Northwestern University Feinberg School of Medicine

Department of Emergency Medicine

Research Publications

Following is information on recent faculty publications. For more information on our research, see the Emergency Medicine section on Northwestern Scholars.

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In-hospital Deaths among Adults with Community-Acquired Pneumonia.

Waterer GW, Self WH, Courtney DM, Grijalva CG, Balk RA, Girard TD, Fakhran SS, Trabue C, McNabb P, Anderson EJ, Williams DJ, Bramley AM, Jain S, Edwards KM, Wunderink RG

Chest. 2018 May 30. pii: S0012-3692(18)30801-8. doi: 10.1016/j.chest.2018.05.021. [Epub ahead of print]

INTRODUCTION:

Adults hospitalized with community-acquired pneumonia are at high risk for short-term mortality. However, it is unclear whether improvements in in-hospital pneumonia care could substantially lower this risk. We extensively reviewed all in-hospital deaths in a large prospective CAP study to assess the cause of each death and assess the extent of potentially preventable mortality.

METHODS:

We enrolled adults hospitalized with CAP at five tertiary-care hospitals in the United States. Five physician investigators reviewed the medical record and study database for each patient who died to identify the cause of death, the contribution of CAP to death, and any preventable factors potentially contributing to death.

RESULTS:

Among 2,320 enrolled patients, 52 (2.2%) died during initial hospitalization. Among these 52 patients, 33 (63.4%) were ≥65 years old, and 32 (61.5%) had ≥2 chronic comorbidities. CAP was judged to be the direct cause of death in 27 (51.9%) patients. Ten (19.2%) patients had do-not-resuscitate orders prior to admission. Four patients were identified in whom a lapse in quality of care potentially contributed to death; pre-existing end-of-life limitations were present in two of these patients. Two patients seeking full medical care experienced a lapse in in-hospital quality of pneumonia care that potentially contributed to death.

CONCLUSION:

In this study of adults with CAP at tertiary-care hospitals with a low mortality rate, most in-hospital deaths did not appear to be preventable with improvements in in-hospital pneumonia care. Pre-existing end-of-life limitations in care, advanced age, and high comorbidity burden were common among those who died.

Discrepancy Between Clinician Gestalt and Subjective Component of the Wells Score in the Evaluation of Pulmonary Embolism.

Akhter M, Kline J, Kannan V, Courtney DM, Kabrhel C

Ann Emerg Med. 2018 Jun;71(6):796-798. doi: 10.1016/j.annemergmed.2018.01.048.

Practice Facilitators' and Leaders' Perspectives on a Facilitated Quality Improvement Program.

McHugh M, Brown T, Liss DT, Walunas TL, Persell SD

Ann Fam Med. 2018 Apr;16(Suppl 1):S65-S71. doi: 10.1370/afm.2197.

PURPOSE:

Practice facilitation is a promising approach to helping practices implement quality improvements. Our purpose was to describe practice facilitators' and practice leaders' perspectives on implementation of a practice facilitator-supported quality improvement program and describe where their perspectives aligned and diverged.

METHODS:

We conducted interviews with practice leaders and practice facilitators who participated in a program that included 35 improvement strategies aimed at the ABCS of heart health (aspirin use in high-risk individuals, blood pressure control, cholesterol management, and smoking cessation). Rapid qualitative analysis was used to collect, organize, and analyze the data.

RESULTS:

We interviewed 17 of the 33 eligible practice leaders, and the 10 practice facilitators assigned to those practices. Practice leaders and practice facilitators both reported value in the program's ability to bring needed, high-quality resources to practices. Practice leaders appreciated being able to set the schedule for facilitation and select among the 35 interventions. According to practice facilitators, however, relying on practice leaders to set the pace of the intervention resulted in a lower level of program intensity than intended. Practice leaders preferred targeted assistance, particularly electronic health record documentation guidance and linkages to state smoking cessation programs. Practice facilitators reported that the easiest interventions were those that did not alter care practices.

CONCLUSIONS:

The dual perspectives of practice leaders and practice facilitators provide a more holistic picture of enablers and barriers to program implementation. There may be greater opportunities to assist small practices through simple, targeted practice facilitator-supported efforts rather than larger, comprehensive quality improvement projects.

