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Racial and economic composition of emergency department visitors and privacy values: Are first-time visitors different from repeat visitors?
RESEARCH FORUM ABSTRACTS
Methods: The multiethnic cohort consists of 35,102 blacks and 47,078 Latinos in Los Angeles, CA. Subjects in the cohort were mailed a first questionnaire asking whether they had a history of hypertension and had taken or were taking antihypertension medications. A second questionnaire was mailed in which patients were queried about their hypertension status. Finally, during biologic specimen collection, each subject was requested to produce actual current medications of all types that were recorded by name (generic or brand), dose, and frequency. We reviewed a random sample of 200 blacks and 200 Latinos and compared their responses to the criterion standard of hypertension as defined by the documented presence of an antihypertension medication on home visit. Results: A single ‘‘Y’’ or ‘‘N’’ on the first questionnaire was associated with a PPV of self-reported hypertension of 91% and a NPV of 44% for blacks and a PPV of 79% and NPV of 56% for Latinos (390 subjects). After the addition of the second questionnaire, 3 ‘‘Y’’ or 3 ‘‘N’’ led to a PPV of 94% and a NPV of 59% in blacks and a PPV of 98% and NPV of 69% in Latinos (N=278; 145 blacks and 133 Latinos). The NPV was lower mostly because individuals did not classify themselves as hypertensive when taking diuretics, a-adrenergic blockers, or digoxin. Conclusion: Increasing the number of items needed for a self-report of chronic hypertension allowed better PPV and NPV in this cohort, especially in the Latino population. These results may underrepresent those with undiagnosed hypertension but do allow identification of those with confirmed disease.
371
The Nonrandom Occurrence of Visits to the Emergency Department
Graber MA, Dly JW, Dawson JD/University of Iowa, Iowa City, IA Study objectives: We determine whether variation in the frequency of emergency department (ED) visits is beyond what would be expected by chance after adjusting for known confounders such as calendar and weather variables. Methods: The Poisson goodness-of-fit test was used to determine whether emergency visits in a Midwestern teaching hospital occurred randomly over time. Total visits, as well as selected diagnoses, were analyzed. Final diagnosis was determined using the physicians’ final chart diagnosis, which was assigned an International Classification of Diseases, Ninth Revision code by one of the investigators. Data on appendicitis were obtained for 6 years to check for randomness of distribution; only cases of operatively confirmed appendicitis were included in the analysis. We also looked at the distribution of specific diagnoses that might be expected to occur randomly (eg, atrial fibrillation, urinary retention, headache). Multivariable Poisson regression was used to control for calendar and weather variables. Autocorrelation coefficients were used to detect ‘‘contagion’’ from one period to the next. Results: There were 24,100 ED visits in 1998, with 2,054 distinct final diagnoses. Forty-six visits were laboratory tests only, and 5 records were lacking a final diagnosis. The most common diagnoses were ‘‘abdominal pain’’ (643 visits), upper respiratory infection (548 visits), and open wound of finger (544 visits). Overall, visits did not occur randomly, even after controlling for time of day, day of week, academic calendar, season, and weather variables (P\.001). Visits were more common on Sundays, in the fall, and on warm days. Of 32 diagnoses we predicted would occur randomly (eg, have a Poisson distribution), 29 did so, including appendicitis, congestive heart failure, chest pain, venous thrombosis, reflux esophagitis, intestinal obstruction, gastrointestinal foreign body, gastrointestinal hemorrhage, hypertension, right-lower-quadrant abdominal pain, subarachnoid hemorrhage, transient ischemic attack, atrial fibrillation, angina, cerebral hemorrhage, constipation, seizure, intermediate coronary syndrome, dizziness, hematuria, kidney stone, migraine, acute pancreatitis, rectal hemorrhage, blood in stool, syncope, tension headache, Tietze syndrome, and urticaria. The other 3, cerebrovascular accident, migraine headache, and back pain, were not randomly distributed. Conclusion: ED visits did not occur randomly over time. Most diagnoses that would be expected to occur randomly did so, but a few exhibited nonrandom variation. ED staff should be alert to nonrandom occurrence of disease as a mechanism for finding unsuspected causes or associations of different diseases.
