Introduction: Emergency department (ED) patients who leave before treatment is complete (LBTC) represent medicolegal risk and lost revenue. We sought to examine LBTC return visits characteristics and potential revenue effects for a large healthcare system. Methods: This retrospective, multicenter study examined all encounters from January 1-December 31, 2019 at 18 EDs. The LBTC patients were divided into left without being seen (LWBS), defined as leaving prior to completed medical screening exam (MSE), and left subsequent to being seen (LSBS), defined as leaving after MSE was complete but before disposition. We recorded 30-day returns by facility type including median return hours, admission rate, and return to index ED. Expected realization rate and potential charges were calculated for each patient visit. Results: During the study period 626,548 ED visits occurred; 20,158 (3.2%) LBTC index encounters occurred, and 6745 (33.5%) returned within 30 days. The majority (41.7%) returned in <24 hours with 76.1% returning in 10 days and 66.4% returning to index ED. Median return time was 43.3 hours, and 23.2% were admitted. Urban community EDs had the highest 30-day return rate (37.8%, 95% confidence interval, 36.41-39.1). Patients categorized as LSBS had longer median return hours (66.0) and higher admission rates (29.8%) than the LWBS cohort. There was a net potential realization rate of $9.5 million to the healthcare system. Conclusion: In our system, LSBS patients had longer return times and higher admission rates than LWBS patients. There was significant potential financial impact for the system. Further studies should examine how healthcare systems can reduce risk and financial impacts of LBTC patients.
Subject
HEALTH facilities; CONFIDENCE intervals; DESCRIPTIVE statistics; MEDICAL cooperation; METROPOLITAN areas; RESEARCH; RETROSPECTIVE studies; PATIENTS; EMERGENCY medical services; LONGITUDINAL method; MEDICAL screening; MEDICAL appointments
Willingness and Ability of Older Adults in the Emergency Department to Provide Clinical Information Using a Tablet Computer.
Creator
Brahmandam Sruti; Holland Wesley C; Mangipudi Sowmya A; Braz Valerie A; Medlin Richard P; Hunold Katherine M; Jones Christopher W; Platts-Mills Timothy F
Publisher
Journal of the American Geriatrics Society
Date
2016
2016-11
Description
OBJECTIVES: To estimate the proportion of older adults in the emergency department (ED) who are willing and able to use a tablet computer to answer questions. DESIGN: Prospective, ED-based cross-sectional study. SETTING: Two U.S. academic EDs. PARTICIPANTS: Individuals aged 65 and older. MEASUREMENTS: As part of screening for another study, potential study participants were asked whether they would be willing to use a tablet computer to answer eight questions instead of answering questions orally. A custom user interface optimized for older adults was used. Trained research assistants observed study participants as they used the tablets. Ability to use the tablet was assessed based on need for assistance and number of questions answered correctly. RESULTS: Of 365 individuals approached, 248 (68%) were willing to answer screening questions, 121 of these (49%) were willing to use a tablet computer; of these, 91 (75%) were able to answer at least six questions correctly, and 35 (29%) did not require assistance. Only 14 (12%) were able to answer all eight questions correctly without assistance. Individuals aged 65 to 74 and those reporting use of a touchscreen device at least weekly were more likely to be willing and able to use the tablet computer. Of individuals with no or mild cognitive impairment, the percentage willing to use the tablet was 45%, and the percentage answering all questions correctly was 32%. CONCLUSION: Approximately half of this sample of older adults in the ED was willing to provide information using a tablet computer, but only a small minority of these were able to enter all information correctly without assistance. Tablet computers may provide an efficient means of collecting clinical information from some older adults in the ED, but at present, it will be ineffective for a significant portion of this population.
