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Open Access Publications from the University of California

Scholarly Works (31 results)

  • Article
  • Peer Reviewed
UC San Francisco Previously Published Works (2013)
Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients' total Medicaid costs. Frequent ED users have a substantial burden of disease, and they have high rates of primary and specialty care use. They also have linkages to outpatient care that are comparable to those of other ED patients. It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.
    Cover page: Dispelling An Urban Legend: Frequent Emergency Department Users Have Substantial Burden Of Disease
    • Article
    • Peer Reviewed
    Academic and Working Papers (2020)

    We found that the Permanent Supportive Housing program intervention was able to house 86 percent of chronically homeless adults randomized to the treatment group based on their high use of multiple systems who were randomized to the treatment group. On average, it took 2.5 months for participants randomized to housing to become housed and 70 percent moved at least once, demonstrating that PSH can be successful with high‐risk participants but requires time and flexibility.

    By using a randomized controlled trial design, we found that those randomized to housing (versus usual care) had lower use of psychiatric emergency departments and shelters, but did not have large reductions in service use described in previous uncontrolled studies.

    This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grant MRP-19-600774.

      Cover page: A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services
      • Article
      • Peer Reviewed
      UC San Francisco Previously Published Works (2015)
      © 2015 Boscardin et al.Background: We examined whether self-reported employee health status data can improve the performance of administrative data-based models for predicting future high health costs, and develop a predictive model for predicting new hig
        • Article
        • Peer Reviewed
        UC San Francisco Previously Published Works (2013)

        Importance

        Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patient's diagnosis upon ED discharge appears to reflect a "nonemergency" condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care.

        Objective

        To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use.

        Design, setting, and participants

        The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all "primary care-treatable" visits. The 2009 NHAMCS data set contains 34,942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses.

        Main outcomes and measures

        Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits.

        Results

        Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care-treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care-treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room.

        Conclusions and relevance

        Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.
          • Article
          • Peer Reviewed
          UC San Francisco Previously Published Works (2013)
          IMPORTANCE: Reduction in emergency department (ED) use is frequently viewed as a potential source for cost savings. One consideration has been to deny payment if the patients diagnosis upon ED discharge appears to reflect a nonemergency condition. This approach does not incorporate other clinical factors such as chief complaint that may inform necessity for ED care. OBJECTIVE: To determine whether ED presenting complaint and ED discharge diagnosis correspond sufficiently to support use of discharge diagnosis as the basis for policies discouraging ED use. DESIGN, SETTING, AND PARTICIPANTS: The New York University emergency department algorithm has been commonly used to identify nonemergency ED visits. We applied the algorithm to publicly available ED visit data from the 2009 National Hospital Ambulatory Medical Care Survey (NHAMCS) for the purpose of identifying all primary care-treatable visits. The 2009 NHAMCS data set contains 34,942 records, each representing a unique ED visit. For each visit with a discharge diagnosis classified as primary care treatable, we identified the chief complaint. To determine whether these chief complaints correspond to nonemergency ED visits, we then examined all ED visits with this same group of chief complaints to ascertain the ED course, final disposition, and discharge diagnoses. MAIN OUTCOMES AND MEASURES: Patient demographics, clinical characteristics, and disposition associated with chief complaints related to nonemergency ED visits. RESULTS: Although only 6.3% (95% CI, 5.8%-6.7%) of visits were determined to have primary care-treatable diagnoses based on discharge diagnosis and our modification of the algorithm, the chief complaints reported for these ED visits with primary care-treatable ED discharge diagnoses were the same chief complaints reported for 88.7% (95% CI, 88.1%-89.4%) of all ED visits. Of these visits, 11.1% (95% CI, 9.3%-13.0%) were identified at ED triage as needing immediate or emergency care; 12.5% (95% CI, 11.8%-14.3%) required hospital admission; and 3.4% (95% CI, 2.5%-4.3%) of admitted patients went directly from the ED to the operating room. CONCLUSIONS AND RELEVANCE: Among ED visits with the same presenting complaint as those ultimately given a primary care-treatable diagnosis based on ED discharge diagnosis, a substantial proportion required immediate emergency care or hospital admission. The limited concordance between presenting complaints and ED discharge diagnoses suggests that these discharge diagnoses are unable to accurately identify nonemergency ED visits.
            Cover page: Comparison of presenting complaint vs discharge diagnosis for identifying nonemergency emergency department visits.
            • Article
            • Peer Reviewed
            UC San Francisco Previously Published Works (2018)
              Cover page: Homelessness and Emergency Medicine: Where Do We Go From Here?
              • Article
              • Peer Reviewed
              UC San Francisco Previously Published Works (2022)
                Creative Commons 'BY' version 4.0 license
                • Article
                • Peer Reviewed
                Academic and Working Papers (2021)
                This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grants M21PR3278.
                  • Article
                  Research Reports (2022)

