Bellamkonda, Venkatesh R.

AbstractObjectivesPatients with limited English proficiency (LEP) have been shown to experience disparities in emergency department (ED) care. The objectives of this study were to examine the associations between LEP and irregular ED departures and return ED visits.MethodsWe conducted a multicenter cross‐sectional analysis of 18 EDs within an integrated health system in the upper Midwest from January 1, 2018, to December 31, 2021. ED visits of pediatric and adult patients who were discharged on the index visit were included for analysis. We analyzed the association of LEP with irregular departures, 72‐h and 7‐day return visits, and ED disposition at the time of that return visit. Multivariable model associations were calculated using generalized estimating equations and reported as odds ratios (OR) with 95% confidence intervals (CIs).ResultsA total of 745,464 total ED visits were analyzed, including 27,906 (3.7%) visits among patients with LEP. The most common preferred languages among patients with LEP were Spanish (12,759; 45.7%), Somali (4978; 17.8%), and Arabic (3185; 11.4%). After multivariable adjustment there were no differences in proportions of irregular departures (OR 1.09, 95% CI 0.99–1.21), 72‐h returns (OR 0.99, 95% CI 0.92–1.06), or 7‐day returns (OR 0.99, 95% CI 0.93–1.05) between patients with LEP or English proficiency. Patients with LEP returning within 72 h (OR 1.19, 95% CI 1.01–1.40) and 7 days (OR 1.15, 95% CI 1.01–1.33) were more likely to be admitted to the hospital.ConclusionsAfter multivariable adjustment, we did not find an increased frequency of irregular ED departures or 72‐h or 7‐day returns among patients with LEP compared with people proficient in English. However, we did find that higher proportions of patients with LEP were admitted to the hospital at the time of the return ED visit.

AbstractBackgroundTo determine the impact of personalized risk communication and opioid prescribing on nonprescribed opioid use, we conducted a secondary analysis of randomized controlled trial participants followed prospectively for 90 days after an emergency department (ED) visit for acute back or kidney stone pain.MethodsA total of 1301 individuals were randomized during an encounter at four academic EDs into a probabilistic risk tool (PRT) arm, a narrative‐enhanced PRT arm, or a general risk information arm (control). In this secondary analysis, both risk tool arms were combined and compared with the control arm. We used logistic regressions to determine associations between receiving personalized risk information, receiving an opioid prescription in the ED, and nonprescribed opioid use in general and by race.ResultsComplete follow‐up data were available for 851 participants; 23.3% (n = 198) were prescribed opioids (34.2% of White vs. 11.6% of Black participants, p < 0.001). Fifty‐six (6.6%) participants used nonprescribed opioids. Participants in the personalized risk communication arms had lower nonprescribed opioid use odds (adjusted odds ratio [aOR] 0.58, 95% confidence interval [CI] 0.4–0.83). Black versus White participants had greater nonprescribed opioid use odds (aOR 3.47, 95% CI 2.05–5.87, p < 0.001). Black participants who were prescribed opioids had a lower marginal probability of using nonprescribed opioids versus those who were not (0.06, 95% CI 0.04–0.08, p < 0.001 vs. 0.10, 95% CI 0.08–0.11, p < 0.001). The absolute risk difference in nonprescribed opioid use for Black and White participants, respectively, in the risk communication versus the control arm, was 9.7% and 0.1% (relative risk ratio 0.43 vs. 0.95).ConclusionsAmong Black but not White participants, personalized opioid risk communication and opioid prescribing were associated with lower odds of nonprescribed opioid use. Our findings suggest that racial disparities in opioid prescribing—which have been previously described within the context of this trial—may paradoxically increase nonprescribed opioid use. Personalized risk communication may effectively reduce nonprescribed opioid use, and future research should be designed specifically to explore this possibility in a larger cohort.

This article presents three successfully litigated medical malpractice cases involving emergency physicians and consultants. We discuss the respective case medical diagnoses, as well as established legal principles that determine in a court proceeding which provider will be liable. Specifically, we explain the legal principles of “patient physician relationship” and “affirmative act.”

AbstractBackgroundGiven that abdominal aorta is a retroperitoneal structure, increased body mass index (BMI) may have an adverse effect upon the quality of aortic ultrasonographic imaging.PurposeTo assess the hypothesis that increased BMI is associated with worsening point‐of‐care abdominal aortic ultrasonographic image quality.MethodsThis is a retrospective single‐center study of point‐of‐care abdominal aortic ultrasound examinations performed in an academic emergency department (ED) with fellowship‐trained emergency ultrasonography faculty performing quality assurance review.ResultsMean ± SD BMI was 27.4 ± 6.2, among the 221 included records. The overall quality rating decreased as BMI increased (correlation coefficient − 0.24; P < .001) and this persisted after adjustment for age and sex (P < .001). Although BMI was higher on average in the records that were of insufficient quality for clinical decisions when compared with those of sufficient quality (mean BMI 28.7 vs 27.0), this did not reach statistical significance in a univariable setting (P = .11) or after adjusting for age and sex (P = .14).ConclusionThis study data shows a decrease in point‐of‐care abdominal aorta ultrasound imaging quality as BMI increases, though this difference did not result in a statistically significant impairment in achieving the minimum quality for clinical decisions. This finding may help ameliorate some clinician concerns about ultrasonography for patients with high BMI.

AbstractBackgroundMany clinicians believe that a patient's body mass index (BMI) affects the likelihood of obtaining high quality ultrasound images.ObjectivesTo assess the hypothesis that increased BMI is associated with worsening focused assessment with sonography in trauma (FAST) image quality.MethodsWe conducted a retrospective single‐center study of FAST examinations performed in a large academic emergency department (ED) with fellowship‐trained emergency ultrasonography faculty performing quality assurance review.ResultsMean (SD) BMI was 28.0 (6.6) among the 302 included studies. The overall quality rating tended to decrease as BMI increased but did not achieve statistical significance in a univariable setting (P = .06) or after adjustment for age and sex (P = .06). Operators perception of image adequacy was largely unaffected by BMI, with the exception of the pericardial view.ConclusionThis study did not identify a statistically significant difference in FAST quality with increased BMI. This result may help assuage clinician concerns about ultrasonography for patients in the ED.