- Email: [email protected]
458: An Emergency Department-Based Model for Providing Colorectal Cancer Screening and Identifying Barriers to Care
Research Forum Abstracts
456
Pediatric Traumatic Brain Injury In South Carolina 1998-2008: Severity, Type, and Socioeconomic Status
Palesch S, Cifuni M, Borg K, Selassie A/Medical University of South Carolina, Charleston, SC
Study Objectives: Traumatic brain injury (TBI) is a devastating and highly prevalent injury in the pediatric population with significant long-term implications. There are few successful interventions after injury; therefore, we sought to better understand factors that contribute to this problem. The purpose of this study was to examine TBI in the pediatric population of South Carolina, looking specifically at multiple socioeconomic variables. Methods: This was a retrospective cohort study, where data on pediatric traumatic brain injury was collected from all hospitals and emergency departments in South Carolina from 1998-2008. The SC TBI Surveillance System was established in 1992 and collects information on all TBI patients from all nonfederal in state acute care hospitals. Information was collected on 55,439 patients, including patient age, severity of TBI, insurance status, patient socioeconomic status, and discharge disposition. Socioeconomic status (SES) was determined by analyzing both zip code and insurance status. Results: There were a total of 55,439 patients evaluated in the study. Patient data was analyzed by developmental age groups (0-2, 3-7, 8-12, and 13-17), with the 1317 age group (n⫽17,090) having the highest incidence (30.8%) of reported TBI. The severity of TBI in all groups was assessed on a scale of mild (91.5%), moderate (3.4%), and severe (5.1%). Although the largest group of patients were reported to have commercial insurance coverage (45.6%), the next two largest groups were insured through Medicaid (34.3%) or were uninsured (11.6%). Overall more than half of the reported TBI cases were patients from lower SES families (56.4%). Utilizing SES we noted that 63% of the TBI patients in the 0-2 age group were from lower SES while only 12.8% of the patients were from higher SES. This pattern continues with lower SES comprising more than 50% of all TBI in all age groups. Conclusion: The incidence of pediatric TBI has been increasing over the last 10 years. This was primarily due to increased numbers of cases in the 0-2 age group. Lower SES patients comprise a disproportionate number of the cases of TBI. Safety and prevention measures might be targeted towards teenagers and infants from lower socioeconomic status, where the highest incidence of injury occurs.
457
Prevalence and Severity of Depression In Emergency Department Patients With Diabetes: What Is the Association With Glycemic Control?
Menchine MD, Solomon T, Marzec K, Rifenbark N, Nayyar M, Patel S, Arora S/ University of Southern California, Los Angeles, CA
Study Objectives: Diabetes has been termed the epidemic of the 21st century affecting roughly 10% of the US population. Despite well-established medical treatments, approximately 50% of emergency department (ED) patients with diabetes are poorly controlled. Mood disorders, particularly depression, are prevalent in patients with diabetes and may be associated with poor glycemic control. We sought to determine: 1) the prevalence and severity of depression in ED patients with diabetes and 2) if the severity of depression is associated with high glycosylated hemoglobin (HbA1C) levels in this population. Methods: This was a prospective study of consecutive patients with a known history of diabetes seen in a Los Angeles urban county ED. Patients who were critically ill or unable to provide written informed consent were ineligible. Research assistants used our electronic tracking system to identify all patients present in the ED with diabetes at two specified times daily. Patients who agreed to participate received a point of care HbA1C using the The Afinion™ AS 100 analyzer. They also completed a questionnaire detailing demographic and biometric data as well as the personal health questionnaire 9 (PHQ-9), a validated, 9-item, screening instrument for depression. Consistent with prior literature, a score of 15 or more on the PHQ-9 defined major depression while a score of 20 or more defined severe major depression. Results: In total, 230 patients with diabetes were enrolled. The median age of the subjects was 53 years and median HbA1C was 8.1% (IQR 6.65-10.7). The mean PHQ-9 score was 11.8 (95% CI 10.7-12.9). A total of 34.2% of patients with diabetes screened positive for depression (16.3% had major depressions and an additional 17.9% of the sample population screened positive for severe major depression). HbA1C varied by severity of depression. Non-depressed patients had median HbA1C of 7.8% while those with major depression and those with severe
S148 Annals of Emergency Medicine
major depression had HbA1C of 8.1% and 9.5% respectively (p ⬍ 0.02 for trend across groups). Conclusions: Major depression and severe major depression affected over 1/3 of ED patients with diabetes in this study and was associated with poor glycemic control. Clinicians and public health professionals should be mindful of this association when treating, educating or developing interventions designed to improve the care of ED patients with diabetes.
