of State ED and Inpatient Databases for two large and diverse states: California and Florida. Outcome measures were frequency of ED visits for AECOPD, 30-day ED revisits, subsequent hospitalizations, near-fatal events (AECOPD involving mechanical ventilation), and charges for both ED and inpatient services (available only for Florida) during the year after the first ED visit.Results
The analytic cohort comprised 98,280 unique patients with 154,736 ED visits for AECOPD. During the 1-year period, 29.4% (95% CI, 29.1%-29.7%) of the patients had two or more (frequent) visits, accounting for 55.2% (95% CI, 54.9%-55.4%) of all ED visits for AECOPD. In the multivariable model, significant predictors of frequent ED visits were age 55–74 years (vs. 40–54 years), male sex, non-Hispanic white or black race, Medicaid insurance (vs. private), and lower median household income (all P < 0.001). At the visit-level, 12.3% of ED visits for AECOPD were 30-day revisit events (95% CI, 12.1%-12.4%). Additionally, 62.8% of ED visits for AECOPD (95% CI, 62.6%-63.0%) resulted in a hospitalization; patients with frequent ED visits comprised 55.5% (95% CI, 55.2%-55.8%) of all hospitalizations. Furthermore, 7.3% (95% CI, 7.3%-7.5%) of ED visits for AECOPD led to a near-fatal event; patients with frequent ED visits accounted for 64.4% (95% CI, 63.5%-65.3%) of all near-fatal events. Total charges for AECOPD were $1.94 billion (95% CI, $1.90-1.97 billion) in Florida; patients with frequent ED visits accounted for $1.07 billion (95% CI, $1.04-1.09 billion).Conclusions
In this large cohort study, we found that 29% had frequent ED visits for AECOPD and that lower socioeconomic status was significantly associated with a higher frequency of ED visits. Individuals with frequent ED visits for AECOPD accounted for a substantial amount of healthcare utilization and financial burden. 相似文献5.
Krisda H. Chaiyachati Kirsha Gordon Theodore Long Woody Levin Ali Khan Emily Meyer Amy Justice Rebecca Brienza 《PloS one》2014,9(5)
Background
One major goal of the Patient-Centered Medical Home (PCMH) is to improve continuity of care between patients and providers and reduce the utilization of non-primary care services like the emergency department (ED).Objective
To characterize continuity under the Veterans Health Administration’s PCMH model – the Patient Aligned Care Team (PACT), at one large Veterans Affair’s (VA’s) primary care clinic, determine the characteristics associated with high levels of continuity, and assess the association between continuity and ED visits.Design
Retrospective, observational cohort study of patients at the West Haven VA (WHVA) Primary Care Clinic from March 2011 to February 2012.Patients
The 13,495 patients with established care at the Clinic, having at least one visit, one year before March 2011.Main Measures
Our exposure variable was continuity of care –a patient seeing their assigned primary care provider (PCP) at each clinic visit. The outcome of interest was having an ED visit.Results
The patients encompassed 42,969 total clinic visits, and 3185 (24%) of them had 15,458 ED visits. In a multivariable logistic regression analysis, patients with continuity of care – at least one visit with their assigned PCP – had lower ED utilization compared to individuals without continuity (adjusted odds ratio [AOR] 0.54; 95% CI: 0.41, 0.71), controlling for frequency of primary care visits, comorbidities, insurance, distance from the ED, and having a trainee PCP assigned. Likewise, the adjusted rate of ED visits was 544/1000 person-year (PY) for patients with continuity vs. 784/1000 PY for patients without continuity (p = 0.001). Compared to patients with low continuity (<33% of visits), individuals with medium (33–50%) and high (>50%) continuity were less likely to utilize the ED.Conclusions
Strong continuity of care is associated with decreased ED utilization in a PCMH model and improving continuity may help reduce the utilization of non-primary care services. 相似文献6.
