Impact of Mental Health and Substance Use Disorders on Emergency Department Visit Outcomes for HIV Patients

INTRODUCTION:

A disproportionate number of individuals with human immunodeficiency virus (HIV) have mental health and substance-use disorders (MHSUDs), and MHSUDs are significantly associated with their emergency department (ED) visits. With an increasing share of older adults among HIV patients, this study investigated the associations of MHSUDs with ED outcomes of HIV patients in four age groups: 21-34, 35-49, 50-64, and 65+ years.

METHODS:

We used the 2012 Nationwide Emergency Department Sample (NEDS) dataset (unweighted n=23,244,819 ED events by patients aged 21+, including 115,656 visits by patients with HIV). Multinomial and binary logistic regression analyses, with "treat-and-release" as the base outcome, were used to examine associations between ED outcomes and MHSUDs among visits that included a HIV diagnosis in each age group.

RESULTS:

• Mood and "other" mental disorders had small effects on ED-to-hospital admissions, as opposed to treat-and-release, in age groups younger than 65+ years, while suicide attempts had medium effects . 
• Cognitive disorders had medium-to-large effects on hospital admissions in all age groups and large effects on death in the 35-49 age groups. 
• Alcohol use disorders (AUDs) had small effects on hospital admission in all age groups. 
• Drug use disorders (DUDs) had small-to-medium effects on hospital admission. AUDs and DUDs were also significantly related to the risk of death, and DUDs had a small effect on the risk of discharge against medical advice in the 35-49 and 50-64 age groups.

CONCLUSION:

The high prevalence of MHSUDs and their significant roles in ED visit outcomes in patients with HIV provide support for integrated care for these patients outside the ED to reduce their ED visits and costly hospital admissions and institutional care that follows, especially for the increasing numbers of older adults with HIV.

Full article at:   http://goo.gl/3tf6pP

By:  Choi BY1, DiNitto DM2, Marti CN2, Choi NG2.

• 1Warren Alpert Medical School at Brown Univeristy and Rhode Island Hospital, Department of Emergency Medicine, Providence, Rhode Island.
• 2The University of Texas at Austin, School of Social Work, Austin, Texas. 
• West J Emerg Med. 2016 Mar;17(2):153-64. doi: 10.5811/westjem.2016.1.28310. Epub 2016 Mar 2.

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High-Impact Hepatitis C Virus Testing for Injection Drug Users in an Urban ED

OBJECTIVES:

We implemented the "High-Impact Testing for Injection Drug Users", or the "HIT IDU" initiative, an emergency physician (EP)-based hepatitis C virus (HCV) testing program. The objective of this study was to evaluate the outcomes of this clinical protocol.

METHODS:

This was a prospective observational pilot study. The HIT IDU initiative encouraged EPs to integrate targeted HCV testing into care, with an emphasis on screening all people who inject drugs (PWID). Physicians selected the primary indication for HCV testing from a drop-down menu integrated into the electronic ordering process. The primary outcome was the absolute number and overall proportion of EP-based HCV antibody positive tests, further stratified by the indication for testing.

RESULTS:

Over the 3-month study period, 14,253 unique patients were evaluated, and EPs tested 155 patients for HCV (1.1%; 95% confidence interval [CI], 0.9%-1.2%), of which 40 (26%, 95% CI, 19%-33%) were HCV antibody positive. The proportion of HCV antibody positivity by testing indication was as follows: PWID 47% (34/73; 95% CI, 35%-59%), patient requested test 10% (4/40; 95% CI, 3%-24%), confirm patient report 67% (2/3; 95% CI, 9%-99%), liver disease of uncertain etiology 0% (0/3; 95% CI, 0%-71%), and other 0% (0/36; 95% CI, 0%-10%). There were 22 patients chronically infected, 19 had a follow-up appointment arranged, 3 attended their follow-up appointment, and 1 patient was treated at 1 year of follow-up.

CONCLUSIONS:

Although the overall number of EP-based HCV tests performed was low, high rates of infection were identified, particularly among PWID. There were significant challenges with linkage to care.

