AEM Early Access

AEM Early Acess 15: Predicting High ED Utilization Among Patients With Asthma Exacerbations

Welcome to the fifteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

  A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING: (open access through June 30, 2018; click on title to access.)

Comparing Statewide and Single-center Data to Predict High-frequency Emergency Department Utilization Among Patients With Asthma Exacerbation. Margaret E. Samuels-Kalow, MD, MPhil, MSHP, Mohammad K. Faridi, MPH, Janice A. Espinola, MPH, Jean E. Klig, MD, and Carlos A. Camargo, Jr., MD, DrPH. Academic Emergency Medicine, 2018.

 

LISTEN NOW: AUTHOR INTERVIEW WITH DR. SAMUELS-KALOW

Recorded on site at SAEM 2018 in Indianapolis.  Stay tuned to the end for a BONUS about Dr. Samuels-Kalow's winning EXCITE project submission, addressing gender disparities and the 'leaky pipeline' of female leadership in academic emergency medicine. 

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Margaret Samuels-Kalow MD MPhil MSHP

Assistant Professor of Emergency Medicine

Massachusetts General Hospital/Harvard Medical School

 

ARTICLE SUMMARY:

Background: Previous studies examining high-frequency emergency department (ED) utilization have primarily used single-center data, potentially leading to ascertainment bias if patients visit multiple centers. The goals of this study were 1) to create a predictive model to prospectively identify patients at risk of high-frequency ED utilization for asthma and 2) to examine how that model differed using statewide versus single-center data.

Methods: To track ED visits within a state, we analyzed 2011 to 2013 data from the New York State Healthcare Cost and Utilization Project State Emergency Department Databases. The first year of data (2011) was used to determine prior utilization, 2012 was used to identify index ED visits for asthma and for demographics, and 2013 was used for outcome ascertainment. High-frequency utilization was defined as 4+ ED visits for asthma within 1 year after the index visit. We performed analyses separately for children (age < 21 years) and adults and constructed two models: one included all statewide (multicenter) visits and the other was restricted to index hospital (single-center) visits. Multivariable logistic regression models were developed from potential predictors selected a priori. The final model was chosen by evaluating model performance using Akaike’s Information Criterion scores, 10-fold cross-validation, and receiver operating characteristic curves.

Results: Among children, high-frequency ED utilization for asthma was observed in 2,417 of 94,258 (2.56%) using all statewide visits, compared to 1,853 of 94,258 (1.97%) for index hospital visits only. Among adults, the corresponding results were 7,779 of 159,874 (4.87%) and 5,053 of 159,874 (3.16%), respectively. In the multicenter visit model, the area under the curve (AUC) from 10-fold cross-validation for children was 0.70 (95% confidence interval [CI] = 0.69–0.72), compared to 0.71 (95% CI = 0.69–0.72) in the single-center visit model. The corresponding AUC results for adults were 0.76 (95% CI = 0.76–0.77) and 0.76 (95% CI = 0.75–0.77), respectively.

Conclusion: Data available at the index ED visit can predict subsequent high-frequency utilization for asthma with AUC ranging from 0.70 to 0.76. Model accuracy was similar regardless of whether outcome ascertainment included all statewide visits (multicenter) or was limited to the index hospital (single-center).

ADDITIONAL READING:

"Looking out for each other": a qualitative study on the role of social network interactions in asthma management among adult Latino patients presenting to an emergency department. Pai S1, Boutin-Foster C, Mancuso CA, Loganathan R, Basir R, Kanna B. 
J Asthma. 2014 Sep;51(7):714-9. doi: 10.3109/02770903.2014.903967. Epub 2014 Apr 7.

"No other choice": reasons for emergency department utilization among urban adults with acute asthma. Lawson CC1, Carroll K, Gonzalez R, Priolo C, Apter AJ, Rhodes KV. Acad Emerg Med 2014 Jan;21(1):1-8. doi: 10.1111/acem.12285.

Duseja R, Bardach NS, Lin GA, et al. Revisit rates and associated costs after an emergency department encounter: a multistate analysis. Ann Intern Med 2015;162:750-6.