Laurent Pereira Christophe Choquet Anne Perozziello Mathias Wargon Gaelle Juillien Luisa Colosi Romain Hellmann Michel Ranaivoson Enrique Casalino 《PloS one》2015,10(4)
Background
Predictors of unscheduled return visits (URV), best time-frame to evaluate URV rate and clinical relationship between both visits have not yet been determined for the elderly following an ED visit.Methods
We conducted a prospective-observational study including 11,521 patients aged ≥75-years and discharged from ED (5,368 patients (53.5%)) or hospitalized after ED visit (6,153 patients). Logistic Regression and time-to-failure analyses including Cox proportional model were performed.Results
Mean time to URV was 17 days; 72-hour, 30-day and 90-day URV rates were 1.8%, 6.1% and 10% respectively. Multivariate analysis indicates that care-pathway and final disposition decisions were significantly associated with a 30-day URV. Thus, we evaluated predictors of 30-day URV rates among non-admitted and hospitalized patient groups. By using the Cox model we found that, for non-admitted patients, triage acuity and diagnostic category and, for hospitalized patients, that visit time (day, night) and diagnostic categories were significant predictors (p<0.001). For URV, we found that 25% were due to closely related-clinical conditions. Time lapses between both visits constituted the strongest predictor of closely related-clinical conditions.Conclusion
Our study shows that a decision of non-admission in emergency departments is linked with an accrued risk of URV, and that some diagnostic categories are also related for non-admitted and hospitalized subjects alike. Our study also demonstrates that the best time frame to evaluate the URV rate after an ED visit is 30 days, because this is the time period during which most URVs and cases with close clinical relationships between two visits are concentrated. Our results suggest that URV can be used as an indicator or quality. 相似文献7.
Lesley J. J. Soril Laura E. Leggett Diane L. Lorenzetti Tom W. Noseworthy Fiona M. Clement 《PloS one》2015,10(4)
Objective
The objective of this study was to establish the effectiveness of interventions to reduce frequent emergency department (ED) use among a general adult high ED-use population.Methods
Systematic review of the literature from 1950-January 2015. Studies were included if they: had a control group (controlled trials or comparative cohort studies), were set in an ED or acute care facility, and examined the impact of an intervention to reduce frequent ED use in a general adult population. Studies reporting non-original data or focused on a specific patient population were excluded. Study design, patient population, intervention, the frequency of ED visits, and costs of frequent ED use and/or interventions were extracted and narratively synthesized.Results
Among 17 included articles, three intervention categories were identified: case management (n = 12), individualized care plans (n = 3), and information sharing (n = 2). Ten studies examining case management reported reductions in mean (-0.66 to -37) or median (-0.1 to -20) number of ED visits after 12-months; one study reported an increase in mean ED visits (+2.79); and one reported no change. Of these, 6 studies also reported reduced hospital costs. Only 1 study evaluating individualized care plans examined ED utilization and found no change in median ED visits post-intervention. Costs following individualized care plans were also only evaluated in 1 study, which reported savings in hospital costs of $742/patient. Evidence was mixed regarding information sharing: 1 study reported no change in mean ED visits and did not examine costs; whereas the other reported a decrease in mean ED visits (-16.9) and ED cost savings of $15,513/patient.Conclusions
The impact of all three frequent-user interventions was modest. Case management had the most rigorous evidence base, yielded moderate cost savings, but with variable reductions in ED use. Future studies evaluating non-traditional interventions, tailoring to patient subgroups or socio-cultural contexts, are warranted. 相似文献8.