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By:  Anderson ES1, Pfeil SK2, Deering LJ2, Todorovic T2, Lippert S3, White DA2.

• 1Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA; Department of Emergency Medicine, Stanford University, Palo Alto, CA. Electronic address: esoremanderson@gmail.com.
• 2Department of Emergency Medicine, Alameda Health System, Highland Hospital, Oakland, CA.
• 3Department of Emergency Medicine, Stanford University, Palo Alto, CA. 
• Am J Emerg Med. 2016 Mar 3. pii: S0735-6757(16)00186-8. doi: 10.1016/j.ajem.2016.03.004. 

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Brief Motivational Intervention to Reduce Alcohol and HIV/Sexual Risk Behavior in Emergency Department Patients

OBJECTIVE:

Given the prevalence of co-occurring risky sexual behavior and drinking among emergency department (ED) patients, we developed a motivational intervention (MI) to address both behaviors. This study tested efficacy of a single-session MI compared to brief advice (BA) for reducing heavy drinking and condomless sex in adult ED patients screening positive for both.

METHOD:

We randomized 372 patients to MI (n = 184) or BA (n = 188). Alcohol and sex risk outcomes were assessed over 9 months.

RESULTS:

Generalized estimating equations models analyzing 327 patients with follow-up data provided strong support for efficacy of this integrated alcohol and sex-risk MI. Compared to BA, and after controlling for baseline covariates, those in MI reported significantly fewer heavy drinking days, drinks per week, and were less likely to engage in excessive drinking over follow-up (all ps < .05). MI was also favored over BA for reducing sex risk. Compared to BA, those in MI reported significantly fewer days on which they engaged in condomless sex with casual partners, had lower odds of reporting any condomless sex with a casual partner, and reported fewer days of sex under the influence of alcohol/other drugs (all ps < .05).

CONCLUSION:

This innovative MI was acceptable, feasible, and successfully delivered in 2 community hospitals and thus shows great promise for scalability and dissemination into complex health settings where newly insured at-risk individuals are likely to seek care. 

Purchase full article at:   http://goo.gl/ai3Yxk

By:  Monti PM, Mastroleo NR, Barnett NP, Colby SM, Kahler CW, Operario D.

J Consult Clin Psychol. 2016 Mar 17.

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Emergency Department Visits for Homelessness or Inadequate Housing in New York City Before and After Hurricane Sandy

Hurricane Sandy struck New York City on October 29, 2012, causing not only a large amount of physical damage, but also straining people's health and disrupting health care services throughout the city. In prior research, we determined that emergency department (ED) visits from the most vulnerable hurricane evacuation flood zones in New York City increased after Hurricane Sandy for several medical diagnoses, but also for the diagnosis of homelessness. 

In the current study, we aimed to further explore this increase in ED visits for homelessness after Hurricane Sandy's landfall. We performed an observational before-and-after study using an all-payer claims database of ED visits in New York City to compare the demographic characteristics, insurance status, geographic distribution, and health conditions of ED patients with a primary or secondary ICD-9 diagnosis of homelessness or inadequate housing in the first week after Hurricane Sandy's landfall versus the baseline weekly average in 2012 prior to Hurricane Sandy. 

We found statistically significant increases in ED visits for diagnosis codes of homelessness or inadequate housing in the week after Hurricane Sandy's landfall. Those accessing the ED for homelessness or inadequate housing were more often elderly and insured by Medicare after versus before the hurricane. 

Secondary diagnoses among those with a primary ED diagnosis of homelessness or inadequate housing also differed after versus before Hurricane Sandy. These observed differences in the demographic, insurance, and co-existing diagnosis profiles of those with an ED diagnosis of homelessness or inadequate housing before and after Hurricane Sandy suggest that a new population cohort-potentially including those who had lost their homes as a result of storm damage-was accessing the ED for homelessness or other housing issues after the hurricane. 

Emergency departments may serve important public health and disaster response roles after a hurricane, particularly for people who are homeless or lack adequate housing. Further, tracking ED visits for homelessness may represent a novel surveillance mechanism to assess post-disaster infrastructure impact and to prepare for future disasters.