A Multicenter Collaboration for Simulation-Based Assessment of ACGME Milestones in Emergency Medicine.

Salzman DH, Watts H, Williamson K, Sergel M, Dobiesz V, DeGarmo N, Vora S, Sharp LJ, Wang EE, Gisondi MA

Simul Healthc. 2018 Apr 3. doi: 10.1097/SIH.0000000000000291. [Epub ahead of print]

In 2014, the six allopathic emergency medicine (EM) residency programs in Chicago established an annual, citywide, simulation-based assessment of all postgraduate year 2 EM residents. The cases and corresponding assessment tools were designed by the simulation directors from each of the participating sites. All assessment tools include critical actions that map directly to numerous EM milestones in 11 different subcompetencies. The 2-hour assessments provide opportunities for residents to lead resuscitations of critically ill patients and demonstrate procedural skills, using mannequins and task trainers respectively. More than 80 residents participate annually and their assessment experiences are essentially identical across testing sites. The assessments are completed electronically and comparative performance data are immediately available to program directors.

Inpatient Trauma Mortality after Implementation of the Affordable Care Act in Illinois.

Weygandt PL, Dresden SM, Powell ES, Feinglass J

West J Emerg Med. 2018 Mar;19(2):301-310. doi: 10.5811/westjem.2017.10.34949. Epub 2018 Feb 19.

Introduction:

Illinois hospitals have experienced a marked decrease in the number of uninsured patients after implementation of the Affordable Care Act (ACA). However, the full impact of health insurance expansion on trauma mortality is still unknown. The objective of this study was to determine the impact of ACA insurance expansion on trauma patients hospitalized in Illinois.

Methods:

We performed a retrospective cohort study of 87,001 trauma inpatients from third quarter 2010 through second quarter 2015, which spans the implementation of the ACA in Illinois. We examined the effects of insurance expansion on trauma mortality using multivariable Poisson regression.

Results:

There was no significant difference in mortality comparing the post-ACA period to the pre-ACA period incident rate ratio (IRR)=1.05 (95% confidence interval [CI] [0.93-1.17]). However, mortality was significantly higher among the uninsured in the post-ACA period when compared with the pre-ACA uninsured population IRR=1.46 (95% CI [1.14-1.88]).

Conclusion:

While the ACA has reduced the number of uninsured trauma patients in Illinois, we found no significant decrease in inpatient trauma mortality. However, the group that remains uninsured after ACA implementation appears to be particularly vulnerable. This group should be studied in order to reduce disparate outcomes after trauma.

An institution-wide approach to submission, review, and funding of simulation-based curricula.

Salzman DH, Wayne DB, Eppich WJ, Hungness ES, Adler MD, Park CS, Barsness KA, McGaghie WC, Barsuk JH

Adv Simul (Lond). 2017 Jun 15;2:9. doi: 10.1186/s41077-017-0042-5. eCollection 2017.

This article describes the development, implementation, and modification of an institutional process to evaluate and fund graduate medical education simulation curricula. The goals of this activity were to (a) establish a standardized mechanism for proposal submission and evaluation, (b) identify simulation-based medical education (SBME) curricula that would benefit from mentored improvement before implementation, and (c) ensure that funding decisions were fair and defensible. Our intent was to develop a process that was grounded in sound educational principles, allowed for efficient administrative oversight, ensured approved courses were high quality, encouraged simulation education research and scholarship, and provided opportunities for medical specialties that had not previously used SBME to receive mentoring and faculty development.

National Practice Patterns of Obtaining Informed Consent for Stroke Thrombolysis.

Mendelson SJ, Courtney DM, Gordon EJ, Thomas LF, Holl JL, Prabhakaran S

Stroke. 2018 Mar;49(3):765-767. doi: 10.1161/STROKEAHA.117.020474. Epub 2018 Feb 12.

BACKGROUND AND PURPOSE:

No standard approach to obtaining informed consent for stroke thrombolysis with tPA (tissue-type plasminogen activator) currently exists. We aimed to assess current nationwide practice patterns of obtaining informed consent for tPA.

METHODS:

An online survey was developed and distributed by e-mail to clinicians involved in acute stroke care. Multivariable logistic regression analyses were performed to determine independent factors contributing to always obtaining informed consent for tPA.