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
372
Racial and Economic Composition of Emergency Department Visitors and Privacy Values: Are First-Time Visitors Different From Repeat Visitors?
Nelson BP, Hurwitz S, Hutson H/Mount Sinai School of Medicine, New York, NY; Brigham and Women’s Hospital, Boston, MA Study objectives: Studies of patient satisfaction after an emergency department (ED) visit often focus on methods of improving willingness to return for further care or postvisit satisfaction measures. However, up to half of ED visits are by first-time visitors, and such measures are not applicable to their initial appearance in the ED. Thus, interventions targeted toward improved satisfaction may not be relevant in addressing the preferences of a large segment of the ED population. This study is undertaken to determine the factors first-time visitors value most when choosing an ED, compared with repeat visitors. In addition, demographic factors affecting ED utilization between these groups were assessed. Methods: An observational, prospective survey at an urban Level I trauma center (annual census 64,000) was undertaken. A convenience sample of 346 patients visiting the ED during July and August 2003 was surveyed. Demographics on age, sex, race, insurance status, primary care access, and income were collected. Before their ED encounter, patients quantified the importance of the following aspects of their care a priori from 1 (not important) to 5 (very important): privacy, attentive nurse, diagnosis, informed of delays, wait time, pain relief, trust in providers, and having concerns addressed. These categories have previously been linked to patient satisfaction. A subset of first-time visitors was contacted several weeks after their initial visit to reevaluate their scores on these criteria. First-time visitors and repeat visitors were compared by Wilcoxon rank-sum test, with statistical significance criteria adjusted for multiple tests. Results: First-time visitors comprised 46% of total visits. Between first-time visitors and repeat visitors, median age was 37 years, 56% were women, 84% were insured, and 77% had a primary care physician. Repeat visitors averaged 2.7 visits per year (95% confidence interval [CI] 1.5 to 3.82) and reported lower median annual income than first-time visitors ($34,000 versus $60,000, P=.002). A greater proportion of repeat visitors were black (23% versus 13%, P=.02) and Hispanic (26% versus 13%, P=.007). Both groups valued ‘‘trust in providers’’ most (mean 4.5, 95% CI 4.4 to 4.7). First-time visitors valued privacy less than repeat visitors (3.8 versus 4.3, P=.0001) but were otherwise similar in their preferences. At follow-up, values of first-time visitors were no longer different from those of repeat visitors. Conclusion: Despite similarities in age, sex, and markers for access to care (insurance and a primary care physician), there are significant differences in the racial and economic backgrounds of repeat visitors compared with first-time visitors, which suggests that other factors contribute to increased utilization in this population. Although first-time visitors initially value privacy less than repeat visitors, this changed after experiencing a complete ED visit, which may reflect an initial naivete´ on the part of first-time visitors about what to expect during a typical ED stay. We conclude that commonly used categories to score patient satisfaction may be used in first-time visitor and repeat visitor populations.
373
Emergency Department Overcrowding: Patient Preference for Boarding Hallway Location
McNamee CS, Kolb J/University of Mississippi Medical Center, Jackson, MS Study objectives: An unfortunate nationwide hospital patient flow epidemic exists. Emergency department (ED) outflow of admitted patients awaiting inpatient ward room placement contributes to this problem. One solution recognized in New York that was withdrawn from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2004 Hospital Accreditation Manual (draft version) was for admitted patients to wait outside the ED. We wish to learn what location patients prefer. Methods: A convenience sample of patients from the ED and inpatient ward in a tertiary urban center completed a survey differentiating boarding location preference, the degree they objected to boarding in each location, and rationale for their preference. None of the patients were actually in the hallway at the survey. The study was conducted from January to March 2004 after an institutional review board–expedited review.