Introduction
Sickle cell anemia has many sequelae that result in emergency department (ED) use, but a minority of patients with sickle cell disease are frequent utilizers and make up the majority of ED visits. If patients who are likely to be frequent ED can be identified in steady state, they can be treated with disease modifying agents in an attempt to reduce ED use frequency. We sought to identify steady state markers for frequent ED use.Methods
We identified all patients with SS/Sβ0 seen at our facilities in 2012. Health care utilization over the entire year was calculated and ED visit numbers categorized as either 0–1, 2–5, or 6 or more visits a year. Steady state and acutely active laboratory parameters were collected and analyzed using analysis of variance models and odds ratios.Results
432 adult sickle cell patients were identified, ages 18–87, 54% female, and 38% had been prescribed hydroxyurea. Of the 432 patients,192 had 0–1 visits in the year, 144 had 2–5 visits in the year, and 96 had >6 visits for a total of 2259 visits. Those who had >6 visits accounted for 1750 (77%) of the total visits for the year. When steady state laboratory markers were examined, each additional 50x109/L platelets was associated with 22% greater risk (p < .001); each 1x109/L of WBC was associated with 11% greater risk (p = .003), and each 1g/dL Hb was associated with 23% lower risk (p = .007) of >6 ED visits/year. We did not observe a relationship between baseline HbF, LDH or reticulocyte count with >6 ED visits.Conclusion
Patients with elevated white blood cell counts, elevated platelet counts, and low hemoglobin levels exhibited higher risk for frequent ED utilization and could be candidates for early and aggressive therapy with disease modifying agents. 相似文献9.
Background and Objectives
Pre-dialysis care by a nephrology out-patient department (OPD) may affect the outcomes of patients who ultimately undergo maintenance dialysis. This study examined the effect of pre-dialysis care by a nephrology OPD on the incidence of one-year major cardiovascular events after initiation of dialysis.Design, Setting Participants, & Measurements
The study consisted of Taiwanese patients with chronic kidney disease (CKD) who commenced dialysis from 2006 to 2008. The number of nephrology OPD visits during the critical care period (within 6 months of initiation of dialysis) and the early care period (6–36 months before initiation of dialysis) were analyzed. The primary outcome measure was one-year major cardiovascular events.Results
A total of 1191 CKD patients who initiated dialysis from 2006 to 2008 were included. Binary logistic regression showed that patients with ≧3 visits during the critical care period and those with ≧11 visits during the early care period had fewer composite major cardiovascular events than those with 0 visits. Patients with early referral are less likely to experience composite major cardiovascular events than those with late referral, with aOR 0.574 (95% CI = 0.43–0.77, P<0.001). Patients with both ≧3 visits during critical care period and ≧11 visits during early care period were less likely to experience composite major cardiovascular events (aOR = 0.25, 95% CI = 0.16–0.39, P < 0.001).Conclusions
Patients with adequate pre-dialysis nephrology OPD visits, not just early referral, may had fewer one-year composite major cardiovascular events after initiation of dialysis. This information may be important to medical care providers and public health policy makers in their efforts to improve the well-being of CKD patients. 相似文献10.
Objectives
To examine epidemiological trends of Traumatic Brain Injury (TBI) treated in the Emergency Department (ED), identify demographic groups at risk of TBI, and determine the factors associated with hospitalization following an ED visit for TBI.Methods
A province-wide database was used to identify all ED visits for TBI in Ontario, Canada between April 2002 and March 2010. Trends were analyzed using linear regression, and predictors of hospital admission were evaluated using logistic regression.Results
There were 986,194 ED visits for TBI over the eight-year study period, resulting in 49,290 hospitalizations and 1,072 deaths. The age- and sex-adjusted rate of TBI decreased by 3%, from 1,013.9 per 100,000 (95% CI 1,008.3–1,010.6) to 979.1 per 100,000 (95% CI 973.7–984.4; p = 0.11). We found trends towards increasing age, comorbidity level, length of stay, and ambulatory transport use. Children and young adults (ages 5–24) sustained peak rates of motor vehicle crash (MVC) and bicyclist-related TBI, but also experienced the greatest decline in these rates (p = 0.003 and p = 0.005). In contrast, peak rates of fall-related TBI occurred among the youngest (ages 0–4) and oldest (ages 85+) segments of the population, but rates remained stable over time (p = 0.52 and 0.54). The 5–24 age group also sustained the highest rates of sports-related TBI but rates remained stable (p = 0.80). On multivariate analysis, the odds of hospital admission decreased by 1% for each year over the study period (OR = 0.991, 95% CI = 0.987–0.995). Increasing age and comorbidity, male sex, and ambulatory transport were significant predictors of hospital admission.Conclusions
ED visits for TBI are involving older populations with increasingly complex comorbidities. While TBI rates are either stable or declining among vulnerable groups such as young drivers, youth athletes, and the elderly, these populations remain key targets for focused injury prevention and surveillance. Clinicians in the ED setting should be cognizant of factors associated with hospitalization following TBI.Level of Evidence
III.Study Design
Cross-sectional. 相似文献11.
