Publications by authors named "Maria C Raven"

40 Publications

Understanding the 100 highest users of health and social services in San Francisco.

Acad Emerg Med 2021 May 21. Epub 2021 May 21.

Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA.

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http://dx.doi.org/10.1111/acem.14299DOI Listing
May 2021

Mortality Among People Experiencing Homelessness in San Francisco 2016-2018.

J Gen Intern Med 2021 Apr 9. Epub 2021 Apr 9.

Street Medicine and Shelter Health, San Francisco Department of Public Health, San Francisco, CA, USA.

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http://dx.doi.org/10.1007/s11606-021-06769-7DOI Listing
April 2021

Health Care for People Experiencing Homelessness-What Outcomes Matter?

JAMA Netw Open 2021 03 1;4(3):e213837. Epub 2021 Mar 1.

Department of Emergency Medicine, UCSF School of Medicine, San Francisco, California.

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http://dx.doi.org/10.1001/jamanetworkopen.2021.3837DOI Listing
March 2021

A randomized trial of permanent supportive housing for chronically homeless persons with high use of publicly funded services.

Health Serv Res 2020 10;55 Suppl 2:797-806

Mathematica Policy Research, Oakland, CA, USA.

Objective: To examine whether randomization to permanent supportive housing (PSH) versus usual care reduces the use of acute health care and other services among chronically homeless high users of county-funded services.

Data Sources: Between 2015 and 2019, we assessed service use from Santa Clara County, CA, administrative claims data for all county-funded health care, jail and shelter, and mortality.

Study Design: We conducted a randomized controlled trial among chronically homeless high users of multiple systems. We compared postrandomization outcomes from county-funded systems using multivariate regression analysis.

Data Collection: We extracted encounter data from an integrated database capturing health care at county-funded facilities, shelter and jails, county housing placement, and death certificates.

Principal Findings: We enrolled 423 participants (199 intervention; 224 control). Eighty-six percent of those randomized to PSH received housing compared with 36 percent in usual care. On average, the 169 individuals housed by the PSH intervention have remained housed for 28.8 months (92.9 percent of the study follow-up period). Intervention group members had lower rates of psychiatric ED visits IRR 0.62; 95% CI [0.43, 0.91] and shelter days IRR 0.30; 95% CI [0.17, 0.53], and higher rates of ambulatory mental health services use IRR 1.84; 95% CI [1.43, 2.37] compared to controls. We found no differences in total ED or inpatient use, or jail. Seventy (37 treatment; 33 control) participants died.

Conclusions: The intervention placed and retained frequent user, chronically homeless individuals in housing. It decreased psychiatric ED visits and shelter use, and increased outpatient mental health care, but not medical ED visits or hospitalizations. Limitations included more than one-third of usual care participants received another form of subsidized housing, potentially biasing results to the null, and loss of power due to high death rates. PSH can house high-risk individuals and reduce emergent psychiatric services and shelter use. Reductions in hospitalizations may be more difficult to realize.
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http://dx.doi.org/10.1111/1475-6773.13553DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7518819PMC
October 2020

Association of Default Electronic Medical Record Settings With Health Care Professional Patterns of Opioid Prescribing in Emergency Departments: A Randomized Quality Improvement Study.

JAMA Intern Med 2020 04;180(4):487-493

Department of Emergency Medicine, University of California, San Francisco.

Importance: Prescription opioids play a significant role in the ongoing opioid crisis. Guidelines and physician education have had mixed success in curbing opioid prescriptions, highlighting the need for other tools that can change prescriber behavior, including nudges based in behavioral economics.

Objective: To determine whether and to what extent changes in the default settings in the electronic medical record (EMR) are associated with opioid prescriptions for patients discharged from emergency departments (EDs).

Design, Setting, And Participants: This quality improvement study randomly altered, during a series of five 4-week blocks, the prepopulated dispense quantities of discharge prescriptions for commonly prescribed opioids at 2 large, urban EDs. These changes were made without announcement, and prescribers were not informed of the study itself. Participants included all health care professionals (physicians, nurse practitioners, and physician assistants) working clinically in either of the 2 EDs. Data were collected from November 28, 2016, through July 9, 2017, and analyzed from July 16, 2017, through May 14, 2018.