RESULTS:

Among 268 respondents, 36.7% reported always obtaining informed consent and 51.8% reported the informed consent process caused treatment delays. Being an emergency medicine physician (odds ratio, 5.8; 95% confidence interval, 2.9-11.5) and practicing at a nonacademic medical center (odds ratio, 2.1; 95% confidence interval, 1.0-4.3) were independently associated with always requiring informed consent. The most commonly cited cause of delay was waiting for a patient's family to reach consensus about treatment.

CONCLUSIONS:

Most clinicians always or often require informed consent for stroke thrombolysis. Future research should focus on standardizing content and delivery of tPA information to reduce delays.

Predictors of Post-discharge Mortality Among Patients Hospitalized for Acute Heart Failure.

Chioncel O, Collins SP, Greene SJ, Pang PS, Ambrosy AP, Antohi EL, Vaduganathan M, Butler J, Gheorghiade M

Card Fail Rev. 2017 Nov;3(2):122-129. doi: 10.15420/cfr.2017:12:1.

Acute Heart Failure (AHF) is a " multi-event disease" and hospitalisation is a critical event in the clinical course of HF. Despite relatively rapid relief of symptoms, hospitalisation for AHF is followed by an increased risk of death and re-hospitalisation. In AHF, risk stratification from clinically available data is increasingly important in evaluating long-term prognosis. From the perspective of patients, information on the risk of mortality and re-hospitalisation would be helpful in providing patients with insight into their disease. From the perspective of care providers, it may facilitate management decisions, such as who needs to be admitted and to what level of care (i.e. floor, step-down, ICU). Furthermore, risk-stratification may help identify patients who need to be evaluated for advanced HF therapies (i.e. left-ventricle assistance device or transplant or palliative care), and patients who need early a post-discharge follow-up plan. Finally, risk stratification will allow for more robust efforts to identify among risk markers the true targets for therapies that may direct treatment strategies to selected high-risk patients. Further clinical research will be needed to evaluate if appropriate risk stratification of patients could improve clinical outcome and resources allocation.

Pneumococcal Community-Acquired Pneumonia Detected by Serotype-Specific Urinary Antigen Detection Assays.

Wunderink RG, Self WH, Anderson EJ, Balk R, Fakhran S, Courtney DM, Qi C, Williams DJ, Zhu Y, Whitney CG, Moore MR, Bramley A, Jain S, Edwards KM, Grijalva CG

Clin Infect Dis. 2018 May 2;66(10):1504-1510. doi: 10.1093/cid/cix1066.

Background:

Streptococcus pneumoniae is considered the leading bacterial cause of pneumonia in adults. Yet, it was not commonly detected by traditional culture-based and conventional urinary testing in a recent multicenter etiology study of adults hospitalized with community-acquired pneumonia (CAP). We used novel serotype-specific urinary antigen detection (SSUAD) assays to determine whether pneumococcal cases were missed by traditional testing.

Methods:

We studied adult patients hospitalized with CAP at 5 hospitals in Chicago and Nashville (2010-2012) and enrolled in the Etiology of Pneumonia in the Community (EPIC) study. Traditional diagnostic testing included blood and sputum cultures and conventional urine antigen detection (ie, BinaxNOW). We applied SSUAD assays that target serotypes included in the 13-valent pneumococcal conjugate vaccine (PCV13) to stored residual urine specimens.

Results:

Among 1736 patients with SSUAD and ≥1 traditional pneumococcal test performed, we identified 169 (9.7%) cases of pneumococcal CAP. Traditional tests identified 93 (5.4%) and SSUAD identified 76 (4.4%) additional cases. Among 14 PCV13-serotype cases identified by culture, SSUAD correctly identified the same serotype in all of them. Cases identified by SSUAD vs traditional tests were similar in most demographic and clinical characteristics, although disease severity and procalcitonin concentration were highest among those with positive blood cultures. The proportion of PCV13 serotype cases identified was not significantly different between the first and second July-June study periods (6.4% vs 4.0%).

Conclusions:

Although restricted to the detection of only 13 serotypes, SSUAD testing substantially increased the detection of pneumococcal pneumonia among adults hospitalized with CAP.

Geriatric Emergency Department Innovations: Transitional Care Nurses and Hospital Use.