Importance
Hypertension is common and costly. Over the past decade, new antihypertensive therapies have been developed, several have lost patent protection and additional evidence regarding the safety and effectiveness of these agents has accrued.Objective
To examine trends in the use of antihypertensive therapies in the United States between 1997 and 2012.Design, Setting and Participants
We used nationally representative audit data from the IMS Health National Disease and Therapeutic Index to examine the ambulatory pharmacologic treatment of hypertension.Outcome Measures
Our primary unit of analysis was a visit where hypertension was a reported diagnosis and treated with a pharmacotherapy (treatment visit). We restricted analyses to the use of six therapeutic classes of antihypertensive medications among individuals 18 years or older.Results
Annual hypertension treatment visits increased from 56.9 million treatment visits (95% confidence intervals [CI], 53.9–59.8) in 1997 to 83.3 million visits (CI 79.2–87.3) in 2008, then declined steadily to 70.9 million visits (CI 66.7–75.0) by 2012. Angiotensin receptor blocker utilization increased substantially from 3% of treatment visits in 1997 to 18% by 2012, whereas calcium channel blocker use decreased from 27% to 18% of visits. Rates of diuretic and beta-blocker use remained stable and represented 24%–30% and 14–16% of visits, respectively. Use of direct renin inhibitor accounted for fewer than 2% of annual visits. The proportion of visits treated using fixed-dose combination therapies increased from 28% to 37% of visits.Conclusions
Several important changes have occurred in the landscape of antihypertensive treatment in the United States during the past decade. Despite their novel mechanism of action, the adoption rate of direct renin inhibitors remains low. 相似文献12.
Michelle L. Dossett Lin Mu Roger B. Davis Iris R. Bell Anthony J. Lembo Ted J. Kaptchuk Gloria Y. Yeh 《PloS one》2015,10(9)
Background
It is unclear whether the benefits that some patients derive from complementary and integrative medicine (CIM) are related to the therapies recommended or to the consultation process as some CIM provider visits are more involved than conventional medical visits. Many patients with gastrointestinal conditions seek out CIM therapies, and prior work has demonstrated that the quality of the patient-provider interaction can improve health outcomes in irritable bowel syndrome, however, the impact of this interaction on gastroesophageal reflux disease (GERD) is unknown. We aimed to assess the safety and feasibility of conducting a 2x2 factorial design study preliminarily exploring the impact of the patient-provider interaction, and the effect of an over-the-counter homeopathic product, Acidil, on symptoms and health-related quality of life in subjects with GERD.Methods
24 subjects with GERD-related symptoms were randomized in a 2x2 factorial design to receive 1) either a standard visit based on an empathic conventional primary care evaluation or an expanded visit with questions modeled after a CIM consultation and 2) either Acidil or placebo for two weeks. Subjects completed a daily GERD symptom diary and additional measures of symptom severity and health-related quality of life.Results
There was no significant difference in GERD symptom severity between the Acidil and placebo groups from baseline to follow-up (p = 0.41), however, subjects who received the expanded visit were significantly more likely to report a 50% or greater improvement in symptom severity compared to subjects who received the standard visit (p = 0.01). Total consultation length, perceived empathy, and baseline beliefs in CIM were not associated with treatment outcomes.Conclusion
An expanded patient-provider visit resulted in greater GERD symptom improvement than a standard empathic medical visit. CIM consultations may have enhanced placebo effects, and further studies to assess the active components of this visit-based intervention are warranted.Trial Registration
ClinicalTrials.gov NCT01915173 相似文献13.
