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Article: Emergency Department Increased use of Observation Care for Elderly Medicare Patients.

Gabayan, Gelareh Z / Liang, Li-Jung / Doyle, Brian / Huang, David Yu-Chuang / Sarkisian, Catherine A

2018 Volume 7, Issue 3, Page(s) 9–16

Abstract: Background: Over the past decade, a growing number of older Medicare beneficiaries visit the Emergency Department (ED) and have been placed in observation care. We investigated and compared the prevalence and factors associated with patients age ≥ 65 ... ...

Abstract	Background: Over the past decade, a growing number of older Medicare beneficiaries visit the Emergency Department (ED) and have been placed in observation care. We investigated and compared the prevalence and factors associated with patients age ≥ 65 years with Medicare insurance who are placed in the hospital, observation care, or discharged following an ED visit. Methods: We conducted a retrospective cohort study using data from a nationally representative 5% sample of Medicare patients age ≥ 65 years during the year 2013. We performed multiple generalized estimating equation (GEE) logistic regression analyses to assess the relationship between placement in a hospital vs. discharge, observation care vs. discharge, and observation care vs. admission. Results: Of 537,455 Medicare beneficiaries age ≥ 65 years who visited an ED in 2013, 48.0% (N= 258,083) were discharged, 10.5% (N=56,184) placed in observation care, and 41.5% (N=223,188) were admitted to the inpatient service following the ED visit. The top 2 diagnoses associated with placement in the hospital vs. discharge were ischemic heart disease and renal disease. Patients with symptomatic diagnoses such as chest pain and dizziness were more likely to be placed in observation care following an ED visit as compared to admission to the hospital. Conclusion: Compared to prior studies, we found a greater number of older Medicare ED patients placed in observation care and a lower number admitted to the hospital. Most common diagnoses of placement in observation care were symptom-based as compared to being admitted to the hospital which were disease-based.
Language	English
Publishing date	2018-03-15
Publishing country	Canada
Document type	Journal Article
ZDB-ID	2710785-1
ISSN	1927-7008 ; 1927-6990
ISSN (online)	1927-7008
ISSN	1927-6990
DOI	10.5430/jha.v7n3p9
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Article ; Online: A Risk Score to Predict Short-term Outcomes Following Emergency Department Discharge.

Gabayan, Gelareh Z / Gould, Michael K / Weiss, Robert E / Chiu, Vicki Y / Sarkisian, Catherine A

The western journal of emergency medicine

2018 Volume 19, Issue 5, Page(s) 842–848

Abstract: Introduction: The emergency department (ED) is an inherently high-risk setting. Risk scores can help practitioners understand the risk of ED patients for developing poor outcomes after discharge. Our objective was to develop two risk scores that predict ...

Abstract	Introduction: The emergency department (ED) is an inherently high-risk setting. Risk scores can help practitioners understand the risk of ED patients for developing poor outcomes after discharge. Our objective was to develop two risk scores that predict either general inpatient admission or death/intensive care unit (ICU) admission within seven days of ED discharge. Methods: We conducted a retrospective cohort study of patients age > 65 years using clinical data from a regional, integrated health system for years 2009-2010 to create risk scores to predict two outcomes, a general inpatient admission or death/ICU admission. We used logistic regression to predict the two outcomes based on age, body mass index, vital signs, Charlson comorbidity index (CCI), ED length of stay (LOS), and prior inpatient admission. Results: Of 104,025 ED visit discharges, 4,638 (4.5%) experienced a general inpatient admission and 531 (0.5%) death or ICU admission within seven days of discharge. Risk factors with the greatest point value for either outcome were high CCI score and a prolonged ED LOS. The C-statistic was 0.68 and 0.76 for the two models. Conclusion: Risk scores were successfully created for both outcomes from an integrated health system, inpatient admission or death/ICU admission. Patients who accrued the highest number of points and greatest risk present to the ED with a high number of comorbidities and require prolonged ED evaluations.
MeSH term(s)	Aged ; Aged, 80 and over ; Emergency Service, Hospital ; Female ; Hospital Mortality ; Humans ; Inpatients/statistics & numerical data ; Intensive Care Units/statistics & numerical data ; Male ; Outcome Assessment, Health Care/methods ; Patient Transfer ; Retrospective Studies ; Risk Factors
Language	English
Publishing date	2018-08-13
Publishing country	United States
Document type	Journal Article ; Multicenter Study
ZDB-ID	2375700-0
ISSN	1936-9018 ; 1936-9018
ISSN (online)	1936-9018
ISSN	1936-9018
DOI	10.5811/westjem.2018.7.37945
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Article ; Online: Predictors of admission after emergency department discharge in older adults.