458
An Emergency Department-Based Model for Providing Colorectal Cancer Screening and Identifying Barriers to Care
Davis SP, Lee J, Burgess J, Bland J, Miller C, Patierno S/George Washington University, Washington, DC
Study Objectives: Colorectal cancer is the fourth most common cancer in the United States and is responsible for 10% of all cancer deaths. In the District of Columbia (DC), the rate of colorectal cancer is comparable to the national average, but the mortality rate is significantly higher than the national average. As mortality rates from colorectal cancer have decreased nationally, rates in DC have been rising. Routine screening with fecal occult blood testing reduces colorectal cancer mortality, and has received a Grade A level recommendation from the US Preventative Services Task Force (USPSTF). Our aim is to quantify the efficacy of an emergency department-based model for colorectal cancer screening, and identify the relative significance of known barriers to receiving health care in obtaining appropriate screening within DC. Methods: Patients over 50 years of age with an Emergency Severity Index (ESI) level 3-5 presenting to an inner-city emergency department within DC were enrolled. All enrolled patients completed an initial survey addressing patient demographics, health insurance status, usual source of care, cancer screening history, and selfidentified barriers to receiving recommended colorectal cancer screening. Patients with DC-residence and out-of-date (expired) colorectal cancer screening were offered fecal occult blood testing (FOBT) to complete at home in accordance with the USPSTF screening guidelines. Patients offered screening were later contacted to identify rates of completed screening. All patients with positive FOBT results were contacted by a patient navigator to facilitate recommended follow-up. Results: Eight hundred fifty-eight patients were enrolled, of which 409 (47.7%) had expired or no prior cancer screening. Patients with expired or no prior screening were more often uninsured or underinsured than those with up-to-date screening (40.1% versus 22.3%, P⫽1.65E-8), and more often identified an emergency department or no usual source for health care than those with up-to-date screening (29.6% versus 16.0%, P⫽0.0000027). Among patients with expired or no prior screening, those who were uninsured or underinsured more often identified lack of awareness regarding colorectal cancer and recommended screening as a barrier to screening than did those with commercial insurance or Medicare (40.2% versus 25.5%, P⫽0.0027). Cost, underinsurance and no usual source of care were rarely self-identified as barriers to receiving screening for all groups (1.7%, 1.5% and 4.2%). Of 293 DC residents who received colorectal cancer screening through the ED, 105 were reached for follow-up (35.8%); 31 (29.5%) completed the provided FOBT screening, 12 (11.4%) reported recently scheduled screening through their primary care provider, and 47 (44.8%) reported intention to complete the provided FOBT screening. Conclusion: Uninsurance, underinsurance and absence of an appropriate usual source of care are associated with lower rates of recommended colorectal cancer screening. However, patients most often self-report health literacy as a barrier to receiving screening. Effective approaches to increasing colorectal cancer screening must include programs to improve health literacy regarding colorectal cancer. Programs offered through emergency departments can provide an effective means to both improve screening and increase health literacy.