Interventions: Default quantities for opioids were changed from status quo quantities of 12 and 20 tablets to null, 5, 10, and 15 tablets according to a block randomization scheme. Regardless of the default quantity, each health care professional decided for whom to prescribe opioids and could modify the quantity prescribed without restriction.

Main Outcomes And Measures: The primary outcome was the number of tablets of opioid-containing medications prescribed under each default setting.

Results: A total of 104 health care professionals wrote 4320 prescriptions for opioids during the study period. Using linear regression, an increase of 0.19 tablets prescribed (95% CI, 0.15-0.22) was found for each tablet increase in default quantity. When evaluating each of the 15 pairwise comparisons of default quantities (eg, 5 vs 15 tablets), a lower default was associated with a lower number of pills prescribed in more than half (8 of the 15) of the pairwise comparisons; there was a higher quantity in 1 and no difference in 6 comparisons.

Conclusions And Relevance: These findings suggest that default settings in the EMR may influence the quantity of opioids prescribed by health care professionals. This low-cost, easily implementable, EMR-based intervention could have far-reaching implications for opioid prescribing and could be used as a tool to help combat the opioid epidemic.

Trial Registration: ClinicalTrials.gov identifier: NCT04155229.
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http://dx.doi.org/10.1001/jamainternmed.2019.6544DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6990860PMC
April 2020

Violence and Emergency Department Use among Community-Recruited Women Who Experience Homelessness and Housing Instability.

J Urban Health 2020 02;97(1):78-87

Department of Psychiatry, University of California, San Francisco, San Francisco, CA, USA.

Women who experience housing instability are at high risk for violence and have disproportionately high rates of emergency department (ED) use. However, little has been done to characterize the violence they experience, or to understand how it may be related to ED use. We recruited homeless and unstably housed women from San Francisco shelters, free meal programs, and single room occupancy (SRO) hotels. We used generalized estimating equations to examine associations between violence and any ED use (i.e., an ED visit for any stated reason) every 6 months for 3 years. Among 300 participants, 44% were African-American, and the mean age was 48 years. The prevalence of violence experienced in the prior 6 months included psychological violence (87%), physical violence without a weapon (48%), physical violence with a weapon (18%), and sexual violence (18%). While most participants (85%) who experienced physical violence with a weapon or sexual violence in the prior 6 months had not visited an ED, these were the only two violence types significantly associated with ED use when all violence types were included in the same model (OR = 1.83, 95% CI 1.02-3.28; OR = 2.15, 95% CI 1.30-3.53). Only violence perpetrated by someone who was not a primary intimate partner was significantly associated with ED use when violence was categorized by perpetrator. The need to reduce violence in this population is urgent. In the context of health care delivery, policies to facilitate trauma-informed ED care and strategies that increase access to non-ED care, such as street-based medicine, could have substantial impact on the health of women who experience homelessness and housing instability.
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http://dx.doi.org/10.1007/s11524-019-00404-xDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7010900PMC
February 2020

Frequent Emergency Department Users: Focusing Solely On Medical Utilization Misses The Whole Person.

Health Aff (Millwood) 2019 11;38(11):1866-1875

Maria C. Raven is an associate professor in the Department of Emergency Medicine and an affiliated faculty member at the Philip R. Lee Institute for Health Policy Studies, UCSF.

Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus <0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.
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http://dx.doi.org/10.1377/hlthaff.2019.00082DOI Listing
November 2019

Homelessness and the Practice of Emergency Medicine: Challenges, Gaps in Care, and Moral Obligations.

Authors:
Maria C Raven

Ann Emerg Med 2019 11;74(5S):S33-S37

University of California, San Francisco, San Francisco, CA. Electronic address:

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http://dx.doi.org/10.1016/j.annemergmed.2019.08.440DOI Listing
November 2019

Policies That Limit Emergency Department Visits and Reimbursements Undermine the Emergency Care System: Instead, Let's Optimize It.

Authors:
Maria C Raven

JAMA Netw Open 2018 10 5;1(6):e183728. Epub 2018 Oct 5.

Department of Emergency Medicine, University of California, San Francisco.

