The Relationship between Same-Day Access and Continuity in Primary Care and Emergency Department Visits.
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ABSTRACT:
SUBMITTER: Yoon J
PROVIDER: S-EPMC4557991 | biostudies-literature | 2015
REPOSITORIES: biostudies-literature
Publications
The Relationship between Same-Day Access and Continuity in Primary Care and Emergency Department Visits.
Yoon Jean J Cordasco Kristina M KM Chow Adam A Rubenstein Lisa V LV
PloS one 20150902 9
We examined how emergency department (ED) visits for potentially preventable, mental health, and other diagnoses were related to same-day access and provider continuity in primary care using administrative data from 71,296 patients in 22 VHA clinics over a three-year period. ED visits were categorized as non-emergent; primary care treatable; preventable; not preventable; or mental health-related. We conducted multi-level regression models adjusted for patient and clinic factors. More same-day ac ...[more]
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Project description:PURPOSE:Previous work has demonstrated that home care patients have an increased risk of visiting the emergency department after a home nursing visit on the same day. We investigated whether this association is modified by greater access to after-hours primary care. METHODS:We conducted a population-based case-crossover study of home care patients in Ontario, Canada in 2014-2016. Emergency department visits after 5:00 pm were selected as case periods and matched, within the same patient, to control periods within the previous week. The association between home nursing visits and same-day emergency department visits was estimated with conditional logistic regression. Access to after-hours primary care, measured on the patient and practice level, was tested for effect modification using an interaction term approach. Analysis was performed separately for all emergency department visits and a less urgent subset not admitted to hospital. RESULTS:A total of 11,840 patients contributed cases to the analysis. Patients with a history of after-hours primary care use had a smaller increased risk of a same-day after-hours emergency department visit (OR = 1.18; 95% CI, 1.06-1.30) compared with patients with no after-hours care (OR = 1.31; 95% CI, 1.25-1.39). The modifying effect was stronger among emergency department visits not admitted to hospital (OR = 1.11; 95% CI, 0.97-1.28 vs OR = 1.41; 95% CI, 1.31-1.51). CONCLUSION:Greater access to after-hours primary care reduced the risk of less-urgent emergency department use associated with home nursing visits. These findings suggest increasing access to after-hours primary care could prevent some less-urgent emergency department visits.
| S-EPMC7489957 | biostudies-literature
Project description:BackgroundAn important goal of the patient-centered medical home is increasing timely access for urgent needs, while maintaining continuity. In academic primary care clinics, meeting this goal, along with training medical residents and associated professionals, is challenging.MethodsThe aim of this study was to understand how academic primary care clinics provide continuity to patients requesting same-day access and identify factors that may affect site-level success. We conducted qualitative interviews from December 2013-October 2014 with primary care leadership involved with residency programs at 19 Veterans Health Administration academically-affiliated medical centers. Interview recordings were transcribed verbatim. To analyze the data, we created comprehensive, structured transcript summaries for each site. Site summaries were then entered into NVivo 10 software and coded by main categories to facilitate within-case and cross-case analyses. Themes and patterns across sites were identified using matrix analysis.ResultsInterviewees found it challenging to provide continuity for same-day in-person visits. Most sites took a team-based approach to ensure continuity and provide coverage for same-day access, notably using NPs, PAs, and RNs in their coverage algorithms. Further, they reported several adaptations that increased multiple types of continuity for walk-in patients, urgent care between in-person visits, and follow-up care. While this study focused on longitudinal continuity, both by individual PCPs or by a team of professionals, informational continuity and continuity of supervision, as well as, to a lesser extent, relational and management continuity, were also addressed in our interviews. Finally, most interviewees reported clinic intention to provide patient-centered, team-based care and a robust educational experience for trainees, and endeavored to structure their clinics in ways that align these two missions.ConclusionsIn contending with the tension between providing continuity and educating new clinicians, clinics have re-conceptualized continuity as team-based, creating alternative strategies to same-day visits with a usual provider, coupled with communication strategies. Understanding the effect of these strategies on different types of continuity as well as patient experience and outcomes are key next steps in the further development and dissemination of effective models for improving continuity and the transition to team-based care in the academic clinic setting.
| S-EPMC6399842 | biostudies-literature
Project description:BackgroundPostoperative visits to the emergency department (ED) generate additional costs on health care systems and consume already limited resources. We sought to determine the rate and reasons why patients who underwent primary knee arthroplasty returned to the ED within 90 days of postoperative discharge, which could guide the development of preventative measures.MethodsWe identified patients who underwent primary knee arthroplasty at 2 hospitals in Nova Scotia, Canada, between April 2021 and March 2022 and who had an ED visit within 90 days of postoperative discharge. We reviewed data for timing and reason for ED visits.ResultsOf 687 patients who had primary knee arthroplasty surgeries, 145 (21.1%) patients visited the ED within 90 days of postoperative discharge. Most visits occurred in the early postoperative period, predominantly for surgical reasons (94.7% within 7 days) and shifting toward medical reasons over time. Pain was the most common surgical reason for ED visits (15.9%), followed by swelling (9.7%), and hematoma drainage (9.7%).ConclusionUnderstanding the reasons for postoperative ED visits after knee arthroplasty is important in developing strategies to reduce ED overcrowding and improve patient outcomes. Implementing targeted interventions, such as enhanced pain management and patient education, may help alleviate the burden on EDs, reduce costs, and improve overall health care delivery for patients undergoing knee arthroplasty.