Subject
*aged; *Attitude to Computers; *Computers; *data collection; *elderly; *emergency department; *Emergency Service; 80 and over; 80 and Over; ACADEMIC medical centers; Academic Medical Centers – North Carolina; Aged; Computers; Confidence Intervals; CONFIDENCE intervals; Convenience Sample; Cross Sectional Studies; CROSS-sectional method; Cross-Sectional Studies; Descriptive Statistics; DESCRIPTIVE statistics; Emergency Care – In Old Age; EMERGENCY medical services; Emergency Service; Female; Handheld; Hospital; HOSPITAL emergency services; Human; Humans; LONGITUDINAL method; Male; Mass Screening/*instrumentation; MEDICAL cooperation; Multicenter Studies; New Jersey; NEW Jersey; North Carolina; NORTH Carolina; OLD age; Patient Attitudes – Evaluation – In Old Age; PATIENTS' attitudes; Portable – Utilization – In Old Age; PORTABLE computers; Prospective Studies; RESEARCH; SCALE analysis (Psychology); Scales; STATISTICAL sampling; Summated Rating Scaling; Surveys and Questionnaires; United States; User-Computer Interface
The Role of Negative Affect on Headache-Related Disability Following Traumatic Physical Injury.
Creator
Pacella Maria L; Hruska Bryce; George Richard L; Delahanty Douglas L
Publisher
Headache
Date
2018
2018-03
Description
OBJECTIVE: Acute postinjury negative affect (NA) may contribute to headache pain following physical injury. Early psychiatric-headache comorbidity conveys increased vulnerability to chronic headache-related disability and impairment. Yet, it is unknown whether NA is involved in the transition to chronic headache related-disability after injury. This prospective observational study examined the role of acute postinjury NA on subacute and chronic headache-related disability above and beyond nonpsychiatric factors. METHODS: Eighty adult survivors of single-incident traumatic physical injury were assessed for negative affect (NA): a composite of depression and anxiety symptoms, and symptoms of posttraumatic stress disorder (PTSS) during the acute 2-week postinjury phase. NA was examined as the primary predictor of subacute (6-week) and chronic (3-month) headache-related disability; secondary analyses examined whether the individual NA components differentially impacted the outcomes. RESULTS: Hierarchical linear regression confirmed NA as a unique predictor of subacute (Cohen's f (2) = 0.130; P = .005) and chronic headache related-disability (Cohen's f (2) = 0.160; P = .004) beyond demographic and injury-related factors (sex, prior headaches, and closed head injury). Upon further analysis, PTSS uniquely predicted greater subacute (Cohen's f (2) = 0.105; P = .012) and chronic headache-related disability (Cohen's f (2) = 0.103; P = .022) above and beyond demographic and injury-related factors, depression, and anxiety. Avoidance was a robust predictor of subacute headache impairment (explaining 15% of the variance) and hyperarousal was a robust predictor of chronic headache impairment (10% of the variance). CONCLUSION: Although NA consistently predicted headache-related disability, PTSS alone was a unique predictor above and beyond nonpsychiatric factors, depression, and anxiety. These results are suggestive that early treatment of acute postinjury PTSS may correlate with reductions in disability and negative physical health sequelae associated with PTSS and chronic headache.
A multi-level modeling approach examining PTSD symptom reduction during prolonged exposure therapy: moderating effects of number of trauma types experienced, having an HIV-related index trauma, and years since HIV diagnosis among
Creator
Junglen Angela G; Smith Brian C; Coleman Jennifer A; Pacella Maria L; Boarts Jessica M; Jones Tracy; Feeny Norah C; Ciesla Jeffrey A; Delahanty Douglas L
Publisher
AIDS care
Date
2017
2017-11
Description
People living with HIV (PLWH) have extensive interpersonal trauma histories and higher rates of posttraumatic stress disorder (PTSD) than the general population. Prolonged exposure (PE) therapy is efficacious in reducing PTSD across a variety of trauma samples; however, research has not examined factors that influence how PTSD symptoms change during PE for PLWH. Using multi-level modeling, we examined the potential moderating effect of number of previous trauma types experienced, whether the index trauma was HIV-related or not, and years since HIV diagnosis on PTSD symptom reduction during a 10-session PE protocol in a sample of 51 PLWH. In general, PTSD symptoms decreased linearly throughout the PE sessions. Experiencing more previous types of traumatic events was associated with a slower rate of PTSD symptom change. In addition, LOCF analyses found that participants with a non-HIV-related versus HIV-related index trauma had a slower rate of change for PTSD symptoms over the course of PE. However, analyses of raw data decreased this finding to marginal. Years since HIV diagnosis did not impact PTSD symptom change. These results provide a better understanding of how to tailor PE to individual clients and aid clinicians in approximating the rate of symptom alleviation. Specifically, these findings underscore the importance of accounting for trauma history and index trauma type when implementing a treatment plan for PTSD in PLWH.