Gabayan, Gelareh Z / Sarkisian, Catherine A / Liang, Li-Jung / Sun, Benjamin C

Journal of the American Geriatrics Society

2015 Volume 63, Issue 1, Page(s) 39–45

Abstract: Objectives: To identify predictors of hospital inpatient admission of older Medicare beneficiaries after discharge from the emergency department (ED).: Design: Retrospective cohort study.: Setting: Nonfederal California hospitals (n = 284).: ... ...

Abstract	Objectives: To identify predictors of hospital inpatient admission of older Medicare beneficiaries after discharge from the emergency department (ED). Design: Retrospective cohort study. Setting: Nonfederal California hospitals (n = 284). Participants: Visits of Medicare beneficiaries aged 65 and older discharged from California EDs in 2007 (n = 505,315). Measurements: Using the California Office of Statewide Health Planning and Development files, predictors of hospital inpatient admission within 7 days of ED discharge in older adults (≥65) with Medicare were evaluated. Results: Hospital inpatient admissions within 7 days of ED discharge occurred in 23,340 (4.6%) visits and were associated with older age (70-74: adjusted odds ratio (AOR) = 1.12, 95% confidence interval (CI) = 1.07-1.17; 75-79: AOR = 1.18, 95% CI = 1.13-1.23; ≥80: AOR = 1.4, 95% CI = 1.35-1.46), skilled nursing facility use (AOR = 1.82, 95% CI = 1.72-1.94), leaving the ED against medical advice (AOR = 1.82, 95% CI = 1.67-1.98), and the following diagnoses with the highest odds of admission: end-stage renal disease (AOR = 3.83, 95% CI = 2.42-6.08), chronic renal disease (AOR = 3.19, 95% CI = 2.26-4.49), and congestive heart failure (AOR = 3.01, 95% CI = 2.59-3.50). Conclusion: Five percent of older Medicare beneficiaries have a hospital inpatient admission after discharge from the ED. Chronic conditions such as renal disease and heart failure were associated with the greatest odds of admission.
MeSH term(s)	Aged ; California ; Emergency Service, Hospital/utilization ; Female ; Humans ; Male ; Medicare ; Patient Discharge ; Patient Readmission/statistics & numerical data ; Retrospective Studies ; Risk Factors ; United States
Language	English
Publishing date	2015-01
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, P.H.S.
ZDB-ID	80363-7
ISSN	1532-5415 ; 0002-8614
ISSN (online)	1532-5415
ISSN	0002-8614
DOI	10.1111/jgs.13185
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Article: Who Has an Unsuccessful Observation Care Stay?

Gabayan, Gelareh Z / Doyle, Brian / Liang, Li-Jung / Donkor, Kwame / Huang, David Yu-Chuang / Sarkisian, Catherine A

Healthcare (Basel, Switzerland)

2018 Volume 6, Issue 4

Abstract: Background: With the recent increase use of observation care, it is important to understand the characteristics of patients that utilize this care and either have a prolonged observation care stay or require admission.: Methods: We a conducted a ... ...