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http://dx.doi.org/10.1001/jamanetworkopen.2018.3728DOI Listing
October 2018

Past Frequent Emergency Department Use Predicts Mortality.

Health Aff (Millwood) 2019 01;38(1):155-158

Maria C. Raven is an associate professor in the Department of Emergency Medicine and an affiliated faculty member at the Philip R. Lee Institute for Health Policy Studies, UCSF.

Little is known about mortality risk among frequent emergency department (ED) users. Using California hospital data for 2005-13 linked to vital statistics data, we found that frequent ED use in the past year was predictive of mortality among the nonelderly in both the short and longer terms.
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http://dx.doi.org/10.1377/hlthaff.2018.05157DOI Listing
January 2019

Mobile Phone, Computer, and Internet Use Among Older Homeless Adults: Results from the HOPE HOME Cohort Study.

JMIR Mhealth Uhealth 2018 Dec 10;6(12):e10049. Epub 2018 Dec 10.

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA, United States.

Background: The median age of single homeless adults is approximately 50 years. Older homeless adults have poor social support and experience a high prevalence of chronic disease, depression, and substance use disorders. Access to mobile phones and the internet could help lower the barriers to social support, social services, and medical care; however, little is known about access to and use of these by older homeless adults.

Objective: This study aimed to describe the access to and use of mobile phones, computers, and internet among a cohort of 350 homeless adults over the age of 50 years.

Methods: We recruited 350 participants who were homeless and older than 50 years in Oakland, California. We interviewed participants at 6-month intervals about their health status, residential history, social support, substance use, depressive symptomology, and activities of daily living (ADLs) using validated tools. We performed clinical assessments of cognitive function. During the 6-month follow-up interview, study staff administered questions about internet and mobile technology use. We assessed participants' comfort with and use of multiple functions associated with these technologies.

Results: Of the 343 participants alive at the 6-month follow-up, 87.5% (300/343) completed the mobile phone and internet questionnaire. The median age of participants was 57.5 years (interquartile range 54-61). Of these, 74.7% (224/300) were male, and 81.0% (243/300) were black. Approximately one-fourth (24.3%, 73/300) of the participants had cognitive impairment and slightly over one-third (33.6%, 100/300) had impairments in executive function. Most (72.3%, 217/300) participants currently owned or had access to a mobile phone. Of those, most had feature phones, rather than smartphones (89, 32.1%), and did not hold annual contracts (261, 94.2%). Just over half (164, 55%) had ever accessed the internet. Participants used phones and internet to communicate with medical personnel (179, 64.6%), search for housing and employment (85, 30.7%), and to contact their families (228, 82.3%). Those who regained housing were significantly more likely to have mobile phone access (adjusted odds ratio [AOR] 3.81, 95% CI 1.77-8.21). Those with ADL (AOR 0.53, 95% CI 0.31-0.92) and executive function impairment (AOR 0.49; 95% CI 0.28-0.86) were significantly less likely to have mobile phones. Moderate to high risk amphetamine use was associated with reduced access to mobile phones (AOR 0.27, 95% CI 0.10-0.72).

Conclusions: Older homeless adults could benefit from portable internet and phone access. However, participants had a lower prevalence of smartphone and internet access than adults aged over 65 years in the general public or low-income adults. Participants faced barriers to mobile phone and internet use, including financial barriers and functional and cognitive impairments. Expanding access to these basic technologies could result in improved outcomes.
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http://dx.doi.org/10.2196/10049DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6305882PMC
December 2018

Frequent Emergency Department Users: A Statewide Comparison Before And After Affordable Care Act Implementation.

Health Aff (Millwood) 2018 06;37(6):881-889

Renee Y. Hsia ( ) is a professor in the Department of Emergency Medicine and a core faculty member at the Philip R. Lee Institute for Health Policy Studies, both at UCSF.