Minimal clinically important differences in the EORTC QLQ-C30 and brief pain inventory in patients undergoing re-irradiation for painful bone metastases.
Creator
Raman Srinivas; Ding Keyue; Chow Edward; Meyer Ralph M; van der Linden Yvette M; Roos Daniel; Hartsell William F; Hoskin Peter; Wu Jackson S Y; Nabid Abdenour; Haas Rick; Wiggenraad Ruud; Babington Scott; Demas William F; Wilson Carolyn F; Wong Rebecca K S; Zhu Liting; Brundage Michael
Publisher
Quality of life research : an international journal of quality of life aspects of treatment, care and rehabilitation
Date
2018
2018-04
Description
PURPOSE: The EORTC QLQ-C30 and the Brief Pain Inventory (BPI) are validated tools for measuring quality of life (QOL) and the impact of pain in patients with advanced cancer. Interpretation of these instrument scores can be challenging and it is difficult to know what numerical changes translate to clinically significant impact in patients' lives. To address this issue, our study sought to establish the minimal clinically important differences (MCID) for these two instruments in a prospective cohort of patients with advanced cancer and painful bone metastases. METHODS: Both anchor-based and distribution-based methods were used to estimate the MCID scores from patients enrolled in a randomized phase III trial evaluating two different re-irradiation treatment schedules. For the anchor-based method, the global QOL item from the QLQ-C30 was chosen as the anchor. Spearman correlation coefficients were calculated for all items and only those items with moderate or better correlation (\textbarr\textbar \textgreater/= 0.30) with the anchor were used for subsequent analysis. A 10-point difference in the global QOL score was used to classify improvement and deterioration, and the MCID scores were calculated for each of these categories. These results were compared with scores obtained by the distribution-method, which estimates the MCID purely from the statistical characteristics of the sample population. RESULTS: A total of 375 patients were included in this study with documented pain responses and completed QOL questionnaires at 2 months. 9/14 items in the QLQ-C30 and 6/10 items in the BPI were found to have moderate or better correlation with the anchor. For deterioration, statistically significant MCID scores were found in all items of the QLQ-C30 and BPI. For improvement, statistically significant MCID scores were found in 7/9 items of the QLQ-C30 and 2/6 items of the BPI. The MCID scores for deterioration were uniformly higher than the MCIDs for improvement. Using the distribution-based method, there was good agreement between the 0.5 standard deviation (SD) values and anchor-based scores for deterioration. For improvement, there was less agreement and the anchor-based scores were lower than the 0.5 SD values obtained from the distribution-based method. CONCLUSION: We present MCID scores for the QLQ-C30 and BPI instruments obtained from a large cohort of patients with advanced cancer undergoing re-irradiation for painful bone metastases. The results from this study were compared to other similar studies which showed larger MCID scores for improvement compared to deterioration. We hypothesize that disease trajectory and patient expectations are important factors in understanding the contrasting results. The results of this study can guide clinicians and researchers in the interpretation of these instruments.
Subject
*Bone metastases; *Brief pain inventory; *EORTC QLQ-C30; *Minimal Clinically Important Difference; *Minimal clinically important differences; *Radiation; 80 and over; 80 and Over; Adolescence; Adolescent; Adult; Aged; Bone Metastases – Radiotherapy; BONE metastasis; BONE metastasis – Treatment; Bone Neoplasms/*complications/radiotherapy/secondary; Brief Pain Inventory; BRIEF Pain Inventory; Cancer Patients; CANCER patients; CANCER radiotherapy; Clinical Assessment Tools; Female; Funding Source; Human; Humans; Instrument Scaling; LONGITUDINAL method; Male; Middle Age; Middle Aged; Pain Management; PAIN management; Pain/*diagnosis; Prospective Studies; Quality of Life/*psychology; Questionnaires; QUESTIONNAIRES; RANDOMIZED controlled trials; Re-Irradiation/*adverse effects; REOPERATION; Repeat Procedures; RESEARCH funding; SCALING (Social sciences); Secondary Analysis; SECONDARY analysis; Surveys and Questionnaires; Young Adult