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Methods: The multiethnic cohort consists of 35,102 blacks and 47,078 Latinos in Los Angeles, CA. Subjects in the cohort were mailed a first questionnaire asking whether they had a history of hypertension and had taken or were taking antihypertension medications. A second questionnaire was mailed in which patients were queried about their hypertension status. Finally, during biologic specimen collection, each subject was requested to produce actual current medications of all types that were recorded by name (generic or brand), dose, and frequency. We reviewed a random sample of 200 blacks and 200 Latinos and compared their responses to the criterion standard of hypertension as defined by the documented presence of an antihypertension medication on home visit. Results: A single ‘‘Y’’ or ‘‘N’’ on the first questionnaire was associated with a PPV of self-reported hypertension of 91% and a NPV of 44% for blacks and a PPV of 79% and NPV of 56% for Latinos (390 subjects). After the addition of the second questionnaire, 3 ‘‘Y’’ or 3 ‘‘N’’ led to a PPV of 94% and a NPV of 59% in blacks and a PPV of 98% and NPV of 69% in Latinos (N=278; 145 blacks and 133 Latinos). The NPV was lower mostly because individuals did not classify themselves as hypertensive when taking diuretics, a-adrenergic blockers, or digoxin. Conclusion: Increasing the number of items needed for a self-report of chronic hypertension allowed better PPV and NPV in this cohort, especially in the Latino population. These results may underrepresent those with undiagnosed hypertension but do allow identification of those with confirmed disease.
371
The Nonrandom Occurrence of Visits to the Emergency Department
Graber MA, Dly JW, Dawson JD/University of Iowa, Iowa City, IA Study objectives: We determine whether variation in the frequency of emergency department (ED) visits is beyond what would be expected by chance after adjusting for known confounders such as calendar and weather variables. Methods: The Poisson goodness-of-fit test was used to determine whether emergency visits in a Midwestern teaching hospital occurred randomly over time. Total visits, as well as selected diagnoses, were analyzed. Final diagnosis was determined using the physicians’ final chart diagnosis, which was assigned an International Classification of Diseases, Ninth Revision code by one of the investigators. Data on appendicitis were obtained for 6 years to check for randomness of distribution; only cases of operatively confirmed appendicitis were included in the analysis. We also looked at the distribution of specific diagnoses that might be expected to occur randomly (eg, atrial fibrillation, urinary retention, headache). Multivariable Poisson regression was used to control for calendar and weather variables. Autocorrelation coefficients were used to detect ‘‘contagion’’ from one period to the next. Results: There were 24,100 ED visits in 1998, with 2,054 distinct final diagnoses. Forty-six visits were laboratory tests only, and 5 records were lacking a final diagnosis. The most common diagnoses were ‘‘abdominal pain’’ (643 visits), upper respiratory infection (548 visits), and open wound of finger (544 visits). Overall, visits did not occur randomly, even after controlling for time of day, day of week, academic calendar, season, and weather variables (P\.001). Visits were more common on Sundays, in the fall, and on warm days. Of 32 diagnoses we predicted would occur randomly (eg, have a Poisson distribution), 29 did so, including appendicitis, congestive heart failure, chest pain, venous thrombosis, reflux esophagitis, intestinal obstruction, gastrointestinal foreign body, gastrointestinal hemorrhage, hypertension, right-lower-quadrant abdominal pain, subarachnoid hemorrhage, transient ischemic attack, atrial fibrillation, angina, cerebral hemorrhage, constipation, seizure, intermediate coronary syndrome, dizziness, hematuria, kidney stone, migraine, acute pancreatitis, rectal hemorrhage, blood in stool, syncope, tension headache, Tietze syndrome, and urticaria. The other 3, cerebrovascular accident, migraine headache, and back pain, were not randomly distributed. Conclusion: ED visits did not occur randomly over time. Most diagnoses that would be expected to occur randomly did so, but a few exhibited nonrandom variation. ED staff should be alert to nonrandom occurrence of disease as a mechanism for finding unsuspected causes or associations of different diseases.