459
Cardiopulmonary Resuscitation Prescription Program: A Prospective Randomized Pilot Study
Greenberg MR, Barr Jr GC, Rupp V, Patel N, Weaver K, Hamilton K, Reed III J/ Lehigh Valley Hospital and Health Network, Allentown, PA
Study Objective: The American Heart Association wants to increase the number of citizens who know how to perform cardiopulmonary resuscitation (CPR). It is unknown whether prescribed advice to patients to learn CPR is effective. We sought to determine if patients with, or at risk for, heart disease and their families were more
Volume , . : September
456
Pediatric Traumatic Brain Injury In South Carolina 1998-2008: Severity, Type, and Socioeconomic Status
Palesch S, Cifuni M, Borg K, Selassie A/Medical University of South Carolina, Charleston, SC
Study Objectives: Traumatic brain injury (TBI) is a devastating and highly prevalent injury in the pediatric population with significant long-term implications. There are few successful interventions after injury; therefore, we sought to better understand factors that contribute to this problem. The purpose of this study was to examine TBI in the pediatric population of South Carolina, looking specifically at multiple socioeconomic variables. Methods: This was a retrospective cohort study, where data on pediatric traumatic brain injury was collected from all hospitals and emergency departments in South Carolina from 1998-2008. The SC TBI Surveillance System was established in 1992 and collects information on all TBI patients from all nonfederal in state acute care hospitals. Information was collected on 55,439 patients, including patient age, severity of TBI, insurance status, patient socioeconomic status, and discharge disposition. Socioeconomic status (SES) was determined by analyzing both zip code and insurance status. Results: There were a total of 55,439 patients evaluated in the study. Patient data was analyzed by developmental age groups (0-2, 3-7, 8-12, and 13-17), with the 1317 age group (n⫽17,090) having the highest incidence (30.8%) of reported TBI. The severity of TBI in all groups was assessed on a scale of mild (91.5%), moderate (3.4%), and severe (5.1%). Although the largest group of patients were reported to have commercial insurance coverage (45.6%), the next two largest groups were insured through Medicaid (34.3%) or were uninsured (11.6%). Overall more than half of the reported TBI cases were patients from lower SES families (56.4%). Utilizing SES we noted that 63% of the TBI patients in the 0-2 age group were from lower SES while only 12.8% of the patients were from higher SES. This pattern continues with lower SES comprising more than 50% of all TBI in all age groups. Conclusion: The incidence of pediatric TBI has been increasing over the last 10 years. This was primarily due to increased numbers of cases in the 0-2 age group. Lower SES patients comprise a disproportionate number of the cases of TBI. Safety and prevention measures might be targeted towards teenagers and infants from lower socioeconomic status, where the highest incidence of injury occurs.
457
Prevalence and Severity of Depression In Emergency Department Patients With Diabetes: What Is the Association With Glycemic Control?
Menchine MD, Solomon T, Marzec K, Rifenbark N, Nayyar M, Patel S, Arora S/ University of Southern California, Los Angeles, CA
Study Objectives: Diabetes has been termed the epidemic of the 21st century affecting roughly 10% of the US population. Despite well-established medical treatments, approximately 50% of emergency department (ED) patients with diabetes are poorly controlled. Mood disorders, particularly depression, are prevalent in patients with diabetes and may be associated with poor glycemic control. We sought to determine: 1) the prevalence and severity of depression in ED patients with diabetes and 2) if the severity of depression is associated with high glycosylated hemoglobin (HbA1C) levels in this population. Methods: This was a prospective study of consecutive patients with a known history of diabetes seen in a Los Angeles urban county ED. Patients who were critically ill or unable to provide written informed consent were ineligible. Research assistants used our electronic tracking system to identify all patients present in the ED with diabetes at two specified times daily. Patients who agreed to participate received a point of care HbA1C using the The Afinion™ AS 100 analyzer. They also completed a questionnaire detailing demographic and biometric data as well as the personal health questionnaire 9 (PHQ-9), a validated, 9-item, screening instrument for depression. Consistent with prior literature, a score of 15 or more on the PHQ-9 defined major depression while a score of 20 or more defined severe major depression. Results: In total, 230 patients with diabetes were enrolled. The median age of the subjects was 53 years and median HbA1C was 8.1% (IQR 6.65-10.7). The mean PHQ-9 score was 11.8 (95% CI 10.7-12.9). A total of 34.2% of patients with diabetes screened positive for depression (16.3% had major depressions and an additional 17.9% of the sample population screened positive for severe major depression). HbA1C varied by severity of depression. Non-depressed patients had median HbA1C of 7.8% while those with major depression and those with severe
S148 Annals of Emergency Medicine
major depression had HbA1C of 8.1% and 9.5% respectively (p ⬍ 0.02 for trend across groups). Conclusions: Major depression and severe major depression affected over 1/3 of ED patients with diabetes in this study and was associated with poor glycemic control. Clinicians and public health professionals should be mindful of this association when treating, educating or developing interventions designed to improve the care of ED patients with diabetes.