Horrocks D, Kinzer D, Afzal S, Alpern J, Sharfstein JM. The Adequacy of Individual Hospital Data to Identify High Utilizers and Assess Community Health. JAMA Intern Med 2016;176:856-8.    

AEM Early Access 14: Cannabis and Mental Health ED Visits in Colorado

Welcome to the fourteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

  A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING:(Click title for open access through may 31, 2018)

Mental Health-Related Emergency Department Visits Associated with Cannabis in Colorado. Katelyn E. Hall MPH, Andrew A. Monte MD, Tae Chang, Jacob Fox, Cody Brevik, Daniel I. Vigil MD, MPH,  Mike Van Dyke PhD, CIH,  Katherine A. James PhD, MSPH. Academic Emergency Medicine, 2018.

LISTEN NOW: AUTHOR INTERVIEW

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Andrew A. Monte, MD

Associate Professor, Departments of Emergency Medicine & PharmaceuticaLSciences
University of Colorado Denver-Anschutz Medical Center Aurora, CO and Rocky Mountain Poison & Drug Center
Denver Health & Hospital Authority
Denver, CO

ARTICLE SUMMARY: 

Objectives:
Across the United States, the liberalization of marijuana use has resulted in a rapid increase in the social acceptability of its use.  Colorado has been at the forefront of marijuana legalization, allowing recreational use beginning in 2014.  Since then, Colorado has positioned itself as the optimal environment to study health-related impacts from marijuana use.  Cannabis use is well-known to exacerbate mental health illness such as schizophrenia, mood disorders, anxiety, and depression.  Since legalization in Colorado, increased healthcare utilization has been associated with acute and chronic marijuana use.  It is currently unknown if cannabis use is associated with increased ED visits in patients with mental illness.  The primary objective of this study was to determine the prevalence ratios of mental health diagnoses among ED visits with cannabis-associated diagnosis compared to those without cannabis-associated diagnoses in Colorado.

Methods:
The study was cross-sectional in design, with discharge diagnostic codes collected from Colorado emergency departments from 2012 to 2014.  Diagnosis codes identified visits associated with both mental health conditions and cannabis.  Prevalence ratios of mental health ED discharges were calculated to compare cannabis-associated visits to those without cannabis.  Rates of mental health and cannabis-associated ED discharges were examined of the study period.  

Results:
State-wide data demonstrated a five-fold higher prevalence of mental health diagnoses in cannabis-associated ED visits (PR: 5.35, 95% CI: 5.27-5.43) compared to visits without cannabis. In the study’s secondary outcome, state-wide rates of ED visits associated with both cannabis and mental health significantly increased from 2012 to 2014 from 224.5 to 268.4 per 100,000 (p<0.0001).

Conclusion:
In Colorado from 2012 to 2014 the prevalence of mental health conditions in ED visits with cannabis-associated diagnostic codes is higher than in those without cannabis.  Due to the nature of the study design, it is unclear if these findings are attributable to cannabis or coincident with increased use and availability.  Per the authors of the paper, ED physicians nationwide should be aware of the detriments of marijuana use on pre-existing mental health conditions and ED management should include counseling on cessation and rehabilitation.
 

AEM Early Access 13: Syncope Prognosis Based on ED Diagnosis

Welcome to the thirteenth episode of AEM Early Access, a FOAMed podcast collaboration between the Academic Emergency Medicine Journal and Brown Emergency Medicine. Each month, we'll give you digital open access to an recent AEM Article or Article in Press, with an author interview podcast and suggested supportive educational materials for EM learners.

Find this podcast series on iTunes here.

  &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp; &nbsp;A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

                   A FOAM Collaboration: Academic Emergency Medicine Journal and Brown EM

DISCUSSING:(Click for Open Access Through 4/30/18)

Syncope Prognosis Based on Emergency Department Diagnosis: A Prospective Cohort Study. Cristian Toarta, MD, Muhammad Mukarram, MBBS, MPH, Kirtana Arcot, MSc, Soo-Min Kim, BScH, Sarah Gaudet, RN, Marco L. A. Sivilotti, MD, MSc, Brian H. Rowe, MD, MSc, and Venkatesh Thiruganasambandamoorthy, MBBS, MSc. Academic Emergency Medicine 2018

LISTEN NOW: AUTHOR INTERVIEW

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Christian Toarta, M.D.