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By:  Doran KM1,2, McCormack RP1, Johns EL3, Carr BG4,5, Smith SW1, Goldfrank LR1, Lee DC6,7.

• 1Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA.
• 2Department of Population Health, New York University School of Medicine, New York, NY, USA.
• 3New York City Center for Innovation through Data Intelligence, New York, NY, USA.
• 4Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA, USA.
• 5Emergency Care Coordination Center, Office of the Assistant Secretary for Preparedness and Response, Department of Health and Human Services, Washington, DC, USA.
• 6Ronald O. Perelman Department of Emergency Medicine, New York University School of Medicine, 462 First Avenue, Room A345, New York, NY, 10016, USA. david.lee@nyumc.org.
• 7Department of Population Health, New York University School of Medicine, New York, NY, USA. david.lee@nyumc.org. 
• J Urban Health. 2016 Mar 15.

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Accuracy of Reported Service Use in a Cohort of People Who Are Chronically Homeless & Seriously Mentally Ill

Background

Self-reported service use is an integral feature of interventional research with people who are homeless and mentally ill. The objective of this study was to investigate the accuracy of self-reported involvement with major categories of publicly funded services (health, justice, social welfare) within this sub-population.

Methods

Measures were administered pre-randomization in two randomized controlled trials, using timeline follow back with calendar aids for Health, Social, and Justice Service Use, compared to linked administrative data. Variables examined were: psychiatric admissions (both extended stays of more than 6 months and two or more stays within 5 years); emergency department visits, general hospitalization and jail in the past 6 months; and income assistance in the past 1 month. Participants (n = 433) met criteria for homelessness and a least one mental illness.

Results

Prevalence adjusted and bias adjusted kappa (PABAK) values ranged between moderate and almost perfect for extended psychiatric hospital separations, multiple psychiatric hospitalizations, emergency department visits, jail, and income assistance. Significant differences in under versus over reporting were also found.

Conclusions

People who are homeless and mentally ill reliably reported their overall use of health, justice, and income assistance services. Evidence of under-reporting and over-reporting of certain variables has implications for specific research questions.

Full article at:   http://goo.gl/ROq2xv

By:  Julian M. Somers, Akm Moniruzzaman, Lauren Currie, Stefanie N. Rezansoff, Angela Russolillo, and Milad Parpouchi

Somers Research Group, Faculty of Health Sciences, Simon Fraser University, Burnaby, Canada

Julian M. Somers, Email: ac.ufs@sremosj.

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Universal Screening for Sexually Transmitted Infections among Asymptomatic Adolescents in an Urban Emergency Department: High Acceptance but Low Prevalence of Infection

OBJECTIVES:

To evaluate acceptance of sexually transmitted infection (STI) screening and measure STI prevalence in an asymptomatic adolescent emergency department (ED) population.

STUDY DESIGN:

This was a prospectively enrolled cross-sectional study of 14- to 21-year-old patients who sought care at an urban pediatric ED with non-STI related complaints. Participants completed a computer-assisted questionnaire to collect demographic and behavioral data and were asked to provide a urine sample to screen for Chlamydia trachomatis and Neisseria gonorrhoeae infection. We calculated STI screening acceptance and STI prevalence. We used logistic regression to identify factors associated with screening acceptance and presence of infection.

RESULTS:

Of 553 enrolled patients, 326 (59.0%) agreed to be screened for STIs. STI screening acceptability was associated with having public health insurance (aOR 1.7; 1.1, 2.5) and being sexually active (sexually active but denying high risk activity [aOR 1.7; 1.1, 2.5]; sexually active and reporting high risk activity [aOR 2.6; 1.5, 4.6]). Sixteen patients (4.9%; 95% CI 2.6, 7.3) had an asymptomatic STI. High-risk sexual behavior (aOR 7.2; 1.4, 37.7) and preferential use of the ED rather than primary care for acute medical needs (aOR 4.0; 1.3, 12.3) were associated with STI.

