Tag: Rose Kleiman

Rose Kleiman

December 11, 2017

Many healthcare systems are trying to find innovate ways to help lower the use of emergency departments (EDs). Often, the focus is on “superutilizers”, patients who frequent the ED many times a year. This cohort of patients only encompasses about 5% of all ED patients, but accounts for about 25% of all ED visits yearly. [i] Reasons for being a frequent user of the ED are multifactorial including complex medical conditions and challenging socioeconomic situations, but often results in more fragmented patient care and higher costs to the healthcare system.

A new study from the University of Tennessee[ii] aimed to help keep frequent ED users from needing the ED through the use of a patient navigator program. The research team created a patient navigator program that worked within the ED to help patients review diagnoses and prescriptions, arrange follow-up appointments and transportation, and identify relevant community resources. The navigator would meet with the patient to perform these tasks during the initial visit, any following ED visit, and by telephone within 2 weeks and 12 months of the initial visit.

Superusers were defined as any patient presenting to the Erlanger Baroness ED for their fifth visit or more within a 1-year period. Once a patient was properly consented for participation in the pilot, they were assigned to the control arm or the experimental arm. The control group also received a call from a research assistant at the 2 week and 12-month time post the initial visit to the ED.

At the two-week follow-up call, visits to a primary care physician (PCP) were reported in 47% of patients in the treatment group and 43% in the control. However, at the twelve-month follow-up, phone survey results found that the experimental group had seen their PCP an average of 6.42 visits (95% CI = 5.14–7.70) over the 12-month follow-up period, which was significantly more than the 4.07 visits (95% CI = 3.38–4.76) over the 12-month follow-up in the control group (p = 0.0013). This suggests that the navigator had a positive influence on getting patients to utilize their PCP to a greater extent.

Community ED visits decreased during the 12-month study period, compared to the 12 months prior to enrollment (2,249 visits prior to enrollment to 2,050 visits 1 year after enrollment, 8.8% decrease) study. While there was a decrease in in ED use in both arms of the study, there was a greater decrease in ED visits from the pre-enrollment year to post-enrollment year in the treatment group (1,148 visits to 996 visits, 13.2% decrease) compared to the control group. (See Figure 1)

Figure 1: Emergency department visits pre- and post-enrollment

The research team reported that the cost of the patient navigator program was $34,808, which consisted of salary, benefits, and program administration costs. Overall health system costs (ED and hospital, excluding ED physician costs) for all 282 patients went from $3,925,233 in the year prior to enrollment to $3,130,510 in the follow-up 12 months (20.2% decrease; 95% CI = 19.5%–20.9%). While costs for ED visits did go down for both study arms, costs for ED visits had a greater decrease in the treatment group ($1,267,280 to $930,584, 26.6% decrease, 95% CI = 26.1%–27.0%) versus the control group ($1,556,536 to $1,283,590, 17.5% decrease, 95% CI = 17.1%–17.9%; p < 0.0001).

Only two other studies have looked at the use of a patient navigator program to help decrease frequent use of the ED and the results have been conflicting[iii] [iv]. But, the University of Tennessee team has shown with this pilot that patient navigators may be an effective way to reduce some of the frequent use and associated costs of the ED. The researchers do note that these findings could represent a placebo effect by entering the study alone might or could represent a regression to the mean for both groups.

As we continue to look for innovative ways to help some of the neediest patients is the healthcare system, patient navigators are uniquely positioned to play an integral role in the changing health care environment by facilitating access to care, as well as addressing language and cultural barriers and may be a key component of helping frequent users of the ED manage their healthcare and social needs.

[i] LaCalle E, Rabin E. Frequent users of emergency departments: the myths, the data and the policy implications. Ann Emerg Med 2010;56:42–48.

[ii] Seaberg, D., Elseroad, S., Dumas, M., Mendiratta, S., Whittle, J., Hyatte, C., & Keys, J. (2017). Patient Navigation for Patients Frequently Visiting the Emergency Department: A Randomized, Controlled Trial. Academic Emergency Medicine, 24(11), 1327-1333.

[iii] Spillane LL, Lumb EW, Cobaugh DJ, Wilcox SR, Clark SR, Schneider SM. Frequent users of the emergency department: can we intervene? Acad Emerg Med 1997;4:574–80.

[iv] Shumway M, Boccellari A, O'Brien K, Okin RL. Cost-effectiveness of clinical case management for ED frequent users: results of a randomized trial. Am J Emerg Med 2008;26:155–64.

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Rose Kleiman is a medical student at the GW School of Medicine & Health Sciences

Rose Kleiman

September 13, 2017

Despite recent efforts to push engagement with primary care and the health system, pregnant women still find themselves seeking emergency department (ED) care[i].

A recent study published in Academic Emergency Medicine sought to better understand the association between maternal comorbidities and ED use. The research team focused on the following comorbidities common in pregnancy: hypertension (pre-eclampsia and eclampsia), diabetes, gestational diabetes, obesity and asthma. The study limited their focus to women between the ages of 18 and 44 who were commercially insured during the pregnancy and up to 6 months afterward. Their analyses control for a known increased use of the ED among rural patients and tries to take into account patient demographics (such as race, ethnicity, income) by controlling for variation in use of the ED by zip code.

