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      Monthly Rates of Patients Who Left Before Accessing Care in US Emergency Departments, 2017-2021

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      , MD 1 , 2 , 3 , , , MD, MHS 1 , 4 , , MD, MBA, MHS 1 , 5
      JAMA Network Open
      American Medical Association

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          Abstract

          This cross-sectional study investigates rates of patients who left emergency departments without being seen from 2017 to 2021.

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          Patients who leave a public hospital emergency department without being seen by a physician. Causes and consequences.

          To determine whether patients who sought care at a public hospital emergency department and left without being seen by a physician needed immediate medical attention and whether they obtained care after leaving. Follow-up study of patients who left without being seen and of patients who waited to be seen by a physician. A public hospital's emergency department in Torrance, Calif. All patients who registered for care and left without being seen (n = 186) and a 20% random sample of patients who waited until they were seen (n = 211) in a 2-week period during spring 1990. At time of presentation: triage nurse urgency assessment, clinical acuity rating, and self-reported health status. At follow-up: hospitalization rates. Patients who left reported that they had waited 6.4 hours before leaving; those who stayed reported a 6.2-hour wait before being seen. There were no differences between those who left and those who stayed in chief complaint, triage nurse assessment, acuity ratings, or self-reported health status. Forty-six percent of those who left were judged to need immediate medical attention, and 29% needed care within 24 to 48 hours. Eleven percent of those who left were hospitalized within the next week, and three patients required emergency surgery. Nine percent of those who waited to be seen were hospitalized. Forty-nine percent of patients who left did not see a physician during the 1-week follow-up period. Overcrowding in this public hospital's emergency department restricts access to needed ambulatory medical care for the poor and uninsured.
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            The Evolving Role of Emergency Departments in the United States.

            The research described in this article was performed to develop a more complete picture of how hospital emergency departments (EDs) contribute to the U.S. health care system, which is currently evolving in response to economic, clinical, and political pressures. Using a mix of quantitative and qualitative methods, it explores the evolving role that EDs and the personnel who staff them play in evaluating and managing complex and high-acuity patients, serving as the key decisionmaker for roughly half of all inpatient hospital admissions, and serving as "the safety net of the safety net" for patients who cannot get care elsewhere. The report also examines the role that EDs may soon play in either contributing to or helping to control the rising costs of health care.
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              Hospital determinants of emergency department left without being seen rates.

              The proportion of patients who leave without being seen in the emergency department (ED) is an outcome-oriented measure of impaired access to emergency care and represents the failure of an emergency care delivery system to meet its goals of providing care to those most in need. Little is known about variation in the amount of left without being seen or about hospital-level determinants. Such knowledge is necessary to target hospital-level interventions to improve access to emergency care. We seek to determine whether hospital-level socioeconomic status case mix or hospital structural characteristics are predictive of ED left without being seen rates. We performed a cross-sectional study of all acute-care, nonfederal hospitals in California that operated an ED in 2007, using data from the California Office of Statewide Health Planning and Development database and the US census. Our outcome of interest was whether a visit to a given hospital ED resulted in left without being seen. The proportion of left without being seen was measured by the number of left without being seen cases out of the total number of visits. We studied 9.2 million ED visits to 262 hospitals in California. The percentage of left without being seen varied greatly over hospitals, ranging from 0% to 20.3%, with a median percentage of 2.6%. In multivariable analyses adjusting for hospital-level socioeconomic status case mix, visitors to EDs with a higher proportion of low-income and poorly insured patients experienced a higher risk of left without being seen. We found that the odds of an ED visit resulting in left without being seen increased by a factor of 1.15 for each 10-percentage-point increase in poorly insured patients, and odds of left without being seen decreased by a factor of 0.86 for each $10,000 increase in household income. When hospital structural characteristics were added to the model, county ownership, trauma center designation, and teaching program affiliation were positively associated with increased probability of left without being seen (odds ratio 2.09; 1.62, and 2.14, respectively), and these factors attenuated the association with insurance status. Visitors to different EDs experience a large variation in their probability of left without being seen, and visitors to hospitals serving a high proportion of low-income and poorly insured patients are at disproportionately higher risk of leaving without being seen. Our findings suggest that there is room for substantial improvement in this outcome, and regional interventions can be targeted toward certain at-risk hospitals to improve access to emergency care. Copyright © 2011 American College of Emergency Physicians. Published by Mosby, Inc. All rights reserved.
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                Author and article information