Frequent emergency department (ED) use often serves as a marker for poor access to non-ED ambulatory care. Policy makers and providers hoped that by expanding coverage, the Affordable Care Act (ACA) would curtail frequent ED use. We used data from California's Office of Statewide Health Planning and Development to compare the characteristics of frequent ED users among nonelderly adults in California before and after implementation of several major coverage expansion provisions in the ACA. Frequent users-patients with four or more annual ED visits-accounted for 7.9 percent of ED patients before and 8.5 percent after those provisions were implemented, and they were responsible for 30.7 percent of all visits before and 31.6 percent after. However, after controlling for patient-level characteristics, we found that the odds of being a frequent ED user were significantly lower post ACA for Medicaid-insured patients. Uninsured patients were also less likely to be frequent users post ACA, while privately insured patients experienced little change. The largest predictors of frequent ED use included having a diagnosis of a mental health condition or a substance use disorder. Interventions to address frequent ED use must involve Medicaid managed care plans, given that more than two-thirds of frequent ED users post ACA have Medicaid as their primary coverage source.
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http://dx.doi.org/10.1377/hlthaff.2017.0784DOI Listing
June 2018

Homelessness and Emergency Medicine: Where Do We Go From Here?

Acad Emerg Med 2018 05 20;25(5):598-600. Epub 2018 Apr 20.

Department of Emergency Medicine, University of California at San Francisco, San Francisco, CA.

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http://dx.doi.org/10.1111/acem.13392DOI Listing
May 2018

Emergency Psychiatric Care: The Authors Reply.

Health Aff (Millwood) 2018 02;37(2):335

University of California, San Francisco San Francisco, California.

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http://dx.doi.org/10.1377/hlthaff.2017.1546DOI Listing
February 2018

A National Study of Outpatient Health Care Providers' Effect on Emergency Department Visit Acuity and Likelihood of Hospitalization.

Ann Emerg Med 2018 06 24;71(6):728-736. Epub 2017 Nov 24.

Université Paris I-Panthéon Sorbonne, Paris, France.

Study Objective: Many policymakers believe that expanding access to outpatient care will reduce emergency department (ED) use. However, outpatient health care providers often refer their patients to EDs for evaluation and management. We examine the factors underlying outpatient provider referral, its effect on ED visit volume, and whether referred ED visits are more likely to result in hospitalization than self-referred visits.

Methods: We conducted a cross-sectional study of 19,342 adult (>18 years) respondents to the 2012 to 2014 National Health Interview Survey who reported they had visited an ED at least once in the past 12 months, representing an estimated 44,152,870 US adults. We categorized individuals as having been referred to the ED by an outside health care provider if they responded affirmatively to "your health care provider advised you to go" as a reason for their most recent ED visit. We performed descriptive analyses and logistic regressions to examine factors associated with outpatient health care provider referral to the ED. Respondents could choose multiple other reasons for their most recent ED visit, and we used existing Centers for Disease Control and Prevention guidelines to group these reasons into 2 categories: seriousness of the medical condition and lack of access to other providers. Our 2 main outcomes were whether an outpatient health care provider referred an individual to the ED and whether that ED visit resulted in hospitalization.

Results: Of the 44,152,870 US adults (18.58%; 95% confidence interval [CI] 18.21% to 18.95%) with one or more ED visits in the previous 12 months, 10,913,271 (24.72%; 95% CI 23.80% to 25.64%) were referred to the ED by an outpatient provider. Respondents who reported their ED visit was due to the seriousness of their medical condition were more likely to be referred to the ED (odds ratio [OR] 2.18; 95% CI 1.91 to 2.49), whereas those reporting a lack of access to other providers were less likely to be referred (OR 0.58; 95% CI 0.52 to 0.64). Visits referred to the ED were more likely to result in hospitalization than self-referrals (OR 2.07; 95% CI 1.87 to 2.31).

Conclusion: Almost one quarter of individuals' most recent ED visits were driven by referrals from outpatient health care providers. Being referred to the ED by an outpatient provider is strongly associated with the seriousness of one's medical condition, which also increases the odds of hospitalization compared with ED discharge. After controlling for seriousness of medical condition, ED referral by an outpatient provider continues to have an independent association with hospitalization.
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http://dx.doi.org/10.1016/j.annemergmed.2017.10.013DOI Listing
June 2018

Persistent Frequent Emergency Department Use: Core Group Exhibits Extreme Levels Of Use For More Than A Decade.

Health Aff (Millwood) 2017 10;36(10):1720-1728

Renee Y. Hsia is a professor in the Department of Emergency Medicine and a core faculty member at the PRL-IHPS, both at UCSF.