Abstract	Background: With the recent increase use of observation care, it is important to understand the characteristics of patients that utilize this care and either have a prolonged observation care stay or require admission. Methods: We a conducted a retrospective cohort study utilizing 5% sample data from Medicare patients age ≥65 years that was nationally representative in the year 2013. We performed a generalized estimating equation (GEE) logistic regression analysis to evaluate the relationship between an unsuccessful observation stay (defined as either requiring an inpatient admission from observation or having a prolonged observation stay) compared to having successful observation care. Observation cut offs of "successful" vs. "unsuccessful" were based on the CMS 2 midnight rule. Results: Of 154,756 observation stays in 2013, 19 percent (n = 29,604) were admitted to the inpatient service and 34,275 (22.2%) had a prolonged observation stay. The two diagnoses most likely to have an unsuccessful observation stay were intestinal infections (OR 1.56, 95% CI 1.32⁻1.83) and pneumonia (OR 1.26, 95% CI 1.13⁻1.41). Conclusion: We found patients placed in observation care with intestinal infections and pneumonia to have the highest odds of either being admitted from observation or having a prolonged observation stay.
Language	English
Publishing date	2018-11-27
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2721009-1
ISSN	2227-9032
ISSN	2227-9032
DOI	10.3390/healthcare6040138
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Article ; Online: Who Has an Unsuccessful Observation Care Stay?

Gelareh Z. Gabayan / Brian Doyle / Li-Jung Liang / Kwame Donkor / David Yu-Chuang Huang / Catherine A. Sarkisian

Healthcare, Vol 6, Iss 4, p

2018 Volume 138

Abstract	Background: With the recent increase use of observation care, it is important to understand the characteristics of patients that utilize this care and either have a prolonged observation care stay or require admission. Methods: We a conducted a retrospective cohort study utilizing 5% sample data from Medicare patients age ≥65 years that was nationally representative in the year 2013. We performed a generalized estimating equation (GEE) logistic regression analysis to evaluate the relationship between an unsuccessful observation stay (defined as either requiring an inpatient admission from observation or having a prolonged observation stay) compared to having successful observation care. Observation cut offs of “successful„ vs. “unsuccessful„ were based on the CMS 2 midnight rule. Results: Of 154,756 observation stays in 2013, 19 percent (n = 29,604) were admitted to the inpatient service and 34,275 (22.2%) had a prolonged observation stay. The two diagnoses most likely to have an unsuccessful observation stay were intestinal infections (OR 1.56, 95% CI 1.32⁻1.83) and pneumonia (OR 1.26, 95% CI 1.13⁻1.41). Conclusion: We found patients placed in observation care with intestinal infections and pneumonia to have the highest odds of either being admitted from observation or having a prolonged observation stay.
Keywords	observation care ; outcomes ; unsuccessful observation care ; observation failure ; Medicine ; R
Language	English
Publishing date	2018-11-01T00:00:00Z
Publisher	MDPI AG
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: A Risk Score to Predict Short-term Outcomes Following Emergency Department Discharge

Gelareh Z. Gabayan / Michael K. Gould / Robert E. Weiss / Vicki Y. Chiu / Catherine A. Sarkisian

Western Journal of Emergency Medicine, Vol 19, Iss

2018 Volume 5

Abstract	Introduction: The emergency department (ED) is an inherently high-risk setting. Risk scores can help practitioners understand the risk of ED patients for developing poor outcomes after discharge. Our objective was to develop two risk scores that predict either general inpatient admission or death/intensive care unit (ICU) admission within seven days of ED discharge. Methods: We conducted a retrospective cohort study of patients age > 65 years using clinical data from a regional, integrated health system for years 2009–2010 to create risk scores to predict two outcomes, a general inpatient admission or death/ICU admission. We used logistic regression to predict the two outcomes based on age, body mass index, vital signs, Charlson comorbidity index (CCI), ED length of stay (LOS), and prior inpatient admission. Results: Of 104,025 ED visit discharges, 4,638 (4.5%) experienced a general inpatient admission and 531 (0.5%) death or ICU admission within seven days of discharge. Risk factors with the greatest point value for either outcome were high CCI score and a prolonged ED LOS. The C-statistic was 0.68 and 0.76 for the two models. Conclusion: Risk scores were successfully created for both outcomes from an integrated health system, inpatient admission or death/ICU admission. Patients who accrued the highest number of points and greatest risk present to the ED with a high number of comorbidities and require prolonged ED evaluations.
Keywords	Medicine ; R ; Medical emergencies. Critical care. Intensive care. First aid ; RC86-88.9
Subject code	610
Language	English
Publishing date	2018-08-01T00:00:00Z
Publisher	eScholarship Publishing, University of California
Document type	Article ; Online
Database	BASE - Bielefeld Academic Search Engine (life sciences selection)