                  People with multiple, complex health and housing needs frequently receive fragmented care because the providing systems operate independently. Typically, individuals who come into frequent contact with the emergency medical system (e.g., emergency departments; emergency medical services) also interact with other health services and public systems such as psychiatric facilities, substance use treatment centers, shelters, and jails. Cross-sector care coordination is limited, in part, because data systems are not linked across physical health, behavioral health (mental health and substance use), housing, and criminal legal systems. To help San Francisco better serve this high need population, the California Policy Lab at UC Berkeley and the UCSF Benioff Homelessness and Housing Initiative worked with our partners in San Francisco’s public health and criminal legal systems to link together ten years of data from the physical health, behavioral health, housing, and criminal legal sectors. Using these linked data, we identify individuals with high utilization of the criminal legal system and the medical and behavioral health systems in a single year. High criminal legal utilization is defined as at least three jail bookings in a year, while high healthcare utilization is seven or more urgent/emergent healthcare contacts in a year. To understand trends before and after a year of high utilization, we analyze two cohorts. The 2011 cohort includes 211 people with high utilization of both systems in fiscal year 2011, while the 2020 cohort includes 161 individuals with high utilization of both systems in fiscal year 2020. This allows us to observe patterns of system use before and after years of high utilization. We find: • Almost all the individuals in both cohorts experienced homelessness (98–99%) • High utilization is linked to premature death: more than one quarter of the 2011 cohort is deceased within 10 years • Between 80–90% of individuals in both cohorts have substance use disorders, and many also have co-occurring mental health and physical health disorders • More than 90% of the individuals in both cohorts have been booked into jail for a felony and a misdemeanor • Many of the individuals in the 2020 cohort were in San Francisco and had contact with at least one of these systems in the prior 10 years. For example, 30% of the 2020 cohort was booked into jail in 2011. These findings highlight the need for coordinated, evidence-based interventions to address these individuals’ complex needs, stabilize housing, and prevent poor health outcomes including untimely death. 

                  This work has been supported, in part, by the University of California Multicampus Research Programs and Initiatives grants MRP-19-600774 and M21PR3278.

                    Cover page: Signals of Distress: High Utilization of Criminal Legal and Urgent and Emergent Health Services in San Francisco
                    • Article
                    • Peer Reviewed
                    UC San Francisco Previously Published Works (2022)

                    Background

                    Frequent emergency department (ED) use and incarceration can be driven by underlying structural factors and social needs. If frequent ED users are at increased risk for incarceration, ED-based interventions could be developed to mitigate this risk. The objective of this study was to determine whether frequent ED use is associated with incarceration.

                    Methods

                    We conducted a retrospective cross-sectional study of 46,752 individuals in San Francisco Department of Public Health's interagency, integrated Coordinated Care Management System (CCMS) during fiscal year 2018-2019. The primary exposure was frequency of ED visits, and the primary outcome was presence of any county jail incarceration during the study period. We performed descriptive and multivariable analysis to determine the association between the frequency of ED use and jail encounters.

                    Results

                    The percentage of those with at least one episode of incarceration during the study period increased with increasing ED visit frequency. Unadjusted odds of incarceration increased with ED use frequency: odds ratio (OR) = 2.14 (95% confidence interval [CI] = 1.94-2.35) for infrequent use, OR = 4.98 (95% CI = 4.43-5.60) for those with frequent ED use, and OR = 12.33 (95% CI = 9.59-15.86) for those with super-frequent ED use. After adjustment for observable confounders, the odds of incarceration for those with super-frequent ED use remained elevated at 2.57 (95% CI = 1.94-3.41). Of those with super-frequent ED use and at least one jail encounter, 18% were seen in an ED within 30 days after release from jail and 25% were seen in an ED within 30 days prior to arrest.

                    Conclusions

                    Frequent ED use is independently associated with incarceration. The ED may be a site for intervention to prevent incarceration among frequent ED users by addressing unmet social needs.
                      Cover page: Understanding the association between frequent emergency department use and jail incarceration: A cross‐sectional analysis
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