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The Role of Social and Clinical Determinants in the Frequent Utilization of Emergency Departments

机译：社会和临床因素在急诊科频繁使用中的作用

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Objective: Patients who utilize Emergency Department (ED) services at least four times per year, also referred to as frequent utilizers of EDs (FUEDs) comprise a high-cost-high-need vulnerable group of patients. Persistent ED users, people who use the ED 4 or more times for two consecutive years are a subset of FUEDs with the greatest needs and poorest health outcomes. FUEDs are less than 10% of all ED patients but account for a quarter of ED visits. Much of the research to date has focused on the clinical conditions and high use of health care services of FUEDs, much less is known about the impact of social determinants of health (SDH) on FUEDs.;Study Design: Analysis of claims data merged with interview data from George Washington University Hospital (GWUH) Frequent User Study was used in a retrospective cohort study design. I used multivariate linear, negative binomial and logistic regression respectively to model the three main study outcomes: (1) number of unmet needs; (2) total and preventable ED visits; and (3) persistent ED use, as a function of structural SDH, intermediary SDH and clinical determinants of health.;Population Studied: 474 DC Medicaid beneficiaries, 18--64 years, who attended GWUH between October 2015--2016 and had 4 or more ED visits in a calendar year.;Principal Findings: In Aim 1, 24 unmet needs grouped into 4 unique domains based on a factor analysis: material resources, health care management and literacy, employment and family-related needs. FUEDs experienced an average of 5.7 unmet needs and had a high burden of mental illness (60%). 80% reported material resource needs, such as housing, food, and transportation. 56% reported health care management and literacy needs (HCML) including dental (30%), medical care needs (22%) and psychiatric needs (20%). 45% reported employment related needs. When the number of unmet needs was modeled as a function of social (SDH) and clinical determinants of health, SDH contributed to 37% of the variance in the number of unmet needs while clinical determinants contributed less (18%). Poor access to food and shelter, and poor behavioral health status were associated with increased number of unmet needs. Social support and higher income levels were associated with decreased number of unmet needs.;Aim 2 revealed that in one year, FUEDs had an average of 16.2 total ED visits and 30% of these ED visits were preventable. 60% of FUEDs had a diagnosed mental illness but there was significant underutilization of psychiatric services. Multivariate analyses revealed that increased physical illness severity, poor behavioral health status, inadequate food and shelter were associated with an increased number of total and preventable ED visits. For example, a one unit increase in the level of social support was associated with a 6% decrease in the number of total ED visits and 14% decrease in preventable ED visits. Physical illness severity and care continuity had a significant positive interaction effect upon both total and preventable ED utilization.;Aim 3 showed that persistent FUEDs are sicker than non-persistent FUEDs. Greater duration of unemployment and cumulative homelessness were significantly associated with persistent ED use, however adjusting for access to public assistance renders their