Many frequent emergency department (ED) users do not sustain high use over time, which makes it difficult to create targeted interventions to address their health needs. We performed a retrospective analysis of nonelderly adult frequent ED users in California to measure the persistence of frequent ED use in the period 2005-15, describe characteristics of persistent and nonpersistent frequent users, and identify predictors of persistent frequent use. Of the frequent ED users in 2005, 30.5 percent remained frequent users in 2006. A small but nontrivial population (16.5 percent, 5.7 percent, and 1.9 percent) exhibited persistent frequent use for three, six, and eleven consecutive years, respectively. The strongest predictor of persistent frequent ED use was the intensity of ED use in the baseline study year. The rate at which frequent users stopped using the ED frequently decreased over time, leaving a core group of chronic persistent users. These persistent frequent users differ from nonpersistent frequent users, who engaged in temporary intense use of the ED. Identifying and differentiating persistent frequent users is important, as they may be candidates for distinct interventions.
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http://dx.doi.org/10.1377/hlthaff.2017.0658DOI Listing
October 2017

Out-of-Network Emergency Department Use among Managed Medicaid Beneficiaries.

Health Serv Res 2017 12 11;52(6):2156-2174. Epub 2016 Nov 11.

Division of General Internal Medicine, University of California, San Francisco/San Francisco General Hospital and Trauma Center, San Francisco, CA.

Objective: Out-of-network emergency department (ED) use, or use that occurs outside the contracted network, may lead to increased care fragmentation and cost. We examined factors associated with out-of-network ED use among Medicaid beneficiaries.

Data Sources And Study Setting: Enrollment, claims, and encounter data for adult Medi-Cal health plan members with 1+ ED visits and complete Medicaid eligibility during the study period from 2013 to 2014.

Study Design: We analyzed the data to identify factors associated with out-of-network ED use classified by mode of arrival (ambulance vs. nonambulance).

Data Extraction Methods: We extracted encounter, ambulance, and ED census data and linked them together based on ED visit date.

Principal Findings: Of 11,143 ED visits, 6,808 (61.1 percent) were out-of-network. The number of hours the study ED was on ambulance diversion increased the odds of out-of-network visits for the 3,365 (30.2 percent) ED visits arriving by ambulance. For all visit types, assignment to a primary care clinic at the in-network hospital and having had any primary care visit during the study period decreased the odds of out-of-network ED care. Individuals were more likely to go out-of-network for ED care if they lived in neighborhoods containing out-of-network EDs.

Conclusions: There are a number of factors related to out-of-network ED use, including the proximity and density of out-of-network EDs, race and ethnicity, a prior history of out-of-network ED use, and individuals' connection to primary care. EDs that serve Medicaid beneficiaries may need to explore alternative sites and modalities of care as alternatives to the ED, and consider their ability to absorb large numbers of out-of-network visits given already limited capacity.
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http://dx.doi.org/10.1111/1475-6773.12604DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5682123PMC
December 2017

Emergency Department Use in a Cohort of Older Homeless Adults: Results From the HOPE HOME Study.

Acad Emerg Med 2017 01;24(1):63-74

Division of General Internal Medicine, University of California at San Francisco/San Francisco General Hospital and Trauma Center, San Francisco, CA.

Objective: The median age of single homeless adults is over 50, yet little is known about their emergency department (ED) use. We describe use of and factors associated with ED use in a sample of homeless adults 50 and older.

Methods: We recruited 350 participants who were homeless and 50 or older in Oakland, California. We interviewed participants about residential history in the prior 6 months, health status, health-related behaviors, and health services use and assessed cognition and mobility. Our primary outcome was the number of ED visits in the prior 6 months based on medical record review. We used negative binomial regression to examine factors associated with ED use.