PGY-3, Emergency Medicine

University of Toronto

 

 

 

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Venkatesh Thiruganasambandamoorthy CCFP-EM, M.Sc
Associate Professor, Dept. of Emergency Medicine, and

School of Epidemiology and Public Health

Scientist, Ottawa Hospital Research Institute

New Investigator, Heart and Stroke Foundation Canada
Staff Attending Physician,The Ottawa Hospital

Twitter: @TeamVenk

 

ARTICLE SUMMARY:

Objectives: Patients presenting to emergency departments (EDs) with syncope are given various diagnoses for cause including: vasovagal, orthostatic hypotension, cardiac and unknown. This study aims to determine short-term outcomes in each diagnostic group up to 30 days following the initial ED visit for syncope.

Methods: Adult syncope patients were prospectively enrolled from six Canadian EDs by treating physicians. Syncope was defined as a transient loss of consciousness followed by complete recovery and those with presyncope, persistent mental status changes, seizures, alcohol or drug intoxication or patients with major trauma were excluded. Additionally, patients with serious conditions identified during the initial ED visit were excluded as the study aimed to prognosticate after diagnosis. Patient demographics, ED management, presumed diagnosis at the end of visit and physician confidence in that diagnosis were collected at the time of visit. Serious outcomes, including death, arrhythmias, myocardial infarction, structural heart disease, pulmonary embolism, subarachnoid hemorrhage, serious hemorrhage or other conditions that would require a return visit or intervention were assessed 30 days following the initial visit.

Results: A total of 5,010 patients were included in the final analysis, of whom the cause of syncope was found to be vasovagal in 2,671 (53.3%) unknown in 1,615 (32.2%), orthostatic in 456 (9.1%) and cardiac in 268 (5.4%) of patients. Of all patients, 177 (3.5%) suffered serious outcomes including 15 deaths (0.3%), 115 cardiac (2.3%) and 47 non-cardiac (0.9%) outcomes. No deaths occurred in the vasovagal syncope group. The proportion of serious outcomes was significantly higher in all groups other than vasovagal, increasing in the following order: vasovagal, orthostatic hypotension, unknown and cardiac (p< 0.01). The proportion of patients among whom diagnostic testing was performed also increased in the same order with least in vasovagal and most in cardiac syncope (p< 0.001), with 42.9% of those with cardiac syncope hospitalized compared to 9.4% overall. The physician confidence in assigning a diagnosis was highest in the vasovagal syncope group and lowest in the unknown syncope group. 

Conclusions: Physician diagnosis strongly correlated with probability of serious outcomes in patients with syncope. This initial diagnosis with physician clinical judgment could be factored into future scores for risk stratification and management of patients with syncope.

 

FURTHER READING:

 1. Thiruganasambandamoorthy V, Kwong K, Wells GA, et al. Development of the Canadian Syncope Risk Score to predict serious adverse events after emergency department assessment of syncope. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2016;188(12):E289-298

 2. Thiruganasambandamoorthy V, Stiell IG, Sivilotti ML, et al. Risk stratification of adult emergency department syncope patients to predict short-term serious outcomes after discharge (RiSEDS) study. BMC Emergency Medicine. 2014;14:8.

3. Costantino G, Casazza G, Reed M, et al. Syncope risk stratification tools vs clinical judgment: an individual patient data meta-analysis. The American Journal of Medicine. 2014;127(11):1126.e1113-1125.

4. Quinn JV, Stiell IG, McDermott DA, Sellers KL, Kohn MA, Wells GA. Derivation of the San Francisco Syncope Rule to predict patients with short-term serious outcomes. Annals of Emergency Medicine. 2004;43(2):224-232.