Zhongliang Zhou Yanfang Su Benjamin Campbell Zhiying Zhou Jianmin Gao Qiang Yu Jiuhao Chen Yishan Pan 《PloS one》2015,10(3)
Objective
With a quasi-experimental design, this study aims to assess whether the Zero-markup Policy for Essential Drugs (ZPED) reduces the medical expense for patients at county hospitals, the major healthcare provider in rural China.Methods
Data from Ningshan county hospital and Zhenping county hospital, China, include 2014 outpatient records and 9239 inpatient records. Quantitative methods are employed to evaluate ZPED. Both hospital-data difference-in-differences and individual-data regressions are applied to analyze the data from inpatient and outpatient departments.Results
In absolute terms, the total expense per visit reduced by 19.02 CNY (3.12 USD) for outpatient services and 399.6 CNY (65.60 USD) for inpatient services. In relative terms, the expense per visit was reduced by 11% for both outpatient and inpatient services. Due to the reduction of inpatient expense, the estimated reduction of outpatient visits is 2% among the general population and 3.39% among users of outpatient services. The drug expense per visit dropped by 27.20 CNY (4.47 USD) for outpatient services and 278.7 CNY (45.75 USD) for inpatient services. The proportion of drug expense out of total expense per visit dropped by 11.73 percentage points in outpatient visits and by 3.92 percentage points in inpatient visits.Conclusion
Implementation of ZPED is a benefit for patients in both absolute and relative terms. The absolute monetary reduction of the per-visit inpatient expense is 20 times of that in outpatient care. According to cross-price elasticity, the substitution between inpatient and outpatient due to the change in inpatient price is small. Furthermore, given that the relative reductions are the same for outpatient and inpatient visits, according to relative thinking theory, the incentive to utilize outpatient or inpatient care attributed to ZPED is equivalent, regardless of the 20-times price difference in absolute terms. 相似文献14.
Background
Studies have examined whether there is a relationship between drinking water turbidity and gastrointestinal (GI) illness indicators, and results have varied possibly due to differences in methods and study settings.Objectives
As part of a water security improvement project we conducted a retrospective analysis of the relationship between drinking water turbidity and GI illness in New York City (NYC) based on emergency department chief complaint syndromic data that are available in near-real-time.Methods
We used a Poisson time-series model to estimate the relationship of turbidity measured at distribution system and source water sites to diarrhea emergency department (ED) visits in NYC during 2002-2009. The analysis assessed age groups and was stratified by season and adjusted for sub-seasonal temporal trends, year-to-year variation, ambient temperature, day-of-week, and holidays.Results
Seasonal variation unrelated to turbidity dominated (~90% deviance) the variation of daily diarrhea ED visits, with an additional 0.4% deviance explained with turbidity. Small yet significant multi-day lagged associations were found between NYC turbidity and diarrhea ED visits in the spring only, with approximately 5% excess risk per inter-quartile-range of NYC turbidity peaking at a 6 day lag. This association was strongest among those aged 0-4 years and was explained by the variation in source water turbidity.Conclusions
Integrated analysis of turbidity and syndromic surveillance data, as part of overall drinking water surveillance, may be useful for enhanced situational awareness of possible risk factors that can contribute to GI illness. Elucidating the causes of turbidity-GI illness associations including seasonal and regional variations would be necessary to further inform surveillance needs. 相似文献15.
Steffie H. A. Brouns Patricia M. Stassen Suze L. E. Lambooij Jeanne Dieleman Irene T. P. Vanderfeesten Harm R. Haak 《PloS one》2015,10(8)
Study objective
To assess the association of patient and organisational factors with emergency department length of stay (ED-LOS) in elderly ED patients (226565 years old) and in younger patients (<65 years old).Methods
A retrospective cohort study of internal medicine patients visiting the emergency department between September 1st 2010 and August 31st 2011 was performed. All emergency department visits by internal medicine patients 226565 years old and a random sample of internal medicine patients <65 years old were included. Organisational factors were defined as non-medical factors. ED-LOS is defined as the time between ED arrival and ED discharge or admission. Prolonged ED-LOS is defined as ≥75th percentile of ED-LOS in the study population, which was 208 minutes.Results
Data on 1782 emergency department visits by elderly patients and 597 emergency department visits by younger patients were analysed. Prolonged ED-LOS in elderly patients was associated with three organisational factors: >1 consultation during the emergency department visit (odds ratio (OR) 3.2, 95% confidence interval (CI) 2.3–4.3), a higher number of diagnostic tests (OR 1.2, 95% CI 1.16–1.33) and evaluation by a medical student or non-trainee resident compared with a medical specialist (OR 4.2, 95% CI 2.0–8.8 and OR 2.3, 95% CI 1.4–3.9). In younger patients, prolonged ED-LOS was associated with >1 consultation (OR 2.6, 95% CI 1.4–4.6). Factors associated with shorter ED-LOS were arrival during nights or weekends as well as a high urgency level in elderly patients and self-referral in younger patients.Conclusion
Organisational factors, such as a higher number of consultations and tests in the emergency department and a lower seniority of the physician, were the main aspects associated with prolonged ED-LOS in elderly patients. Optimisation of the organisation and coordination of emergency care is important to accommodate the needs of the continuously growing number of elderly patients in a better way. 相似文献16.