CONCLUSIONS:

STI screening is acceptable to adolescents in the ED, especially among those who declare sexual experience. Overall, there was a low prevalence of asymptomatic STI. Risk of STI was higher among youth engaging in high-risk sexual behavior and those relying on the ED for acute health care access. Targeted screening interventions may be more efficient than universal screening for STI detection in the ED.

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By:  Goyal MK1, Teach SJ2, Badolato GM3, Trent M4, Chamberlain JM2.

• 1Children's National Health System, Washington, DC; Departments of Pediatrics and Emergency Medicine, the George Washington University School of Medicine and Health Sciences, Washington, DC. Electronic address: mgoyal@childrensnational.org.
• 2Children's National Health System, Washington, DC; Departments of Pediatrics and Emergency Medicine, the George Washington University School of Medicine and Health Sciences, Washington, DC.
• 3Children's National Health System, Washington, DC.
• 4Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD.
• J Pediatr. 2016 Feb 2. pii: S0022-3476(16)00021-4. doi: 10.1016/j.jpeds.2016.01.019. 

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Impact of Mandatory HIV Screening in the Emergency Department: A Queuing Study

To improve HIV screening rates, New York State in 2010 mandated that all persons 13-64 years receiving health care services, including care in emergency departments (EDs), be offered HIV testing. Little attention has been paid to the effect of screening on patient flow. 

Time-stamped ED visit data from patients eligible for HIV screening, 7,844 of whom were seen by providers and 767 who left before being seen by providers, were retrieved from electronic health records in one adult ED. During day shifts, 10% of patients left without being seen, and during evening shifts, 5% left without being seen. All patients seen by providers were offered testing, and 6% were tested for HIV. 

Queuing models were developed to evaluate the effect of HIV screening on ED length of stay, patient waiting time, and rate of leaving without being seen. Base case analysis was conducted using actual testing rates, and sensitivity analyses were conducted to evaluate the impact of increasing the testing rate. 

Length of ED stay of patients who received HIV tests was 24 minutes longer on day shifts and 104 minutes longer on evening shifts than for patients not tested for HIV. Increases in HIV testing rate were estimated to increase waiting time for all patients, including those who left without being seen. 

Our simulation suggested that incorporating HIV testing into ED patient visits not only adds to practitioner workload but also increases patient waiting time significantly during busy shifts, which may increase the rate of leaving without being seen. 

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By:  Liu N1, Stone PW2, Schnall R3.

• 1Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY.
• 2School of Nursing, Columbia University, New York, NY.
• 3School of Nursing, Columbia University, 617 West 168th Street, New York, NY, 10032. 
• Res Nurs Health. 2016 Feb 1. doi: 10.1002/nur.21710.

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The Impact of Nurse-Driven Targeted HIV Screening in 8 Emergency Departments: Study Protocol for the DICI-VIH Cluster-Randomized Two-Period Crossover Trial

Background

In 2010, to reduce late HIV diagnosis, the French national health agency endorsed non-targeted HIV screening in health care settings. Despite these recommendations, non-targeted screening has not been implemented and only physician-directed diagnostic testing is currently performed. A survey conducted in 2010 in 29 French Emergency Departments (EDs) showed that non-targeted nurse-driven screening was feasible though only a few new HIV diagnoses were identified, predominantly among high-risk groups. A strategy targeting high-risk groups combined with current practice could be shown to be feasible, more efficient and cost-effective than current practice alone.