458
An Emergency Department-Based Model for Providing Colorectal Cancer Screening and Identifying Barriers to Care
Davis SP, Lee J, Burgess J, Bland J, Miller C, Patierno S/George Washington University, Washington, DC
Study Objectives: Colorectal cancer is the fourth most common cancer in the United States and is responsible for 10% of all cancer deaths. In the District of Columbia (DC), the rate of colorectal cancer is comparable to the national average, but the mortality rate is significantly higher than the national average. As mortality rates from colorectal cancer have decreased nationally, rates in DC have been rising. Routine screening with fecal occult blood testing reduces colorectal cancer mortality, and has received a Grade A level recommendation from the US Preventative Services Task Force (USPSTF). Our aim is to quantify the efficacy of an emergency department-based model for colorectal cancer screening, and identify the relative significance of known barriers to receiving health care in obtaining appropriate screening within DC. Methods: Patients over 50 years of age with an Emergency Severity Index (ESI) level 3-5 presenting to an inner-city emergency department within DC were enrolled. All enrolled patients completed an initial survey addressing patient demographics, health insurance status, usual source of care, cancer screening history, and selfidentified barriers to receiving recommended colorectal cancer screening. Patients with DC-residence and out-of-date (expired) colorectal cancer screening were offered fecal occult blood testing (FOBT) to complete at home in accordance with the USPSTF screening guidelines. Patients offered screening were later contacted to identify rates of completed screening. All patients with positive FOBT results were contacted by a patient navigator to facilitate recommended follow-up. Results: Eight hundred fifty-eight patients were enrolled, of which 409 (47.7%) had expired or no prior cancer screening. Patients with expired or no prior screening were more often uninsured or underinsured than those with up-to-date screening (40.1% versus 22.3%, P⫽1.65E-8), and more often identified an emergency department or no usual source for health care than those with up-to-date screening (29.6% versus 16.0%, P⫽0.0000027). Among patients with expired or no prior screening, those who were uninsured or underinsured more often identified lack of awareness regarding colorectal cancer and recommended screening as a barrier to screening than did those with commercial insurance or Medicare (40.2% versus 25.5%, P⫽0.0027). Cost, underinsurance and no usual source of care were rarely self-identified as barriers to receiving screening for all groups (1.7%, 1.5% and 4.2%). Of 293 DC residents who received colorectal cancer screening through the ED, 105 were reached for follow-up (35.8%); 31 (29.5%) completed the provided FOBT screening, 12 (11.4%) reported recently scheduled screening through their primary care provider, and 47 (44.8%) reported intention to complete the provided FOBT screening. Conclusion: Uninsurance, underinsurance and absence of an appropriate usual source of care are associated with lower rates of recommended colorectal cancer screening. However, patients most often self-report health literacy as a barrier to receiving screening. Effective approaches to increasing colorectal cancer screening must include programs to improve health literacy regarding colorectal cancer. Programs offered through emergency departments can provide an effective means to both improve screening and increase health literacy.
459
Cardiopulmonary Resuscitation Prescription Program: A Prospective Randomized Pilot Study
Greenberg MR, Barr Jr GC, Rupp V, Patel N, Weaver K, Hamilton K, Reed III J/ Lehigh Valley Hospital and Health Network, Allentown, PA
Study Objective: The American Heart Association wants to increase the number of citizens who know how to perform cardiopulmonary resuscitation (CPR). It is unknown whether prescribed advice to patients to learn CPR is effective. We sought to determine if patients with, or at risk for, heart disease and their families were more
Volume , . : September