effects non-significant. Public assistance is strongly and positively associated with increased odds of persistent ED use, and may buffer the influence of cumulative homelessness and severe behavioral illness on the odds of persistent ED use. Greater physical illness severity is strongly associated with persistent ED use.;Conclusion: Frequent ED use will not change substantially without addressing SDH such as low social support and lack of adequate food and housing that significantly contribute to the unmet needs, frequent and persistent ED utilization. Behavioral health is a significant clinical determinant of unmet needs and total and preventable ED utilization among FUEDs. Clinical determinants such as increased clinical illness severity are significant drivers of persistent ED use, with social determinants having lesser influence.;Policy Implications: This research is directly applicable to DC Medicaid Care Coordination initiatives whereby patients with multiple chronic illnesses can receive a care coordination benefit. Some of the clinical problems cannot be coordinated effectively in this high need vulnerable population unless social adversities are addressed. Curbing ED use by FUEDs will require a two-pronged approach: adequate and coordinated ambulatory care for those most at risk as well as attention to specific social determinants they experience. Data from this research can inform state based Accountable Health Community and Health Home initiatives. FUEDs will benefit from tailored interventions that address food and housing needs and provide social support, especially in a patient population that has a high burden of mental illness. (Abstract shortened by ProQuest.).
机译：目的：每年至少使用四次急诊科（ED）服务的患者，也被称为EDs（FUEDs）的经常使用者，是一组高成本，高需求的易受伤害患者。永久性ED用户，即连续两年连续使用4次或以上ED的人是需求最大，健康结果最差的FUED的子集。 FUED不到所有ED患者的10％，但占ED访问的四分之一。迄今为止，许多研究都集中在FUED的临床状况和医疗服务的高使用上，而对健康的社会决定因素（SDH）对FUED的影响知之甚少。研究设计：索赔数据分析与FUED合并回顾性队列研究设计使用了乔治华盛顿大学医院（GWUH）的访谈数据。我分别使用多元线性，负二项式和逻辑回归建模三个主要研究结果：（1）未满足需求的数量； （2）全面和可预防的急诊就诊； （3）根据结构性SDH，中间性SDH和健康的临床决定因素而持续使用ED;人口研究：474名DC医疗补助受益人，年龄18-64岁，他们在2015年10月--2016年10月期间参加了GWUH，有4名主要发现：在目标1中，根据因素分析，将24个未满足的需求分为4个独特的领域：物质资源，医疗保健管理和识字，就业和与家庭相关的需求。 FUED平均经历了5.7个未满足的需求，并且精神疾病负担高（60％）。 80％的人报告了物质资源需求，例如住房，食物和交通。 56％的人报告了医疗保健管理和扫盲需求（HCML），包括牙科（30％），医疗保健需求（22％）和精神病学需求（20％）。 45％报告了与就业相关的需求。将未满足需求的数量建模为社会（SDH）和健康的临床决定因素的函数时，SDH导致未满足需求数量变化的37％，而临床决定因素的贡献则较小（18％）。无法获得食物和住所以及行为健康状况不佳与未满足需求的数量增加有关。社会支持和较高的收入水平与未满足需求的减少有关。目标2显示，在一年中，FUED进行的ED访问总数平均为16.2，而这些访问中的30％是可以预防的。 60％的FUED患者被诊断出患有精神疾病，但是精神病服务的利用率很低。多变量分析显示，身体疾病的严重程度增加，行为健康状况差，食物和住房不足都与急诊就诊的总数和可预防次数增加有关。例如，社会支持水平每增加1个单位，急诊就诊总数减少6％，可预防急诊就诊减少14％。身体疾病的严重程度和护理连续性对总的和可预防的ED利用率均具有显着的积极相互作用。;目标3表明，持久性FUED较非持久性FUED病态。持续时间较长的失业率和累积的无家可归现象与长期使用ED密切相关，但是对获得公共援助的机会进行调整使其影响不显着。公共援助与持续使用ED的几率有很大的正相关关系，并且可以缓冲累积的无家可归者和严重的行为疾病对持续使用ED的几率的影响。较高的身体疾病严重程度与持续使用ED密切相关。 。行为健康是未满足需求以及FUED中ED的总体利用和可预防利用的重要临床决定因素。临床决定因素，例如增加的临床疾病严重程度，是持续使用ED的重要驱动因素，而社会决定因素的影响较小。；政策含义：这项研究直接适用于DC Medicaid Care Coordination倡议，患有多种慢性病的患者可以获得医疗协调利益。除非解决社会逆境，否则在这种高需求脆弱人群中无法有效协调某些临床问题。遏制FUED使用ED的方法有两个方面：对风险最大的人群进行充分，协调的门诊护理，并关注他们所经历的特定社会决定因素。这项研究的数据可以为基于州的“负责任的健康社区”和“健康之家”计划提供信息。 FUED将受益于针对食品和住房需求并提供社会支持的量身定制的干预措施，尤其是在精神疾病负担高的患者人群中。 （摘要由ProQuest缩短。）。

著录项

  • 作者

    Mohammed Moazam Ali, Maliha.;

  • 作者单位

    The George Washington University.;

  • 授予单位 The George Washington University.;
  • 学科 Public health.;Public policy.
  • 学位 Dr.P.H.
  • 年度 2018
  • 页码 195 p.
  • 总页数 195
  • 原文格式 PDF
  • 正文语种 eng
  • 中图分类
  • 关键词

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