                Journal
                JAMA Netw Open
                JAMA Netw Open
                JAMA Network Open
                American Medical Association
                2574-3805
                30 September 2022
                September 2022
                30 September 2022
                : 5
                : 9
                : e2233708
                Affiliations
                [1 ]Department of Emergency Medicine, Yale School of Medicine, New Haven Connecticut
                [2 ]Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
                [3 ]Now with VA Ann Arbor Healthcare System/University of Michigan, National Clinician Scholars Program, Ann Arbor
                [4 ]Division of Health Informatics, Department of Biostatistics, Yale School of Public Health, New Haven, Connecticut
                [5 ]Center for Outcomes Research and Evaluation, Yale School of Medicine, New Haven, Connecticut
                Author notes
                Article Information
                Accepted for Publication: August 11, 2022.
                Published: September 30, 2022. doi:10.1001/jamanetworkopen.2022.33708
                Open Access: This is an open access article distributed under the terms of the CC-BY License. © 2022 Janke AT et al. JAMA Network Open.
                Corresponding Author: Alexander T. Janke, MD, VA Ann Arbor Healthcare System/University of Michigan, National Clinician Scholars Program, North Campus Research Complex, 2800 Plymouth Rd, Bldg 14, Room G100-36, Ann Arbor, MI 48105 ( atjanke@ 123456med.umich.edu ).
                Author Contributions: Dr Janke had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
                Concept and design: All authors.
                Acquisition, analysis, or interpretation of data: Janke, Melnick.
                Drafting of the manuscript: Janke.
                Critical revision of the manuscript for important intellectual content: All authors.
                Statistical analysis: Janke, Melnick.
                Obtained funding: Melnick, Venkatesh.
                Administrative, technical, or material support: Melnick.
                Supervision: Melnick, Venkatesh.
                Conflict of Interest Disclosures: Dr Janke reported receiving support from the Veterans Affairs (VA) Office of Academic Affiliations through the VA/National Clinician Scholars Program and the University of Michigan and funding from an Emerging Infectious Diseases and Preparedness grant from the Society for Academic Emergency Medicine Foundation. Dr Melnick reported receiving grants from the National Institute on Drug Abuse, American Medical Association, and Agency for Healthcare Research and Quality outside the submitted work. Dr Venkatesh reported receiving grants from the Centers for Medicare & Medicaid Services and American College of Emergency Physicians outside the submitted work, receiving funding from an Emergency Infectious Diseases and Preparedness grant from the Society for Academic Emergency Medicine Foundation, and having committee leadership roles with the American College of Emergency Physicians and the Society for Academic Emergency Medicine. No other disclosures were reported.
                Funding/Support: Dr Venkatesh was supported by the American Board of Emergency Medicine-National Academy of Medicine Fellowship.
                Role of the Funder/Sponsor: The funder had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
                Disclaimer: The contents do not represent the views of the US Department of Veterans Affairs or the United States government.
                Article
                zld220216 zld220216
                10.1001/jamanetworkopen.2022.33708
                9526078
                36178693
                3aa891a3-d59c-46dd-beb4-547a812ac12b
                Copyright 2022 Janke AT et al. JAMA Network Open.

                This is an open access article distributed under the terms of the CC-BY License.

                History
                : 26 May 2022
                : 11 August 2022
                Categories
                Research
                Research Letter
                Online Only
                Health Policy

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