Results: In the 6 months prior to enrollment, 46.3% of participants spent the majority of their time unsheltered; 25.1% cycled through multiple institutions including shelters, hospitals, and jails; 16.3% primarily stayed with family or friends; and 12.3% had become homeless recently after spending much of the prior 6 months housed. Half (49.7%) of participants made at least one ED visit in the past 6 months; 6.6% of participants accounted for 49.9% of all visits. Most (71.8%) identified a regular non-ED source of healthcare; 7.3% of visits resulted in hospitalization. In multivariate models, study participants who used multiple institutions (incidence rate ratio [IRR] = 2.27; 95% confidence interval [CI] = 1.08 to 4.77) and who were unsheltered (IRR = 2.29; 95% CI = 1.17 to 4.48) had higher ED use rates than participants who had been housed for most of the prior 6 months. In addition, having health insurance/coverage (IRR = 2.6; CI = 1.5 to 4.4), a history of psychiatric hospitalization (IRR = 1.80; 95% CI = 1.09 to 2.99), and severe pain (IRR = 1.72; 95% CI = 1.07 to 2.76) were associated with higher ED visit rates.

Conclusions: A sample of adults aged 50 and older who were homeless at study entry had higher rates of ED use in the prior 6 months than the general U.S. age-matched population. Within the sample, ED use rates varied based on individuals' residential histories, suggesting that individuals' ED use is related to exposure to homelessness.
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http://dx.doi.org/10.1111/acem.13070DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5857347PMC
January 2017

The Effectiveness of Emergency Department Visit Reduction Programs: A Systematic Review.

Ann Emerg Med 2016 10 8;68(4):467-483.e15. Epub 2016 Jun 8.

Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, CA; Department of Epidemiology and Biostatistics and California Medicaid Research Institute, University of California, San Francisco, San Francisco, CA; Division of General Internal Medicine, University of California, San Francisco/San Francisco General Hospital and Trauma Center, San Francisco, CA.

Study Objective: Previous reviews of emergency department (ED) visit reduction programs have not required that studies meet a minimum quality level and have therefore included low-quality studies in forming conclusions about the benefits of these programs. We conduct a systematic review of ED visit reduction programs after judging the quality of the research. We aim to determine whether these programs are effective in reducing ED visits and whether they result in adverse events.

Methods: We identified studies of ED visit reduction programs conducted in the United States and targeted toward adult patients from January 1, 2003, to December 31, 2014. We evaluated study quality according to the Grading of Recommendations Assessment, Development, and Evaluation criteria and included moderate- to high-quality studies in our review. We categorized interventions according to whether they targeted high-risk or low-acuity populations.

Results: We evaluated the quality of 38 studies and found 13 to be of moderate or high quality. Within these 13 studies, only case management consistently reduced ED use. Studies of ED copayments had mixed results. We did not find evidence for any increase in adverse events (hospitalization rates or mortality) from the interventions in either high-risk or low-acuity populations.

Conclusion: High-quality, peer-reviewed evidence about ED visit reduction programs is limited. For most program types, we were unable to draw definitive conclusions about effectiveness. Future ED visit reduction programs should be regarded as demonstrations in need of rigorous evaluation.
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http://dx.doi.org/10.1016/j.annemergmed.2016.04.015DOI Listing
October 2016

Predicting cost of care using self-reported health status data.

BMC Health Serv Res 2015 Sep 23;15:406. Epub 2015 Sep 23.

Department of Emergency Medicine, University of California, San Francisco, School of Medicine, San Francisco, CA, USA.

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 high cost individuals.

Methods: This retrospective cohort study used data from 8,917 Safeway employees self-insured by Safeway during 2008 and 2009. We created models using step-wise multivariable logistic regression starting with health services use data, then socio-demographic data, and finally adding the self-reported health status data to the model.

Results: Adding self-reported health data to the baseline model that included only administrative data (health services use and demographic variables; c-statistic = 0.63) increased the model" predictive power (c-statistic = 0.70). Risk factors associated with being a new high cost individual in 2009 were: 1) had one or more ED visits in 2008 (adjusted OR: 1.87, 95 % CI: 1.52, 2.30), 2) had one or more hospitalizations in 2008 (adjusted OR: 1.95, 95 % CI: 1.38, 2.77), 3) being female (adjusted OR: 1.34, 95 % CI: 1.16, 1.55), 4) increasing age (compared with age 18-35, adjusted OR for 36-49 years: 1.28; 95 % CI: 1.03, 1.60; adjusted OR for 50-64 years: 1.92, 95 % CI: 1.55, 2.39; adjusted OR for 65+ years: 3.75, 95 % CI: 2.67, 2.23), 5) the presence of self-reported depression (adjusted OR: 1.53, 95 % CI: 1.29, 1.81), 6) chronic pain (adjusted OR: 2.22, 95 % CI: 1.81, 2.72), 7) diabetes (adjusted OR: 1.73, 95 % CI: 1.35, 2.23), 8) high blood pressure (adjusted OR: 1.42, 95 % CI: 1.21, 1.67), and 9) above average BMI (adjusted OR: 1.20, 95 % CI: 1.04, 1.38).