Hwang U, Dresden SM, Rosenberg MS, Garrido MM, Loo G, Sze J, Gravenor S, Courtney DM, Kang R, Zhu CW, Vargas-Torres C, Grudzen CR, Richardson LD, GEDI WISE Investigators

J Am Geriatr Soc. 2018 Mar;66(3):459-466. doi: 10.1111/jgs.15235. Epub 2018 Jan 10.

OBJECTIVES:

To examine the effect of an emergency department (ED)-based transitional care nurse (TCN) on hospital use.

DESIGN:

Prospective observational cohort.

SETTING:

Three U.S. (NY, IL, NJ) EDs from January 1, 2013, to June 30, 2015.

PARTICIPANTS:

Individuals aged 65 and older in the ED (N = 57,287).

INTERVENTION:

The intervention was first TCN contact. Controls never saw a TCN during the study period.

MEASUREMENTS:

We examined sociodemographic and clinical characteristics associated with TCN use and outcomes. The primary outcome was inpatient admission during the index ED visit (admission on Day 0). Secondary outcomes included cumulative 30-day admission (any admission on Days 0-30) and 72-hour ED revisits.

RESULTS:

A TCN saw 5,930 (10%) individuals, 42% of whom were admitted. After accounting for observed selection bias using entropy balance, results showed that when compared to controls, TCN contact was associated with lower risk of admission (site 1: -9.9% risk of inpatient admission, 95% confidence interval (CI) = -12.3% to -7.5%; site 2: -16.5%, 95% CI = -18.7% to -14.2%; site 3: -4.7%, 95% CI = -7.5% to -2.0%). Participants with TCN contact had greater risk of a 72-hour ED revisit at two sites (site 1: 1.5%, 95% CI = 0.7-2.3%; site 2: 1.4%, 95% CI = 0.7-2.1%). Risk of any admission within 30 days of the index ED visit also remained lower for TCN patients at both these sites (site 1: -7.8%, 95% CI = -10.3% to -5.3%; site 2: -13.8%, 95% CI = -16.1% to -11.6%).

CONCLUSION:

Targeted evaluation by geriatric ED transitions of care staff may be an effective delivery innovation to reduce risk of inpatient admission.

When good times go bad: managing 'legal high' complications in the emergency department.

Caffrey CR, Lank PM

Open Access Emerg Med. 2017 Dec 20;10:9-23. doi: 10.2147/OAEM.S120120. eCollection 2018.

Patients can use numerous drugs that exist outside of existing regulatory statutes in order to get "legal highs." Legal psychoactive substances represent a challenge to the emergency medicine physician due to the sheer number of available agents, their multiple toxidromes and presentations, their escaping traditional methods of analysis, and the reluctance of patients to divulge their use of these agents. This paper endeavors to cover a wide variety of "legal highs," or uncontrolled psychoactive substances that may have abuse potential and may result in serious toxicity. These agents include not only some novel psychoactive substances aka "designer drugs," but also a wide variety of over-the-counter medications, herbal supplements, and even a household culinary spice. The care of patients in the emergency department who have used "legal high" substances is challenging. Patients may misunderstand the substance they have been exposed to, there are rarely any readily available laboratory confirmatory tests for these substances, and the exact substances being abused may change on a near-daily basis. This review will attempt to group legal agents into expected toxidromes and discuss associated common clinical manifestations and management. A focus on aggressive symptom-based supportive care as well as management of end-organ dysfunction is the mainstay of treatment for these patients in the emergency department.

Corporate Philanthropy Toward Community Health Improvement in Manufacturing Communities.

McHugh M, Farley D, Maechling CR, Dunlop DD, French DD, Holl JL

J Community Health. 2018 Jun;43(3):560-565. doi: 10.1007/s10900-017-0452-2.

Virtually all large employers engage in corporate philanthropy, but little is known about the extent to which it is directed toward improving community health. We conducted in-depth interviews with leaders of corporate philanthropy from 13 of the largest manufacturing companies in the US to understand how giving decisions were made, the extent to which funding was directed towards improving community health, and whether companies coordinate with local public health agencies. We found that corporate giving was sizable and directed towards communities in which the manufacturers have a large presence. Giving was aligned with the social determinants of health (i.e., aimed at improving economic stability, the neighborhood and physical environment, education, food security and nutrition, the community and social context, and the health care system). However, improving public health was not often cited as a goal of corporate giving, and coordination with public health agencies was limited. Our results suggest that there may be opportunities for public health agencies to help guide corporate philanthropy, particularly by sharing community-level data and offering their measurement and evaluation expertise.

