Introduction: Emergency department (ED) screening and counseling for alcohol misuse have been shown to reduce at-risk drinking. However, barriers to more widespread adoption of this service remain unclear.

Methods: We performed a secondary analysis of a nationwide survey of 277 EDs to determine the proportion of EDs that routinely perform alcohol screening and counseling among patients presenting with alcohol-related complaints and to identify potential institutional barriers and facilitators to routine screening and counseling. The survey was randomly mailed to 350 EDs sampled from the 2007 National Emergency Department Inventory (NEDI), with 80% of ED medical directors responding after receiving the mailing or follow-up fax/email. The survey asked about a variety of preventive services and ED directors’ opinions regarding perceived barriers to offering preventive services in their EDs.

Results: Overall, only 27% of all EDs and 22% of Level I/II trauma center EDs reported routinely screening and counseling patients presenting with drinking-related complaints. Rates of routine screening and counseling were similar across geographic areas, crowding status, and urban-rural status. EDs that performed routine screening and counseling often offered other preventive services, such as tobacco cessation (P<0.01) and primary care linkage (P=0.01). EDs with directors who expressed concern about increased financial costs to the ED, inadequate follow-up, and diversion of nurse/physician time all had lower rates of screening and counseling and also more frequently reported lacking the perceived capacity to perform routine counseling and screening. Among EDs that did not routinely perform alcohol screening and counseling, more crowded than non-crowded (P<0.01) and more metro than rural (P<0.01) EDs reported lacking the capacity to perform routine screening and counseling. The capacity to perform routine screening also decreased as ED visit volume increased (P=0.04).

Conclusion: To increase routine alcohol screening and counseling for patients presenting with alcohol-related complaints, ED directors’ perceived barriers related to an ED’s capacity to perform screening, such as limited financial and staff resources, should be addressed, as should directors’ concerns regarding the implementation of preventive health services in EDs. Uniform reimbursement methods should be used to increase ED compensation for performing this important and effective service. [West J Emerg Med. 2014;15(4):438-445.]

Introduction: As millions of uninsured citizens who use emergency department (ED) services are now eligible for health insurance under the Affordable Care Act, the ED is ideally situated to facilitate linkage to insurance. Forty percent of U.S. EDs report having an insurance linkage program. This is the first national study to examine the characteristics of EDs that offer or do not offer these programs.

Methods: This was a secondary analysis of data from the National Survey for Preventive Health Services in U.S. EDs conducted in 2008-09. We compared EDs with and without insurance programs across demographic and operational factors using univariate analysis. We then tested our hypotheses using multivariable logistic regression. We also further examined program capacity and priority among the sub-group of EDs with no insurance linkage program.

Results: After adjustment, ED-insurance linkage programs were more likely to be located in the West (RR= 2.06, 95% CI = 1.33 – 2.72). The proportion of uninsured patients in an ED, teaching hospital status, and public ownership status were not associated with insurance linkage availability. EDs with linkage programs also offer more preventive services (RR = 1.87, 95% CI = 1.37–2.35) and have greater social worker availability (RR = 1.71, 95% CI = 1.12–2.33) than those who do not.  Four of five EDs with a patient mix of ≥25% uninsured and no insurance linkage program reported that they could not offer a program with existing staff and funding.

Conclusion: Availability of insurance linkage programs in the ED is not associated with the proportion of uninsured patients served by an ED. Policy or hospital-based interventions to increase insurance linkage should first target the 27% of EDs with high rates of uninsured patients that lack adequate program capacity. Further research on barriers to implementation and cost effectiveness may help to facilitate increased adoption of insurance linkage programs. [West J Emerg Med. 2014;15(4):529–535.]

Introduction: In March 2020, shelter-in-place orders were enacted to attenuate the spread of coronavirus 2019 (COVID-19). Emergency departments (EDs) experienced unexpected and dramatic decreases in patient volume, raising concerns about exacerbating health disparities.