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Article ; Online: Emergency Department Vital Signs and Outcomes After Discharge.

Gabayan, Gelareh Z / Gould, Michael K / Weiss, Robert E / Derose, Stephen F / Chiu, Vicki Y / Sarkisian, Catherine A

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine

2017 Volume 24, Issue 7, Page(s) 846–854

Abstract: Objective: Vital signs are critical markers of illness severity in the emergency department (ED). Providers need to understand the abnormal vital signs in older adults that are problematic. We hypothesized that in patients age > 65 years discharged from ...

Abstract	Objective: Vital signs are critical markers of illness severity in the emergency department (ED). Providers need to understand the abnormal vital signs in older adults that are problematic. We hypothesized that in patients age > 65 years discharged from the ED, there are abnormal vital signs that are associated with an admission to an inpatient bed within 7 days of discharge. Methods: We conducted a retrospective cohort study using data from a regional integrated health system of members age > 65 years during the years 2009 to 2010. We used univariate contingency tables to assess the relationship between hospital admission within 7 days of discharge and vital sign (including systolic blood pressure [sBP], heart rate [HR], body temperature, and pulse oximetry [SpO Results: Of 104,025 ED discharges, 4,638 (4.5%) were followed by inpatient admission within 7 days. Vital signs had a greater odds of admission beyond a single cutoff. The vital signs with at least twice the odds of admission were sBP < 97 mm Hg (odds ratio [OR] = 2.02, 95% CI = 1.57-2.60), HR > 101 beats/min (OR = 2.00 95% CI = 1.75-2.29), body temperature > 37.3°C (OR = 2.14, 95% CI = 1.90-2.41), and pulse oximetry < 92 SpO Conclusion: While we found a majority of patients discharged with abnormal vital signs as defined by the analysis, not to be admitted after discharge, we identified vital signs associated with at least twice the odds of admission.
MeSH term(s)	Aged ; Aged, 80 and over ; Emergency Service, Hospital/statistics & numerical data ; Female ; Hospitalization/statistics & numerical data ; Humans ; Male ; Odds Ratio ; Patient Discharge/statistics & numerical data ; Retrospective Studies ; Sensitivity and Specificity ; Vital Signs/physiology
Language	English
Publishing date	2017-04-20
Publishing country	United States
Document type	Journal Article ; Multicenter Study
ZDB-ID	1329813-6
ISSN	1553-2712 ; 1069-6563
ISSN (online)	1553-2712
ISSN	1069-6563
DOI	10.1111/acem.13194
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Article ; Online: Patterns and preexisting risk factors of 30-day mortality after a primary discharge diagnosis of syncope or near syncope.

Derose, Stephen F / Gabayan, Gelareh Z / Chiu, Vicki Y / Sun, Benjamin C

Academic emergency medicine : official journal of the Society for Academic Emergency Medicine

2012 Volume 19, Issue 5, Page(s) 488–496

Abstract: Objectives: The risk of short-term mortality after an emergency department (ED) visit for syncope is poorly understood, resulting in prognostic uncertainty and frequent hospital admission. The authors determined patterns and risk factors for short-term ... ...