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department.

Lin MP, Probst MA, Puskarich MA, Dehon E, Kuehl DR, Wang RC, Hess EP, Butler K, Runyon MS, Wang H, Courtney DM, Muckley B, Hobgood CD, Hall CL, Kline JA

Patient Educ Couns. 2018 Apr;101(4):717-722. doi: 10.1016/j.pec.2017.11.012. Epub 2017 Nov 22.

OBJECTIVE:

We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging.

METHODS:

Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning.

RESULTS:

We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%).

CONCLUSION:

The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing.

PRACTICE IMPLICATIONS:

Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.

Acute Dyspnea and Decompensated Heart Failure.

Pang PS, Collins SP, Gheorghiade M, Butler J

Cardiol Clin. 2018 Feb;36(1):63-72. doi: 10.1016/j.ccl.2017.09.003.

The majority of patients hospitalized with acute heart failure (AHF) initially present to the emergency department (ED). Correct diagnosis followed by prompt treatment ensures optimal outcomes. Paradoxically, identification of high risk is not the unmet need, given nearly all ED AHF patients are hospitalized; rather, it is identification of low-risk. Currently, no risk-stratification instrument can be universally recommended to safely discharge ED patients. With the exception of diagnosis, management recommendations are largely expert opinion, informed by existing evidence and tradition. In the absence of robust evidence, we propose a framework for management to guide the busy clinician.

Opioid vs Nonopioid Acute Pain Management in the Emergency Department.

Kyriacou DN

JAMA. 2017 Nov 7;318(17):1655-1656. doi: 10.1001/jama.2017.16725.

Impact of Discharge Anticoagulation Education by Emergency Department Pharmacists at a Tertiary Academic Medical Center.

Zdyb EG, Courtney DM, Malik S, Schmidt MJ, Lyden AE

J Emerg Med. 2017 Dec;53(6):896-903. doi: 10.1016/j.jemermed.2017.06.008. Epub 2017 Sep 21.

BACKGROUND:

Although pharmacists commonly provide patient education and help manage high-risk anticoagulant medications in inpatient and outpatient settings, the evidence for these interventions in the emergency department (ED) is less established, especially in the era of direct-acting oral anticoagulants. In 2013, a formal program was initiated whereby patients discharged with a new prescription for any anticoagulant receive education from an ED pharmacist when on-site. In addition, they received follow-up phone calls from an ED pharmacist within 72 hours of discharge.

OBJECTIVE:

We sought to identify the impact of pharmacist education, defined as the need for intervention on callback, versus physician and nursing-driven discharge measures on patient understanding and appropriate use of anticoagulant medications.

METHODS:

A single-center retrospective analysis included patients discharged from the ED between May 2013 and May 2016 with a new anticoagulant prescription. Electronic callback records were reviewed to assess patients' adherence and understanding of discharge instructions as well as for an anticoagulant-related hospital readmission within 90 days.

RESULTS:

One hundred seventy-four patients were evaluated in a per protocol analysis. Patients who did not receive pharmacist education prior to discharge required an increased need for intervention during callback versus those who did (36.4% vs. 12.9%, p = 0.0005) related to adherence, inappropriate administration, and continued use of interacting medications or supplements, among other concerns. In addition, patients who had not received pharmacist counseling were more likely to be readmitted to a hospital or return to the ED within 90 days after their initial visit for an anticoagulation-related problem versus patients who had (12.12% vs. 1.85%, p = 0.0069).

CONCLUSION:

Discharge education by ED pharmacists leads to improved patient understanding and appropriate use of anticoagulants.

What Did You Google? Describing Online Health Information Search Patterns of ED patients and Their Relationship with Final Diagnoses.

McCarthy DM, Scott GN, Courtney DM, Czerniak A, Aldeen AZ, Gravenor S, Dresden SM

West J Emerg Med. 2017 Aug;18(5):928-936. doi: 10.5811/westjem.2017.5.34108. Epub 2017 Jul 14.