| S-EPMC11573429 | biostudies-literature
Project description:BackgroundHealth services across the world increasingly face pressures on the use of expensive hospital services. Better organisation and delivery of primary care has the potential to manage demand and reduce costs for hospital services, but routine primary care services are not open during evenings and weekends. Extended access (evening and weekend opening) is hypothesized to reduce pressure on hospital services from emergency department visits. However, the existing evidence-base is weak, largely focused on emergency out-of-hours services, and analysed using a before-and after-methodology without effective comparators.Methods and findingsThroughout 2014, 56 primary care practices (346,024 patients) in Greater Manchester, England, offered 7-day extended access, compared with 469 primary care practices (2,596,330 patients) providing routine access. Extended access included evening and weekend opening and served both urgent and routine appointments. To assess the effects of extended primary care access on hospital services, we apply a difference-in-differences analysis using hospital administrative data from 2011 to 2014. Propensity score matching techniques were used to match practices without extended access to practices with extended access. Differences in the change in "minor" patient-initiated emergency department visits per 1,000 population were compared between practices with and without extended access. Populations registered to primary care practices with extended access demonstrated a 26.4% relative reduction (compared to practices without extended access) in patient-initiated emergency department visits for "minor" problems (95% CI -38.6% to -14.2%, absolute difference: -10,933 per year, 95% CI -15,995 to -5,866), and a 26.6% (95% CI -39.2% to -14.1%) relative reduction in costs of patient-initiated visits to emergency departments for minor problems (absolute difference: -£767,976, -£1,130,767 to -£405,184). There was an insignificant relative reduction of 3.1% in total emergency department visits (95% CI -6.4% to 0.2%). Our results were robust to several sensitivity checks. A lack of detailed cost reporting of the running costs of extended access and an inability to capture health outcomes and other health service impacts constrain the study from assessing the full cost-effectiveness of extended access to primary care.ConclusionsThe study found that extending access was associated with a reduction in emergency department visits in the first 12 months. The results of the research have already informed the decision by National Health Service England to extend primary care access across Greater Manchester from 2016. However, further evidence is needed to understand whether extending primary care access is cost-effective and sustainable.
| S-EPMC5012704 | biostudies-literature
Project description: Not available
| S-EPMC7753296 | biostudies-literature
Project description:ObjectiveTo identify factors associated with unplanned return visits to the emergency department (ED) among the population aged 75 years and older. Moreover, it aims to determine the association between patients' access to primary care and unplanned return visits.DesignData were collected from structured interviews, administrative databases, and medical charts at the index visits, and follow-up telephone calls were made at 3 months.SettingEmergency departments of the 3 tertiary care hospitals in Montréal, Que.ParticipantsCommunity-dwelling patients aged 75 years and older.Main outcome measuresZero-inflated negative binomial regression analysis was conducted of unplanned return visits within 3 months. Rate ratios (RRs) and odds ratios (ORs) with 95% CIs are presented.ResultsDuring the study period, 4577 patients were identified, 2303 were recruited, and 1998 were retained for the analysis. Among the analysis sample, 33% were 85 and older, 34% lived alone, and 91% had a family physician. Before their ED visits, 16% of patients attempted to contact their family physicians. More than half of the patients reported having difficulty seeing their physicians for urgent problems, more than 40% had difficulty speaking with their family physicians by telephone, and more than one-third had difficulty booking appointments for new health problems. Within 3 months, 562 patients (28%) had made 894 return visits. Factors associated with a lower return visit rate included age 85 years and older (RR=0.80; 95% CI 0.67 to 0.96), less severe triage score (RR=0.83; 95% CI 0.74 to 0.92), and hospitalization at the index visit (RR=0.76; 95% CI 0.64 to 0.90). Factors that resulted in a higher return visit rate were difficulty booking appointments for new problems with their family physicians (RR=1.19; 95% CI 1.01 to 1.41), having had ED visits within the previous 6 months (RR=1.47; 95% CI 1.28 to 1.68), and higher Charlson comorbidity index scores (RR=1.06; 95% CI 1.01 to 1.11). Having had ED visits within the previous 6 months (OR=2.11; 95% CI 1.27 to 3.49), having a higher Charlson comorbidity index score (OR=1.41; 95% CI 1.19 to 1.68), and having received community care services (OR=3.00; 95% CI 0.95 to 9.53) also increased the odds of return visits.ConclusionAlthough most people 75 years and older have a family physician, problems still exist in terms of timely access. Unplanned return visits to the ED are associated with having more comorbidities, having had previous ED visits, having already received community services, and having difficulty booking appointments with family physicians for new problems.