Discussion: The comparison of the models between the full sample and the sample without theprevious high cost members indicated significant differences in the predictors. This has importantimplications for models using only the health service use (administrative data) given that the past high costis significantly correlated with future high cost and often drive the predictive models.

Conclusions: Self-reported health data improved the ability of our model to identify individuals at risk for being high cost beyond what was possible with administrative data alone.
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http://dx.doi.org/10.1186/s12913-015-1063-1DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4580365PMC
September 2015

Medicaid dental coverage alone may not lower rates of dental emergency department visits.

Health Aff (Millwood) 2015 Aug;34(8):1349-57

Maria C. Raven is an associate professor of emergency medicine at the University of California, San Francisco.

Medicaid was expanded to millions of individuals under the Affordable Care Act, but many states do not provide dental coverage for adults under their Medicaid programs. In the absence of dental coverage, patients may resort to costly emergency department (ED) visits for dental conditions. Medicaid coverage of dental benefits could help ease the burden on the ED, but ED use for dental conditions might remain a problem in areas with a scarcity of dentists. We examined county-level rates of ED visits for nontraumatic dental conditions in twenty-nine states in 2010 in relation to dental provider density and Medicaid coverage of nonemergency dental services. Higher density of dental providers was associated with lower rates of dental ED visits by patients with Medicaid in rural counties but not in urban counties, where most dental ED visits occurred. County-level Medicaid-funded dental ED visit rates were lower in states where Medicaid covered nonemergency dental services than in other states, although this difference was not significant after other factors were adjusted for. Providing dental coverage alone might not reduce Medicaid-funded dental ED visits if patients do not have access to dental providers.
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http://dx.doi.org/10.1377/hlthaff.2015.0223DOI Listing
August 2015

Patient-centered medical homes may reduce emergency department use: what does this tell us?

Authors:
Maria C Raven

Ann Emerg Med 2015 Jun 12;65(6):661-3. Epub 2015 Mar 12.

UCSF School of Medicine, San Francisco, CA. Electronic address:

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http://dx.doi.org/10.1016/j.annemergmed.2015.03.001DOI Listing
June 2015

EMS-STARS: Emergency Medical Services "Superuser" Transport Associations: An Adult Retrospective Study.

Prehosp Emerg Care 2015 January-March;19(1):61-67. Epub 2014 Aug 5.

Abstract Objective. Emergency medical services (EMS) "superusers" -those who use EMS services at extremely high rates -have not been well characterized. Recent interest in the small group of individuals who account for a disproportionate share of health-care expenditures has led to research on frequent users of emergency departments and other health services, but little research has been done regarding those who use EMS services. To inform policy and intervention implementation, we undertook a descriptive analysis of EMS superusers in a large urban community. In this paper we compare EMS superusers to low, moderate, and high users to characterize factors contributing to EMS use. We also estimate the financial impact of EMS superusers. Methods. We conducted a retrospective cross-sectional study based on 1 year of data from an urban EMS system. Data for all EMS encounters with patients age ≥18 years were extracted from electronic records generated on scene by paramedics. We identified demographic and clinical variables associated with levels of EMS use. EMS users were characterized by the annual number of EMS encounters: low (1), moderate (2-4), high (5-14), and superusers (≥15). In addition, we performed a financial analysis using San Francisco Fire Department (SFFD) 2009 charge and reimbursement data. Results. A total of 31,462 adults generated 43,559 EMS ambulance encounters, which resulted in 39,107 transports (a 90% transport rate). Encounters for general medical reasons were common among moderate and high users and less frequent among superusers and low users, while alcohol use was exponentially correlated with encounter frequency. Superusers were significantly younger than moderate EMS users, and more likely to be male. The superuser group created a significantly higher financial burden/person than any other group, comprising 0.3% of the study population, but over 6% of annual EMS charges and reimbursements. Conclusions. In this retrospective study, adult EMS "superusers" emerged as a distinct, predominantly male population and their EMS encounters were associated with alcohol use. Continued analysis of this unique, high-cost, and frequently transported population will likely illuminate specific intervention strategies.
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http://dx.doi.org/10.3109/10903127.2014.936630DOI Listing
August 2014

Presenting quality data to vulnerable groups: charts, summaries or behavioral economic nudges?