The study found that 20% of the women had one or more ED visit and that among those who had used the ED, almost 30 percent (20%) had two or more visits, and over 10 percent (11%) had three or more visits. The mean number of ED visits among pregnant women who received emergency care was 1.52 visits. Even though many sought ED care, only 0.4% of the visits resulted in a hospital admission.

The research team also found that those who sought out any ED care were significantly more likely to have one or more comorbid condition (30 percent vs. 21 percent). All of the comorbid conditions that the group identified as common pregnancy related comorbidities were associated with increased odds of seeking emergency care. Asthma in particular increased the likelihood of a woman receiving emergency care by 2.5 times, which is consistent with other studies of conditions that drive ED use. Table 1 (below) summarizes which patient characteristics lead to increased likelihood of an ED visit.

Table 1. Adjusted Parameter Estimates for Any Prenatal ED Visit

One limitation of this study is that it focused solely on commercially-insured women. It would be interesting to look at ED use among publically-insured women, who may not have the same routine prenatal care that commercially insured women do. Some studies have shown that almost 50% of low-income pregnant women receive emergency care at least once during their pregnancy[ii]. Thus it will be important to look at use of the ED in populations of women who are not commercially insured and try to further study if there are predictors that can be used to help identify potential pregnant frequent ED users.

This study shows that insurance coverage alone does not sufficiently meet the care needs of pregnant women, specifically those with comorbid conditions. A lot of work in healthcare delivery and policy reform has been focused on alternative models of care to keep people out of the ED and increase access to alternative sites.  Pregnant women are a population who might benefit from models of care that focus on extended office hours and more involved case management.

[i] Cunningham, S. D., Magriples, U., Thomas, J. L., Kozhimannil, K. B., Herrera, C., Barrette, E., ... & Ickovics, J. R. (2017). Association between Maternal Comorbidities and Emergency Department Use among a National Sample of Commercially‐insured Pregnant Women. Academic Emergency Medicine.

[ii] Magriples U, Kershaw TS, Rising SS, Massey Z, Ickovics JR. Prenatal health care beyond the obstetrics service: utilization and predictors of unscheduled care. Am J Obstet Gynecol 2008;

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Rose Kleiman is a medical student at the GW School of Medicine & Health Sciences

Rose Kleiman

June 26, 2017

Is the emergency department (ED) the right place to inquire about a patient’s sexual orientation? A recent study published in JAMA Internal Medicine points toward yes[i].

While lesbian, gay, bisexual, transgender, and queer (LGBTQ) populations often report poorer health and less access to health insurance and health services, lack of data on sexual orientation is a barrier to understanding and addressing these disparities. Recent efforts to capture data on sexual orientation have been made by both the US Department of Health and Human Services and the National Academy of Medicine. Yet, few health systems or emergency departments (EDs) regularly collect data on sexual orientation.

Researchers for the Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity (EQUALITY) Study used a mixed-methods approach to try and understand the willingness of patients to disclose and of providers to collect information on sexual orientation in the ED. The research team conducted in-depth interviews with patients and ED professionals in the Baltimore, Maryland, and Washington, DC, areas and used results from the first, qualitative phase to develop a national survey of patients and ED providers.

Findings from their qualitative interviews (see Table 2 below) highlight the following themes when discussing routine collection of sexual orientation in the ED: Medical relevance, normalization, and recognition.

The qualitative interviews describe the disconnect between patients and providers. Emergency providers felt if sexual orientation was not relevant for a patient’s immediate care plan, it was not necessary to know and thus not important to ask. Patients felt that their sexual orientation was essential information for their overall health and wellness, similar to inquiring about family history of heart disease or exercise habits, and thus should be a routine part of screening. Therefore, the lack of screening on sexual orientation may be a missed-opportunity for providers to build meaningful relationships with patients.

Similar findings were reflected in the quantitative results from the national survey. A total of 80% of emergency providers reported they thought patients would be offended if asked their sexual orientation in the ED, with 78% believing patients would refuse to provide this information. By contrast, only 10% of patients reported they would refuse to provide such information in the ED and only 11% reported that they would be offended if sexual orientation data were routinely collected.

Patients in the survey also emphasized the importance of collecting data on sexual orientation for recognition and normalization of LGBTQ individuals in society. It was expressed that standardizing the collection of this information may help to further promote patient-centered care for all patients.

The research team found that the preferred method of both patients and clinicians for collecting this information was through a nonverbal self-report. The EQUALITY team currently has a trial under way to study the different ways of collecting this information to determine the optimal method.

This study does have some limitations. First, the qualitative interviews were only sampled from one region of the United States; however, the interviews informed the development of the survey, which found similar themes on a national level. In addition, the study did not test how patients actually respond when asked about sexual orientation information in a clinical setting.

While this article highlights the significance of collecting data on sexual orientation, it leads to an important message for emergency providers: patients believe that their sexual orientation is an important component of their overall health and feel that it is necessary information for their providers to know. Whether it is essential to determining an immediate treatment plan or not, querying about a person’s sexual orientation can lead to a more person-centered approach to care.

[i] Haider, Adil H., et al. "Emergency Department Query for Patient-Centered Approaches to Sexual Orientation and Gender Identity: The EQUALITY Study." JAMA Internal Medicine (2017).

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Rose Kleiman is a medical student at the GW School of Medicine & Health Sciences