Carol Dayo Obure Sedona Sweeney Vanessa Darsamo Christine Michaels-Igbokwe Lorna Guinness Fern Terris-Prestholt Esther Muketo Zelda Nhlabatsi Integra Initiative Charlotte E. Warren Susannah Mayhew Charlotte Watts Anna Vassall 《PloS one》2015,10(5)
Objective
To present evidence on the total costs and unit costs of delivering six integrated sexual reproductive health and HIV services in a high and medium HIV prevalence setting, in order to support policy makers and planners scaling up these essential services.Design
A retrospective facility based costing study conducted in 40 non-government organization and public health facilities in Kenya and Swaziland.Methods
Economic and financial costs were collected retrospectively for the year 2010/11, from each study site with an aim to estimate the cost per visit of six integrated HIV and SRH services. A full cost analysis using a combination of bottom-up and step-down costing methods was conducted from the health provider’s perspective. The main unit of analysis is the economic unit cost per visit for each service. Costs are converted to 2013 International dollars.Results
The mean cost per visit for the HIV/SRH services ranged from $Int 14.23 (PNC visit) to $Int 74.21 (HIV treatment visit). We found considerable variation in the unit costs per visit across settings with family planning services exhibiting the least variation ($Int 6.71-52.24) and STI treatment and HIV treatment visits exhibiting the highest variation in unit cost ranging from ($Int 5.44-281.85) and ($Int 0.83-314.95), respectively. Unit costs of visits were driven by fixed costs while variability in visit costs across facilities was explained mainly by technology used and service maturity.Conclusion
For all services, variability in unit costs and cost components suggest that potential exists to reduce costs through better use of both human and capital resources, despite the high proportion of expenditure on drugs and medical supplies. Further work is required to explore the key drivers of efficiency and interventions that may facilitate efficiency improvements. 相似文献17.
Background
Several point-of-care (POC) tests are available for evaluation of febrile patients, but the data about their performance in acute care setting is sparse. We investigated the analytical accuracy and feasibility of POC tests for white blood cell (WBC) count and C-reactive protein (CRP) at the pediatric emergency department (ED).Methods
In the first part of the study, HemoCue WBC and Afinion AS100 CRP POC analyzers were compared with laboratory’s routine WBC (Sysmex XE-2100) and CRP (Modular P) analyzers in the hospital central laboratory in 77 and 48 clinical blood samples, respectively. The POC tests were then adopted in use at the pediatric ED. In the second part of the study, we compared WBC and CRP levels measured by POC and routine methods during 171 ED patient visits by 168 febrile children and adolescents. Attending physicians performed POC tests in capillary fingerprick samples.Results
In parallel measurements in the laboratory both WBC and CRP POC analyzers showed good agreement with the reference methods. In febrile children at the emergency department (median age 2.4 years), physician performed POC determinations in capillary blood gave comparable results with those in venous blood analyzed in the laboratory. The mean difference between POC and reference test result was 1.1 E9/L (95% limits of agreement from -6.5 to 8.8 E9/L) for WBC and -1.2 mg/L (95% limits of agreement from -29.6 to 27.2 mg/L) for CRP.Conclusions
POC tests are feasible and relatively accurate methods to assess CRP level and WBC count among febrile children at the ED. 相似文献18.