| S-EPMC9374085 | biostudies-literature
Project description:OBJECTIVE:To examine the impact of integrating behavioral health services using the primary care behavioral health (PCBH) model on emergency department (ED) utilization. DATA SOURCES:Utilization data from three Dane County, Wisconsin hospitals and four primary care clinics from 2003 to 2011. STUDY DESIGN:We used a retrospective, quasi-experimental, controlled, pre-post study design. Starting in 2007, two clinics began integrating behavioral health into their primary care practices with a third starting in 2010. A fourth, nonimplementing, community clinic served as control. Change in emergency department and primary care utilization (number of visits) for patients diagnosed with mood and anxiety disorders was the outcomes of interest. DATA COLLECTION:Retrospective data were obtained from electronic patient records from the three main area hospitals along with primary care data from participating clinics. PRINCIPAL FINDINGS:Following the introduction of the PCBH model, one clinic experienced a statistically significant (p < .01, 95 percent CI 6.3-16.3 percent), 11.3 percent decrease in the ratio of ED visits to primary care encounters, relative to a control site, but two other intervention clinics did not. CONCLUSIONS:The PCBH model may be associated with a reduction in ED utilization, but better-controlled studies are needed to confirm this result.
| S-EPMC6232427 | biostudies-literature
Project description:The expansion of health insurance to millions of Americans through the Affordable Care Act has given rise to concerns about increased use of emergency department (ED) and hospital services by previously uninsured populations. Prior research has demonstrated that continuity with a regular source of primary care is associated with lower use of these services and with greater patient satisfaction. We assessed the impact of a policy to increase patients' adherence to an individual primary care provider or clinic on subsequent use of ED and hospital services in a California coverage program for previously uninsured adults called the Health Care Coverage Initiative. We found that the policy was associated with a 42 percent greater probability of adhering to primary care providers. Furthermore, patients who were always adherent had a higher probability of having no ED visits (change in probability: 2.1 percent) and no hospitalizations (change in probability: 1.7 percent), compared to those who were never adherent. Adherence to a primary care provider can reduce the use of costly care because it allows patients' care needs to be managed within the less costly primary care setting.
| S-EPMC4499851 | biostudies-literature
Project description:BackgroundUnplanned visits to the emergency department (ED) and inpatient setting are expensive and associated with poor outcomes in thoracic surgery. We assessed 30-d postoperative ED visits and inpatient readmissions following thoracotomy, a high morbidity procedure.Materials and methodsWe retrospectively analyzed inpatient and ED administrative data from California, Florida, and New York, 2010-2011. "Return to care" was defined as readmission to inpatient facility or ED within 30 d of discharge. Factors associated with return to care were analyzed via multivariable logistic regressions with a fixed effect for hospital variability.ResultsOf 30,154 thoracotomies, 6.3% were admitted to the ED and 10.2% to the inpatient setting within 30 d of discharge. Increased risk of inpatient readmission was associated with Medicare (odds ratio [OR] 1.30; P < 0.001) and Medicaid (OR 1.31; P < 0.0001) insurance status compared to private insurance and black race (OR 1.18; P = 0.02) compared to white race. Lung cancer diagnosis (OR 0.83; P < 0.001) and higher median income (OR 0.89; P = 0.04) were associated with decreased risk of inpatient readmission. Postoperative ED visits were associated with Medicare (OR 1.24; P < 0.001) and Medicaid insurance status (OR 1.59; P < 0.001) compared to private insurance and Hispanic race (OR 1.19; P = 0.04) compared to white race.ConclusionsFollowing thoracotomy, postoperative ED visits and inpatient readmissions are common. Patients with public insurance were at high risk for readmission, while patients with underlying lung cancer diagnosis had a lower readmission risk. Emphasizing postoperative management in at-risk populations could improve health outcomes and reduce unplanned returns to care.
| S-EPMC6732253 | biostudies-literature
Project description:ObjectiveTo examine the contributions of individual- and neighborhood-level spatial access to care to the utilization of emergency departments (EDs) for preventable conditions through implementation of novel local spatial access measures.Data sources/study settingEmergency department admissions data are from four HealthLNK member hospitals in Chicago from 2007 to 2011. Primary care physician office and clinic locations were obtained from the American Medical Association and the City of Chicago.Study designMultilevel logit regression was used to model the relationship between individual- and neighborhood-level attributes and preventable ED use.Data collection/extraction methodsEmergency department admissions data were classified based on the primary diagnosis for each encounter. Spatial access to care indices were generated in ArcGIS, and values were extracted at each ZIP code centroid to match patients' ZIP codes.Principal findingsBeyond sociodemographic factors such as gender and race, patients living in medically underserved areas (MUAs) and areas with lower spatial access to primary care clinics had higher odds of preventable ED use.ConclusionsPreventable ED use can be associated with sociodemographic characteristics, as well as spatial access to primary care services. This study reveals potential for using local measures of spatial accessibility for preventable ED analyses.
| S-EPMC5785320 | biostudies-literature