INTRODUCTION:

Emergency department (ED) patients' Internet search terms prior to arrival have not been well characterized. The objective of this analysis was to characterize the Internet search terms patients used prior to ED arrival and their relationship to final diagnoses.

METHODS:

We collected data via survey; participants listed Internet search terms used. Terms were classified into categories: symptom, specific diagnosis, treatment options, anatomy questions, processes of care/physicians, or "other." We categorized each discharge diagnosis as either symptom-based or formal diagnosis. The relationship between the search term and final diagnosis was assigned to one of four categories of search/diagnosis combinations (symptom search/symptom diagnosis, symptom search/formal diagnosis, diagnosis search/symptom diagnosis, diagnosis search/formal diagnosis), representing different "trajectories."

RESULTS:

We approached 889 patients; 723 (81.3%) participated. Of these, 177 (24.5%) used the Internet prior to ED presentation; however, seven had incomplete data (N=170). Mean age was 47 years (standard deviation 18.2); 58.6% were female and 65.7% white. We found that 61.7% searched symptoms and 40.6% searched a specific diagnosis. Most patients received discharge diagnoses of equal specificity as their search terms (34% flat trajectory-symptoms and 34% flat trajectory-diagnosis). Ten percent searched for a diagnosis by name but received a symptom-based discharge diagnosis with less specificity. In contrast, 22% searched for a symptom and received a detailed diagnosis. Among those who searched for a diagnosis by name (n=69) only 29% received the diagnosis that they had searched.

CONCLUSION:

The majority of patients used symptoms as the basis of their pre-ED presentation Internet search. When patients did search for specific diagnoses, only a minority searched for the diagnosis they eventually received.

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois.

Feinglass J, Cooper AJ, Rydland K, Powell ES, McHugh M, Kang R, Dresden SM

West J Emerg Med. 2017 Aug;18(5):811-820. doi: 10.5811/westjem.2017.5.34007. Epub 2017 Jul 17.

INTRODUCTION:

This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012-2013) pre-ACA period and a 24-month post-ACA (2014-2015) period across 88 socioeconomically diverse areas of Illinois.

METHODS:

We used annual American Community Survey estimates for 2012-2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18-64 residents. Over 12 million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents of each PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. We then estimated n=88 correlations between population insurance-status changes and changes in ED visit rates per 1,000 residents comparing the two years before and after ACA implementation.

RESULTS:

The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductions in uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment. Compared to 2012-2013, 2014-2015 average monthly ED visits by the uninsured dropped 42%, but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increases in Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollment was the only significant correlate of area change in total ED visits and explained a third of variation across the 88 PUMAs.

CONCLUSION:

ACA implementation in Illinois accelerated existing trends towards greater use of hospital ED care. It remains to be seen whether providing better access to primary and preventive care to the formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a part of continued, long-term growth. Monitoring ED use at the local level is critical to the success of new home- and community-based care coordination initiatives.

Effect of cervical cancer education and provider recommendation for screening on screening rates: A systematic review and meta-analysis.

Musa J, Achenbach CJ, O'Dwyer LC, Evans CT, McHugh M, Hou L, Simon MA, Murphy RL, Jordan N

PLoS One. 2017 Sep 5;12(9):e0183924. doi: 10.1371/journal.pone.0183924. eCollection 2017.

BACKGROUND:

Although cervical cancer is largely preventable through screening, detection and treatment of precancerous abnormalities, it remains one of the top causes of cancer-related morbidity and mortality globally.

OBJECTIVES:

The objective of this systematic review is to understand the evidence of the effect of cervical cancer education compared to control conditions on cervical cancer screening rates in eligible women population at risk of cervical cancer. We also sought to understand the effect of provider recommendations for screening to eligible women on cervical cancer screening (CCS) rates compared to control conditions in eligible women population at risk of cervical cancer.