OCTOBER 2004
44:4
ANNALS OF EMERGENCY MEDICINE
372
Racial and Economic Composition of Emergency Department Visitors and Privacy Values: Are First-Time Visitors Different From Repeat Visitors?
Nelson BP, Hurwitz S, Hutson H/Mount Sinai School of Medicine, New York, NY; Brigham and Women’s Hospital, Boston, MA Study objectives: Studies of patient satisfaction after an emergency department (ED) visit often focus on methods of improving willingness to return for further care or postvisit satisfaction measures. However, up to half of ED visits are by first-time visitors, and such measures are not applicable to their initial appearance in the ED. Thus, interventions targeted toward improved satisfaction may not be relevant in addressing the preferences of a large segment of the ED population. This study is undertaken to determine the factors first-time visitors value most when choosing an ED, compared with repeat visitors. In addition, demographic factors affecting ED utilization between these groups were assessed. Methods: An observational, prospective survey at an urban Level I trauma center (annual census 64,000) was undertaken. A convenience sample of 346 patients visiting the ED during July and August 2003 was surveyed. Demographics on age, sex, race, insurance status, primary care access, and income were collected. Before their ED encounter, patients quantified the importance of the following aspects of their care a priori from 1 (not important) to 5 (very important): privacy, attentive nurse, diagnosis, informed of delays, wait time, pain relief, trust in providers, and having concerns addressed. These categories have previously been linked to patient satisfaction. A subset of first-time visitors was contacted several weeks after their initial visit to reevaluate their scores on these criteria. First-time visitors and repeat visitors were compared by Wilcoxon rank-sum test, with statistical significance criteria adjusted for multiple tests. Results: First-time visitors comprised 46% of total visits. Between first-time visitors and repeat visitors, median age was 37 years, 56% were women, 84% were insured, and 77% had a primary care physician. Repeat visitors averaged 2.7 visits per year (95% confidence interval [CI] 1.5 to 3.82) and reported lower median annual income than first-time visitors ($34,000 versus $60,000, P=.002). A greater proportion of repeat visitors were black (23% versus 13%, P=.02) and Hispanic (26% versus 13%, P=.007). Both groups valued ‘‘trust in providers’’ most (mean 4.5, 95% CI 4.4 to 4.7). First-time visitors valued privacy less than repeat visitors (3.8 versus 4.3, P=.0001) but were otherwise similar in their preferences. At follow-up, values of first-time visitors were no longer different from those of repeat visitors. Conclusion: Despite similarities in age, sex, and markers for access to care (insurance and a primary care physician), there are significant differences in the racial and economic backgrounds of repeat visitors compared with first-time visitors, which suggests that other factors contribute to increased utilization in this population. Although first-time visitors initially value privacy less than repeat visitors, this changed after experiencing a complete ED visit, which may reflect an initial naivete´ on the part of first-time visitors about what to expect during a typical ED stay. We conclude that commonly used categories to score patient satisfaction may be used in first-time visitor and repeat visitor populations.
373
Emergency Department Overcrowding: Patient Preference for Boarding Hallway Location
McNamee CS, Kolb J/University of Mississippi Medical Center, Jackson, MS Study objectives: An unfortunate nationwide hospital patient flow epidemic exists. Emergency department (ED) outflow of admitted patients awaiting inpatient ward room placement contributes to this problem. One solution recognized in New York that was withdrawn from the Joint Commission on Accreditation of Healthcare Organizations (JCAHO) 2004 Hospital Accreditation Manual (draft version) was for admitted patients to wait outside the ED. We wish to learn what location patients prefer. Methods: A convenience sample of patients from the ED and inpatient ward in a tertiary urban center completed a survey differentiating boarding location preference, the degree they objected to boarding in each location, and rationale for their preference. None of the patients were actually in the hallway at the survey. The study was conducted from January to March 2004 after an institutional review board–expedited review.
S 1 1 5