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Predictive factors for hospitalization of nonurgent patients in the emergency department.

ABSTRACT: Nonurgent emergency department (ED) patients are a controversial issue in the era of ED overcrowding. However, a substantial number of post-ED hospitalizations were found, which prompted for investigation and strategy management. The objective of this study is to identify risk factors for predicting the subsequent hospitalization of nonurgent emergency patients. This was a retrospective study of a database of adult nontrauma ED visits in a medical center for a period of 12 months from January 2013 to December 2013. Patient triages as either Taiwan Triage and Acuity Scale (TTAS) level 4 or 5 were considered "nonurgent." Basic demographic data, primary and secondary diagnoses, clinical parameters including blood pressure, heart rate, body temperature, and chief complaint category in TTAS were analyzed to determine if correlation exists between potential predictors and hospitalization in nonurgent patients.A total of 16,499 nonurgent patients were included for study. The overall hospitalization rate was 12.47 % (2058/16,499). In the multiple logistic regression model, patients with characteristics of males (odds ratio, OR = 1.37), age more than 65 years old (OR = 1.56), arrival by ambulance (OR = 2.40), heart rate more than 100/min (OR = 1.47), fever (OR = 2.73), and presented with skin swelling/redness (OR = 4.64) were predictors for hospitalization. The area under receiver-operator calibration curve (AUROC) for the prediction model was 0.70. Nonurgent patients might still be admitted for further care especially in male, the elderly, with more secondary diagnoses, abnormal vital signs, and presented with dermatologic complaints. Using the TTAS acuity level to identify patients for diversion away from the ED is unsafe and will lead to inappropriate refusal of care for many patients requiring hospital treatment.

SUBMITTER: Ng CJ

PROVIDER: S-EPMC4937954 | biostudies-literature |

REPOSITORIES: biostudies-literature

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Project description:PurposeTo determine the frequency of emergency department (ED) visits for nonurgent and urgent ocular conditions and risk factors associated with ED use for nonurgent and urgent ocular problems.DesignRetrospective, longitudinal cohort analysis.ParticipantsAll enrollees aged 21 years or older in a United States managed care network during 2001-2014.MethodsWe identified all enrollees visiting an ED for ocular conditions identified by International Classification of Diseases, billing codes. Diagnosis is well-described as urgent, nonurgent, or other. We assessed the frequency of ED visits for urgent and nonurgent ocular conditions and how they changed over time. Next, we performed multivariable Cox regression modeling to determine factors associated with visiting an ED for urgent or nonurgent ocular conditions.Main outcome measuresHazard ratios (HRs) with 95% confidence intervals (CIs) of visiting an ED for urgent or nonurgent ocular conditions.ResultsOf the 11 160 833 enrollees eligible for this study, 376 680 (3.4%) had 1 or more ED visit for an eye-related problem over a mean ± standard deviation of 5.4±3.3 years' follow-up. Among these enrolled, 86 473 (23.0%) had 1 or more ED visits with a nonurgent ocular condition and 25 289 (6.7%) had at least 1 ED visit with an urgent ocular condition. Use of the ED for nonurgent ocular problems was associated with younger age (P < 0.0001 for all comparisons), black race or Latino ethnicity (P < 0.0001 for both), male sex (P < 0.0001), lower income (P < 0.0001 for all comparisons), and those who frequently sought treatment at an ED for nonophthalmologic medical problems in a given year (P < 0.0001). Enrollees with established eye care professionals had a 10% reduced hazard of visiting the ED for nonurgent ocular conditions (adjusted HR, 0.90; 95% CI, 0.88-0.92; P < 0.0001).ConclusionsNearly one-quarter of enrollees who visited the ED for an ocular problem received a diagnosis of a nonurgent condition. Better educating and incentivizing patients to seek care for nonurgent ocular diseases in an office-based setting could yield considerable cost savings without adversely affecting health outcomes and could allow EDs to better serve patients with more severe conditions.

Project description:BackgroundOvercrowding in emergency department (EDs) is partly due to the use of EDs by nonurgent patients. In France, the authorities responded to the problem by creating primary care units (PCUs): alternative structures located near hospitals. The aims of the study were to assess the willingness of nonurgent patients to be reoriented to a PCU and to collect the reasons that prompted them to accept or refuse.MethodsWe carried out a cross sectional survey on patients' use of EDs. The study was conducted in a French hospital ED. Patients were interviewed about their use of health services, ED visits, referrals, activities of daily living, and insurance coverage status. Patients' medical data were also collected.Results85 patients considered nonurgent by a triage nurse were asked to respond to a questionnaire. Sex ratio was 1.4; mean age was 36.3 +/- 11.7 years.Most patients went to the ED autonomously (76%); one third (31.8%) had consulted a physician. The main reasons for using the ED were difficulty to get an appointment with a general practitioner (22.3%), feelings of pain (68.5%), and the availability of medical services in the ED, like imaging, laboratory tests, and drug prescriptions (37.6%). Traumatisms and wounds were the main medical reasons for going to the ED (43.5%).More than two-thirds of responders (68%) were willing to be reoriented towards PCUs. In the multivariate analysis, only employment and the level of urgency perceived by the patient were associated with the willingness to accept reorientation. Employed persons were 4.5 times more likely to accept reorientation (OR = 4.5 CI (1.6-12.9)). Inversely, persons who perceived a high level of urgency were the least likely to accept reorientation (OR = 0.9 CI (0.8-0.9).ConclusionsOur study provides information on the willingness of ED patients to accept reorientation and shows the limits of its feasibility. Alternative structures such as PCUs near the ED seem to respond appropriately to the growing demands of nonurgent patients. Reorientation, however, will be successful only if the new structures adapt their opening hours to the needs of nonurgent patients and if their physicians can perform specific technical skills.

Project description:Objective. This study investigates potential of a new financial incentive policy, the GP-referral discount scheme introduced in Singapore, in reducing nonurgent emergency department (ED) visits, and compares it with alternative interventions. Methods. A discrete choice experiment (DCE) was designed to elicit patients' preferences for ED and general practitioner (GP) under hypothetical nonurgent medical conditions. Through latent class multinomial logistic regression, choice models were estimated to quantify how patients' choices are influenced by GP-referral discount, other ED/GP attributes (waiting time, test facilities, and payment), patient demographics, and their perception of severity. The choice models were used to predict uptake of the GP-referral discount scheme and other countermeasures suggested by these models. Results. Survey responses from 849 respondents recruited from a public hospital in Singapore were included in the study. The choice model identified two prominent classes of patients, one of which was highly sensitive to GP-referral discount and the other to test-facility-availability. Patients' perceptions of severity ("critical" v. "not critical" enough to go to ED directly) were highly significant in influencing preference heterogeneity. Predictive analysis based on the choice model showed that GP-referral discount is more effective when patients visit ED expecting "shorter" waits, as opposed to test-facility provision at GPs and perception-correction measures that showed stronger effects under "longer" expected waits. Conclusions. The new GP-referral financial incentive introduced in Singapore can be effective in reducing nonurgent ED visits, if it reasonably covers the (extra) cost of visiting a GP. It may serve as a complement to test-facility provision at GPs or perception-correction measures, as the financial incentive and the latter two measures appear to influence distinct classes (discount-sensitive and facility-sensitive) of patients.

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Predictive factors for hospitalization of nonurgent patients in the emergency department.

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