METHODS:

We used the PICO (Problem or Population, Interventions, Comparison and Outcome) framework as described in the Cochrane Collaboration Handbook to develop our search strategy. The details of our search strategy has been described in our systematic review protocol published in the International Prospective Register of systematic reviews (PROSPERO). The protocol registration number is CRD42016045605 available at: http://www.crd.york.ac.uk/prospero/display_record.asp?src=trip&ID=CRD42016045605. The search string was used in Pubmed, Embase, Cochrane Systematic Reviews and Cochrane CENTRAL register of controlled trials to retrieve study reports that were screened for inclusion in this review. Our data synthesis and reporting was guided by the Preferred Reporting Items for Systematic Reviews and Meta-analysis (PRISMA). We did a qualitative synthesis of evidence and, where appropriate, individual study effects were pooled in meta-analyses using RevMan 5.3 Review Manager. The Higgins I2 was used to assess for heterogeneity in studies pooled together for overall summary effects. We did assessment of risk of bias of individual studies included and assessed risk of publication bias across studies pooled together in meta-analysis by Funnel plot.

RESULTS:

Out of 3072 study reports screened, 28 articles were found to be eligible for inclusion in qualitative synthesis (5 of which were included in meta-analysis of educational interventions and 8 combined in meta-analysis of HPV self-sampling interventions), while 45 were excluded for various reasons. The use of theory-based educational interventions significantly increased CCS rates by more than double (OR, 2.46, 95% CI: 1.88, 3.21). Additionally, offering women the option of self-sampling for Human Papillomavirus (HPV) testing increased CCS rates by nearly 2-fold (OR = 1.71, 95% CI: 1.32, 2.22). We also found that invitation letters alone (or with a follow up phone contact), making an appointment, and sending reminders to patients who are due or overdue for screening had a significant effect on improving participation and CCS rates in populations at risk.

CONCLUSION:

Our findings supports the implementation of theory-based cervical cancer educational interventions to increase women's participation in cervical cancer screening programs, particularly when targeting communities with low literacy levels. Additionally, cervical cancer screening programs should consider the option of offering women the opportunity for self-sample collection particularly when such women have not responded to previous screening invitation or reminder letters for Pap smear collection as a method of screening.

Trends in Adult Cancer-Related Emergency Department Utilization: An Analysis of Data From the Nationwide Emergency Department Sample.

Rivera DR, Gallicchio L, Brown J, Liu B, Kyriacou DN, Shelburne N

JAMA Oncol. 2017 Oct 12;3(10):e172450. doi: 10.1001/jamaoncol.2017.2450. Epub 2017 Oct 12.

Importance:

The emergency department (ED) is used to manage cancer-related complications among the 15.5 million people living with cancer in the United States. However, ED utilization patterns by the population of US adults with cancer have not been previously evaluated or described in published literature.

Objective:

To estimate the proportion of US ED visits made by adults with a cancer diagnosis, understand the clinical presentation of adult patients with cancer in the ED, and examine factors related to inpatient admission within this population.

Design, Setting, and Participants:

Nationally representative data comprised of 7 survey cycles (January 2006-December 2012) from the Nationwide Emergency Department Sample were analyzed. Identification of adult (age ≥18 years) cancer-related visits was based on Clinical Classifications Software diagnoses documented during the ED visit. Weighted frequencies and proportions of ED visits among adult patients with cancer by demographic, geographic, and clinical characteristics were calculated. Weighted multivariable logistic regression was used to examine the associations between inpatient admission and key demographic and clinical variables for adult cancer-related ED visits.

Main Outcomes and Measures:

Adult cancer-related ED utilization patterns; identification of primary reason for ED visit; patient-related factors associated with inpatient admission from the ED.

Results:

Among an estimated 696 million weighted adult ED visits from January 2006 to December 2012, 29.5 million (4.2%) were made by a patient with a cancer diagnosis. The most common cancers associated with an ED visit were breast, prostate, and lung cancer, and most common primary reasons for visit were pneumonia (4.5%), nonspecific chest pain (3.7%), and urinary tract infection (3.2%). Adult cancer-related ED visits resulted in inpatient admissions more frequently (59.7%) than non-cancer-related visits (16.3%) (P < .001). Septicemia (odds ratio [OR], 91.2; 95% CI, 81.2-102.3) and intestinal obstruction (OR, 10.94; 95% CI, 10.6-11.4) were associated with the highest odds of inpatient admission.

Conclusions and Relevance:

Consistent with national prevalence statistics among adults, breast, prostate, and lung cancer were the most common cancer diagnoses presenting to the ED. Pneumonia was the most common reason for adult cancer-related ED visits with an associated high inpatient admission rate. This analysis highlights cancer-specific ED clinical presentations and the opportunity to inform patient and system-directed prevention and management strategies.