Methods: We queried our electronic health record to describe the overall change in visits to a two-ED healthcare system in Northern California from March–June 2020 compared to 2019. We compared weekly absolute numbers and proportional change in visits focusing on race/ethnicity, insurance, household income, and acuity. We calculated the z-score to identify whether there was a statistically significant difference in proportions between 2020 and 2019.

Results: Overall ED volume declined 28% during the study period. The nadir of volume was 52% of 2019 levels and occurred five weeks after a shelter-in-place order was enacted. Patient demographics also shifted. By week 4 (April 5), the proportion of Hispanic patients decreased by 3.3 percentage points (pp) (P = 0.0053) compared to a 6.2 pp increase in White patients (P = 0.000005). The proportion of patients with commercial insurance increased by 11.6 pp, while Medicaid visits decreased by 9.5 pp (P < 0.00001) at the initiation of shelter-in-place orders. For patients from neighborhoods <300% federal poverty levels (FPL), visits were –3.8 pp (P = 0.000046) of baseline compared to +2.9 pp (P = 0.0044) for patients from ZIP codes at >400% FPL the week of the shelter-in-place order. Overall, 2020 evidenced a consistently elevated proportion of high-acuity Emergency Severity Index (ESI) level 1 patients compared to 2019. Increased acuity was also demonstrated by an increase in the admission rate, with a 10.8 pp increase from 2019. Although there was an increased proportion of high-acuity patients, the overall census was decreased.

Conclusion: Our results demonstrate changing ED utilization patterns circa the shelter-in-place orders. Those from historically vulnerable populations such as Hispanics, those from lower socioeconomic areas, and Medicaid users presented at disproportionately lower rates and numbers than other groups. As the pandemic continues, hospitals should use operations data to monitor utilization patterns by demographic, in addition to clinical indicators. Messaging about availability of emergency care and other services should include vulnerable populations to avoid exacerbating healthcare disparities.

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Introduction: Hospitals commonly use Press Ganey (PG) patient satisfaction surveys forbenchmarking physician performance. PG scores range from 1 to 5, with 5 being the highest,which is known as the “topbox” score. Our objective was to identify patient and physician factorsassociated with topbox PG scores in the emergency department (ED).

Methods: We looked at PG surveys from January 2015–December 2017 at an academic, urbanhospital with 78,000 ED visits each year. Outcomes were topbox scores for the questions:“Likelihood of your recommending our ED to others”; and “Courtesy of the doctor.” We analyzedtopbox scores using generalized estimating equation models clustered by physician and adjustedfor patient and physician factors. Patient factors included age, gender, race, ethnicity, and ED areawhere patient was seen. The ED has four areas based on patient acuity: emergent; urgent; vertical(urgent but able to sit in a recliner rather than a gurney); and fast track (non-urgent). Physicianfactors included age, gender, race, ethnicity, and number of years at current institution.

Results: We analyzed a total of 3,038 surveys. For “Likelihood of your recommending our ED toothers,” topbox scores were more likely with increasing patient age (odds ratio [OR] 1.07; 95%confidence interval [CI], 1.03-1.12); less likely among female compared to male patients (OR 0.81;95% CI, 0.70-0.93); less likely among Asian compared to White patients (OR 0.71; 95% CI, 0.60-0.83); and less likely in the urgent (OR 0.71; 95% CI, 0.54-0.93) and vertical areas (OR 0.71; 95% CI0.53-0.95) compared to fast track. For “Courtesy of the doctor,” topbox scores were more likely withincreasing patient age (OR 1.1; CI, 1.06-1.14); less likely among Asian (OR 0.70; 95% CI, 0.58-0.84),Black (OR 0.66; 95% CI ,0.45-0.96), and Hispanic patients (OR 0.68; 95% CI ,0.55-0.83) compared toWhite patients; and less likely in urgent area (OR 0.69; 95% CI ,0.50-0.95) compared to fast track.

Conclusion: Increasing patient age was associated with increased likelihood of topbox scores,while Asian patients, and urgent and vertical areas had decreased likelihood of topbox scores. Weencourage hospitals that use PG topbox scores as financial incentives to understand the contributionof non-service factors to these scores.

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