Methods/Design

DICI-VIH (acronym for nurse-driven targeted HIV screening) is a multicentre, cluster-randomized, two-period crossover trial. The primary objective is to compare the effectiveness of 2 strategies for diagnosing HIV among adult patients visiting EDs: nurse-driven targeted HIV screening combined with current practice (physician-directed diagnostic testing) versus current practice alone. Main secondary objectives are to compare access to specialist consultation and how early HIV diagnosis occurs in the course of the disease between the 2 groups, and to evaluate the implementation, acceptability and cost-effectiveness of nurse-driven targeted screening. The 2 strategies take place during 2 randomly assigned periods in 8 EDs of metropolitan Paris, where 42 % of France’s new HIV patients are diagnosed every year. All patients aged 18 to 64, not presenting secondary to HIV exposure are included. During the intervention period, patients are invited to fill a 7-item questionnaire (country of birth, sexual partners and injection drug use) in order to select individuals who are offered a rapid test. If the rapid test is reactive, a follow-up visit with an infectious disease specialist is scheduled within 72 h. Assuming an 80 % statistical power and a 5 % type 1 error, with 1.04 and 3.38 new diagnoses per 10,000 patients in the control and targeted groups respectively, a sample size of 140,000 patients was estimated corresponding to 8,750 patients per ED and per period. Inclusions started in June 2014. Results are expected by mid-2016.

Discussion

The DICI-VIH study is the first large randomized controlled trial designed to assess nurse-driven targeted HIV screening. This study can provide valuable information on HIV screening in health care settings.

Below:  DICI-VIH questionnaire

Below:  DICI-VIH flow diagram following CONSORT

Below:  DICI-VIH flow chart

Full article at:   http://goo.gl/gTxZgV

By:  Judith Leblanc, Alexandra Rousseau, Gilles Hejblum, Isabelle Durand-Zaleski, Pierre de Truchis, France Lert,Dominique Costagliola, Tabassome Simon, and Anne-Claude Crémieux

Assistance Publique – Hôpitaux de Paris (AP-HP), Groupe Hospitalier des Hôpitaux Universitaires Est Parisien, Clinical Research Center of East of Paris (CRC-Est), F75012 Paris, France

Université Paris Saclay - Université Versailles Saint-Quentin, Doctoral School of Public Health (EDSP), UMR 1173, F92380 Garches, France

AP-HP, Groupe Hospitalier des Hôpitaux Universitaires Est Parisien, Clinical Research Unit of East of Paris (URC-Est), F75012 Paris, France

Sorbonne Universités, UPMC Univ Paris 06, INSERM, Institut Pierre Louis d’Épidémiologie et de Santé Publique (IPLESP UMRS 1136), F75012 Paris, France

AP-HP, Hôpital Hôtel-Dieu, URC Eco Île-de-France, F75004 Paris, France

Université Paris Diderot, Univ Paris 07, INSERM, ECEVE, UMR 1123, F75019 Paris, France

AP-HP, Hôpital Henri-Mondor, Santé publique, F94010 Créteil, France

AP-HP, Hôpital Raymond-Poincaré, Infectious Disease Department, F92380 Garches, France

Université Paris Sud, Univ Paris 11, INSERM, Centre for research in Epidemiology and population health, U 1018, F94800 Villejuif, France

AP-HP, Groupe Hospitalier des Hôpitaux Universitaires Est Parisien, Department of clinical pharmacology and Clinical Research Center of East of Paris (CRC-Est), F75012 Paris, France

Sorbonne Universités, UPMC Univ Paris 06, INSERM, UMR 1148, F75018 Paris, France

Université Versailles Saint-Quentin, UMR 1173, F92380 Garches, France

Judith Leblanc, Phone: +33 1 49 28 22 02, Email: rf.phpa@cnalbel.htiduj.

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Sexually Transmitted Infection History among Adolescents Presenting to the Emergency Department

BACKGROUND:

Adolescents and young adults account for about half of the annual diagnoses of sexually transmitted infections (STI) in the United States. Screening and treatment for STIs, as well as prevention, are needed in health-care settings to help offset the costs of untreated STIs.

OBJECTIVE:

Our aim was to evaluate the prevalence and correlates of self-reported STI history among adolescents presenting to an emergency department (ED).

METHODS:

Over two and a half years, 4389 youth (aged 14-20 years) presenting to the ED completed screening measures for a randomized controlled trial. About half (56%) reported lifetime sexual intercourse and were included in analyses examining sexual risk behaviors (e.g., inconsistent condom use), and relationships of STI history with demographics (sex, age, race, school enrollment), reason for ED presentation (i.e., medical or injury), and substance use.