Background
Many people living with HIV access healthcare systems through the emergency department (ED), and increased ED use may be indicative of disenfranchisement with primary HIV care, under-managed comorbid disease, or coincide with use of other healthcare resources. The goal of this study was to investigate ED use by HIV-infected prisoners transitioning to communities.Methods
We evaluated ED use by 151 HIV-infected released prisoners who were enrolled in a randomized controlled trial of directly administered versus self-administered antiretroviral therapy in Connecticut. Primary outcomes were quantity and type of ED visits and correlates of ED use were evaluated with multivariate models by Poisson regression.Results
In the 12 months post-release, there were 227 unique ED contacts made by 85/151 (56%) subjects. ED visits were primarily for acute febrile syndromes (32.6%) or pain (20.3%), followed by substance use issues (19.4%), trauma (18%), mental illness (11%), and social access issues (4.4%). Compared to those not utilizing the ED, users were more likely to be white, older, and unmarried, with less trust in their physician and poorer perceived physical health but greater social support. In multivariate models, ED use was correlated with moderate to severe depression (IRR = 1.80), being temporarily housed (IRR = 0.54), and alcohol addiction severity (IRR = 0.21) but not any surrogates of HIV severity.Conclusions
EDs are frequent sources of care after prison-release with visits often reflective of social and psychiatric instability. Future interventions should attempt to fill resource gaps, engage released prisoners in continuous HIV care, and address these substantial needs. 相似文献19.
Importance
There is growing evidence that vitamin D plays a role in the pathogenesis of asthma but it is unclear whether supplementation during childhood may improve asthma outcomes.Objectives
The objective of this systematic review and meta-analysis was to evaluate the efficacy and safety of vitamin D supplementation as a treatment or adjunct treatment for asthma.Data Sources
We searched MEDLINE, Embase, CENTRAL, and CINAHL through July 2014.Study Selection
We included RCTs that evaluated vitamin D supplementation in children versus active control or placebo for asthma.Data Extraction and Synthesis
One reviewer extracted data and one reviewer verified data accuracy. We qualitatively summarized the main results of efficacy and safety and meta-analyzed data on comparable outcomes across studies. We used GRADE for strength of evidence.Main Outcome Measures
Main planned outcomes measures were ED visits and hospitalizations. As secondary outcomes, we examined measures of asthma control, including frequency of asthma exacerbations, asthma symptom scores, measures of lung function, β2-agonist use and daily steroid use, adverse events and 25-hydroxyvitamin D levels.Results
Eight RCTs (one parallel, one crossover design) comprising 573 children aged 3 to 18 years were included. One study (moderate-quality, n = 100) reported significantly less ED visits for children treated with vitamin D. No other studies examined the primary outcome (ED visits and hospitalizations). There was a reduced risk of asthma exacerbations in children receiving vitamin D (low-quality; RR 0.41, 95% CI 0.27 to 0.63, 3 studies, n = 378). There was no significant effect for asthma symptom scores and lung function. The serum 25(OH)D level was higher in the vitamin D group at the end of the intervention (low-quality; MD 19.66 nmol/L, 95% CI 5.96 nmol/L to 33.37 nmol/L, 5 studies, n = 167).Limitations
We identified a high degree of clinical diversity (interventions and outcomes) and methodological heterogeneity (sample size and risk of bias) in included trials.Conclusions and Relevance
Randomized controlled trials provide some low-quality evidence to support vitamin D supplementation for the reduction of asthma exacerbations. Evidence on the benefits of vitamin D supplementation for other asthma-related outcomes in children is either limited or inconclusive. We recommend that future trials focus on patient-relevant outcomes that are comparable across studies, including standardized definitions of asthma exacerbations. 相似文献20.
Peter Aitken Richard Charles Franklin Jenine Lawlor Rob Mitchell Kerrianne Watt Jeremy Furyk Niall Small Leone Lovegrove Peter Leggat 《PloS one》2015,10(6)