J Health Serv Res Policy 2014 Jul 24;19(3):161-168. Epub 2014 Feb 24.

Assistant Clinical Professor, Department of Emergency Medicine, University of California, San Francisco, USA.

Objectives: Despite the increased focus on health care consumers' active choice, not enough is known about how to best facilitate the choice process. We sought to assess methods of improving this process for vulnerable consumers in the United States by testing alternatives that emphasize insights from behavioral economics, or 'nudges'.

Methods: We performed a hypothetical choice experiment where subjects were randomized to one of five experimental conditions and asked to choose a health center (location where they would receive all their care). The conditions presented the same information about health centers in different ways, including graphically as a chart, via written summary and using behavioral economics, 'nudging' consumers toward particular choices. We hypothesized that these 'nudges' might help simplify the choice process. Our primary outcomes focused on the health center chosen and whether consumers were willing to accept 'nudges'.

Results: We found that consumer choice was influenced by the method of presentation and the majority of consumers accepted the health center they were 'nudged' towards.

Conclusions: Consumers were accepting of choices grounded in insights from behavioral economics and further consideration should be given to their role in patient choice.
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http://dx.doi.org/10.1177/1355819614524186DOI Listing
July 2014

Emergency department use: the authors reply.

Health Aff (Millwood) 2014 Feb;33(2):346

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http://dx.doi.org/10.1377/hlthaff.2013.1461DOI Listing
February 2014

Capsule commentary on Capp et al., National study of health insurance type and reasons for emergency department use.

Authors:
Maria C Raven

J Gen Intern Med 2014 Apr;29(4):651

Department of Emergency Medicine, University of California, San Francisco, CA, 94143-0208, USA,

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http://dx.doi.org/10.1007/s11606-014-2771-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3965736PMC
April 2014

Reasons for emergency department use: do frequent users differ?

Am J Manag Care 2014 Nov 1;20(11):e506-14. Epub 2014 Nov 1.

Department of Emergency Medicine, Bellevue Hospital Center Room A-345, First Ave and 27th St, New York, NY 10016. E-mail:

Objectives: To examine patients' reasons for using the emergency department (ED) for low-acuity health complaints, and determine whether reasons differed for frequent ED users versus nonfrequent ED users.

Study Design: Prospective cross-sectional survey.

Methods: Patients presenting to an urban public hospital for low-acuity health complaints were surveyed about their reasons for visiting the ED rather than a private doctor's office or clinic. Patients with 3 or more visits to the study hospital ED over the past year were classified as frequent ED users. Multivariable logistic regression was used to determine if frequent ED users gave different reasons for ED use than nonfrequent ED users, while controlling for differences in other baseline patient characteristics.

Results: 940 patients, including 163 frequent ED users, completed the study questionnaire. Commonly cited reasons for using the ED were that coming to the ED was easier than making a clinic appointment (82.3% agreed); the problem could not wait (78.8%); they didn't know how to make a clinic appointment (66.7%); they felt the ED provided better care (56.7%); and they believed the clinic would cost more (54.8%). After controlling for other patient characteristics, there were no significant differences found in reasons for ED use given by frequent versus nonfrequent ED users.

Conclusions: Frequent ED users gave similar reasons for using the ED for low-acuity health complaints compared with nonfrequent ED users. Access, convenience, cost, and quality concerns, as well as feeling that ED care was needed, were all commonly cited as reasons for using the ED.
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November 2014

Dispelling an urban legend: frequent emergency department users have substantial burden of disease.

Health Aff (Millwood) 2013 Dec;32(12):2099-108

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.
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http://dx.doi.org/10.1377/hlthaff.2012.1276DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC4892700PMC
December 2013