Abstract	Objectives: The risk of short-term mortality after an emergency department (ED) visit for syncope is poorly understood, resulting in prognostic uncertainty and frequent hospital admission. The authors determined patterns and risk factors for short-term mortality after a diagnosis of syncope or near syncope to aid in medical decision-making. Methods: A retrospective cohort study was performed of adult members of Kaiser Permanente Southern California seen at 11 EDs from 2002 to 2006 with a primary discharge diagnosis of syncope or near syncope (International Classification of Diseases, Ninth Revision [ICD-9] 780.2). The outcome was 30-day mortality. Proportional hazards time-to-event regression models were used to identify risk factors. Results: There were 22,189 participants with 23,951 ED visits, resulting in 307 deaths by 30 days. A relatively lower risk of death was reached within 2 weeks for ages 18 to 59 years, but not until 3 months or more for ages 60 and older. Preexisting comorbidities associated with increased mortality included heart failure (hazard ratio [HR] = 14.3 in ages 18 to 59 years, HR = 3.09 in ages 60 to 79 years, HR = 2.34 in ages 80 years plus; all p < 0.001), diabetes (HR = 1.49, p = 0.002), seizure (HR = 1.65, p = 0.016), and dementia (HR = 1.41, p = 0.034). If the index visit followed one or more visits for syncope in the previous 30 days, it was associated with increased mortality (HR = 1.86, p = 0.024). Absolute risk of death at 30 days was under 0.2% in those under 60 years without heart failure and more than 2.5% across all ages in those with heart failure. Conclusions: The low risk of death after an ED visit for syncope or near syncope in patients younger than 60 years old without heart failure may be helpful when deciding who to admit for inpatient evaluation. The presence of one or more comorbidities that predict death and a prior visit for syncope should be considered in clinical decisions and risk stratification tools for patients with syncope. Close clinical follow-up seems advisable in patients 60 years and older due to a prolonged risk of death.
MeSH term(s)	Adolescent ; Adult ; Aged ; Aged, 80 and over ; California/epidemiology ; Cohort Studies ; Comorbidity ; Dementia/epidemiology ; Emergency Service, Hospital ; Female ; Follow-Up Studies ; Heart Failure/epidemiology ; Humans ; Logistic Models ; Male ; Middle Aged ; Patient Discharge ; Retrospective Studies ; Risk Factors ; Survival Rate ; Syncope/diagnosis ; Syncope/mortality ; Time Factors ; Young Adult
Language	English
Publishing date	2012-05-18
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't
ZDB-ID	1329813-6
ISSN	1553-2712 ; 1069-6563
ISSN (online)	1553-2712
ISSN	1069-6563
DOI	10.1111/j.1553-2712.2012.01336.x
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Article ; Online: Emergency department crowding predicts admission length-of-stay but not mortality in a large health system.

Derose, Stephen F / Gabayan, Gelareh Z / Chiu, Vicki Y / Yiu, Sau C / Sun, Benjamin C

Medical care

2014 Volume 52, Issue 7, Page(s) 602–611

Abstract: Background: Emergency department (ED) crowding has been identified as a major threat to public health.: Objectives: We assessed patient transit times and ED system crowding measures based on their associations with outcomes.: Research design: ... ...