RESULTS:

Among sexually active youth, 10% reported that a medical professional had ever told them they had an STI (212 females, 35 males). Using logistic regression, female sex, older age, non-Caucasian race, not being enrolled in school, medically related ED chief complaint, and inconsistent condom use were associated with increased odds of self-reported STI history.

CONCLUSIONS:

One in 10 sexually active youth in the ED reported a prior diagnosed STI. Previous STI was significantly higher among females than males. ED providers inquiring about inconsistent condom use and previous STI among male and female adolescents may be one strategy to focus biological testing resources and improve screening for current STI.

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By:  Bonar EE1, Walton MA2, Caldwell MT3, Whiteside LK4, Barry KL5, Cunningham RM6.

• 1Department of Psychiatry, Addiction Research Center, University of Michigan, Ann Arbor, Michigan.
• 2Department of Psychiatry, Addiction Research Center, University of Michigan, Ann Arbor, Michigan; Injury Center, University of Michigan, Ann Arbor, Michigan.
• 3Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine, Henry Ford Health System, Detroit, Michigan.
• 4Division of Emergency Medicine, University of Washington, Seattle, Washington.
• 5Department of Veterans Affairs National Serious Mental Illness Treatment Resource and Evaluation Center, Ann Arbor, Michigan; Department of Psychiatry, Mental Health Services Outcomes and Translation Section, University of Michigan, Ann Arbor, Michigan.
• 6Injury Center, University of Michigan, Ann Arbor, Michigan; Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan; School of Public Health, University of Michigan, Ann Arbor, Michigan. 
• J Emerg Med. 2015 Nov;49(5):613-22. doi: 10.1016/j.jemermed.2015.02.017. Epub 2015 May 4.

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Emergency Department-Based Opioid Harm Reduction: Moving Physicians from Willing to Doing

OBJECTIVES:

Develop and internally validate a survey tool to assess emergency department (ED) physician attitudes, clinical practice, and willingness to perform opiate harm reduction (OHR) interventions. Identify barriers and facilitators in translating willingness to action METHODS: Anonymous, web-based survey based on the Theory of Planned Behavior of ED physicians at three tertiary referral centers. Construction and internal validation of scaled questions was assessed through Principal Component and Cronbach's Alpha analyses. Stepwise linear regression was conducted to measure impact of physician knowledge, attitudes, confidence, and self-efficacy on willingness to perform OHR interventions including opioid overdose education, naloxone prescribing and referral to naloxone, methadone, and syringe access programs.

RESULTS:

200/278 (71.9%) physicians completed the survey. Principal Component Analysis yielded five components: Attitude, Confidence, Self-Efficacy, Professional Impact Factors, and Personal Impact Factors. Overall, respondents were willing to perform OHR interventions, but few actually do. Willingness was correlated with attitude, confidence, and self-efficacy (R² =0.50), however overall physicians lacked confidence (mean = 3.06 out of 5 [95% CI 2.94, 3.18]). Knowledge, time, training, and institutional support were all prohibitive barriers. Physicians reported that research evidence, professional organization recommendations, and opinions of ED leaders would strongly influence a change in their clinical practice to incorporate OHR interventions (mean = 4.25 out of 5 [95% CI 4.18, 4.32]).

CONCLUSION:

Compared to prior studies, EM physicians had increased willingness to perform OHR interventions, but there remains a disparity between willingness and clinical practice. Influential factors that may move physicians from "willing" to "doing" include dissemination of supportive research evidence, professional organization endorsement, ED leadership opinion, and addressing time, knowledge, and institutional barriers.

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By:  Samuels EA1, Dwyer K2, Mello MJ1, Baird J1, Kellogg A3, Bernstein E2.

• 1Brown University Department of Emergency Medicine, Providence, RI, USA.
• 2Boston Medical Center Department of Emergency Medicine, Boston, MA, USA.
• 3Baystate Medical Center Department of Emergency Medicine, Springfield, MA, USA. 
• Acad Emerg Med. 2016 Jan 27. doi: 10.1111/acem.12910

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