Abstract	Background: Emergency department (ED) crowding has been identified as a major threat to public health. Objectives: We assessed patient transit times and ED system crowding measures based on their associations with outcomes. Research design: Retrospective cohort study. Subjects: We accessed electronic health record data on 136,740 adults with a visit to any of 13 health system EDs from January 2008 to December 2010. Measures: Patient transit times (waiting, evaluation and treatment, boarding) and ED system crowding [nonindex patient length-of-stay (LOS) and boarding, bed occupancy] were determined. Outcomes included individual inpatient mortality and admission LOS. Covariates included demographic characteristics, past comorbidities, severity of illness, arrival time, and admission diagnoses. Results: No patient transit time or ED system crowding measure predicted increased mortality after control for patient characteristics. Index patient boarding time and lower bed occupancy were associated with admission LOS (based on nonoverlapping 95% CI vs. the median value). As boarding time increased from none to 14 hours, admission LOS increased an additional 6 hours. As mean occupancy decreased below the median (80% occupancy), admission LOS decreased as much as 9 hours. Conclusions: Measures indicating crowded ED conditions were not predictive of mortality after case-mix adjustment. The first half-day of boarding added to admission LOS rather than substituted for it. Our findings support the use of boarding time as a measure of ED crowding based on robust prediction of admission LOS. Interpretation of measures based on other patient ED transit times may be limited to the timeliness of care.
MeSH term(s)	Adolescent ; Adult ; Aged ; Aged, 80 and over ; Electronic Health Records ; Emergency Service, Hospital/statistics & numerical data ; Female ; Hospital Mortality ; Humans ; Length of Stay/statistics & numerical data ; Male ; Middle Aged ; Retrospective Studies ; Time Factors ; Waiting Lists ; Young Adult
Language	English
Publishing date	2014-06-12
Publishing country	United States
Document type	Journal Article ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't
ZDB-ID	411646-x
ISSN	1537-1948 ; 0025-7079
ISSN (online)	1537-1948
ISSN	0025-7079
DOI	10.1097/MLR.0000000000000141
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Article ; Online: Emergency Department Crowding and Outcomes After Emergency Department Discharge.

Gabayan, Gelareh Z / Derose, Stephen F / Chiu, Vicki Y / Yiu, Sau C / Sarkisian, Catherine A / Jones, Jason P / Sun, Benjamin C

Annals of emergency medicine

2015 Volume 66, Issue 5, Page(s) 483–492.e5

Abstract: Study objective: We assess whether a panel of emergency department (ED) crowding measures, including 2 reported by the Centers for Medicare & Medicaid Services (CMS), is associated with inpatient admission and death within 7 days of ED discharge.: ... ...

Abstract	Study objective: We assess whether a panel of emergency department (ED) crowding measures, including 2 reported by the Centers for Medicare & Medicaid Services (CMS), is associated with inpatient admission and death within 7 days of ED discharge. Methods: We conducted a retrospective cohort study of ED discharges, using data from an integrated health system for 2008 to 2010. We assessed patient transit-level (n=3) and ED system-level (n=6) measures of crowding, using multivariable logistic regression models. The outcome measures were inpatient admission or death within 7 days of ED discharge. We defined a clinically important association by assessing the relative risk ratio and 95% confidence interval (CI) difference and also compared risks at the 99th percentile and median value of each measure. Results: The study cohort contained a total of 625,096 visits to 12 EDs. There were 16,957 (2.7%) admissions and 328 (0.05%) deaths within 7 days. Only 2 measures, both of which were patient transit measures, were associated with the outcome. Compared with a median evaluation time of 2.2 hours, the evaluation time of 10.8 hours (99th percentile) was associated with a relative risk of 3.9 (95% CI 3.7 to 4.1) of an admission. Compared with a median ED length of stay (a CMS measure) of 2.8 hours, the 99th percentile ED length of stay of 11.6 hours was associated with a relative risk of 3.5 (95% CI 3.3 to 3.7) of admission. No system measure of ED crowding was associated with outcomes. Conclusion: Our findings suggest that ED length of stay is a proxy for unmeasured differences in case mix and challenge the validity of the CMS metric as a safety measure for discharged patients.
MeSH term(s)	California ; Crowding ; Emergency Service, Hospital/organization & administration ; Female ; Humans ; Length of Stay/statistics & numerical data ; Male ; Patient Discharge ; Retrospective Studies ; Waiting Lists
Language	English
Publishing date	2015-11
Publishing country	United States
Document type	Journal Article ; Multicenter Study ; Research Support, N.I.H., Extramural ; Research Support, Non-U.S. Gov't ; Research Support, U.S. Gov't, P.H.S.
ZDB-ID	603080-4
ISSN	1097-6760 ; 0196-0644
ISSN (online)	1097-6760
ISSN	0196-0644
DOI	10.1016/j.annemergmed.2015.04.009
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