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

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.

Evaluating diverse electronic consultation programs with a common framework.

Background: Electronic consultation is an emerging mode of specialty care delivery that allows primary care providers and their patients to obtain specialist expertise without an in-person visit. While studies of individual programs have demonstrated benefits related to timely access to specialty care, electronic consultation programs have not achieved widespread use in the United States. The lack of common evaluation metrics across health systems and concerns related to the generalizability of existing evaluation efforts may be hampering further growth.

A cohort study of a general surgery electronic consultation system: safety implications and impact on surgical yield.

Background: Electronic consultation (eConsult) systems have enhanced access to specialty expertise and enhanced care coordination among primary care and specialty care providers, while maintaining high primary care provider (PCP), specialist and patient satisfaction. Little is known about their impact on the efficiency of specialty care delivery, in particular surgical yield (percent of ambulatory visits resulting in a scheduled surgical case).

Methods: Retrospective cohort of a random selection of 150 electronic consults from PCPs to a safety-net general surgery clinic for the three most common general surgery procedures (herniorrhaphy, cholecystectomy, anorectal procedures) in 2014.

Specialty Care Access in the Safety Net-the Role of Public Hospitals and Health Systems.

Access to specialty care in the United States safety net, already strained, is fac-ing increasing pressure with an influx of patients following the passage of the Affordable Care Act (ACA). We surveyed 18 public hospitals and health systems across the country to describe the current state of specialty care delivery in safety-net systems. We elicited information regarding challenges, provider models, metrics of access and productivity, and strategies for improving access.

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

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.

Minding the Gaps: Assessing Communication Outcomes of Electronic Preconsultation Exchange.

Background: Effective communication between referring and specialty providers is key to optimizing patient safety. Communication was assessed in an electronic referral system by review of referrals to a public urban health care system's gastroenterology clinic that were not scheduled for appointments.

Methods: All electronic referrals to a publicly funded, urban health care system's adult gastroenterology clinic from November 1, 2009, to November 30, 2010, were reviewed that did not result in scheduling of appointments.

Displaying radiation exposure and cost information at order entry for outpatient diagnostic imaging: a strategy to inform clinician ordering.

Background: Displaying radiation exposure and cost information at electronic order entry may encourage clinicians to consider the value of diagnostic imaging.

Methods: An urban safety-net health system displayed radiation exposure information for CT and cost information for CT, MRI and ultrasound on an electronic referral system for outpatient ordering. We assessed whether there were differences in numbers of outpatient CT scans and MRIs per month relative to ultrasounds before and after the intervention, and evaluated primary care clinicians' responses to the intervention.

Leveraging an electronic referral system to build a medical neighborhood.

Background: Electronic referral and consultation systems are gaining popularity, but their contribution to the patient centered medical home-neighborhood framework of coordinated care delivery is not clear. We examined how specialists leverage an electronic referral and consultation system to deliver specialty care, identified determinants of high-quality electronic specialist communication and measured the impact of feedback to specialists on communication quality.

Methods: Referral patterns were identified for 19 specialties using eReferral in the San Francisco public health care delivery system.

Facilitators and barriers to implementing electronic referral and/or consultation systems: a qualitative study of 16 health organizations.

Background: Access to specialty care remains a challenge for primary care providers and patients. Implementation of electronic referral and/or consultation (eCR) systems provides an opportunity for innovations in the delivery of specialty care. We conducted key informant interviews to identify drivers, facilitators, barriers and evaluation metrics of diverse eCR systems to inform widespread implementation of this model of specialty care delivery.

Changes in research on language barriers in health care since 2003: A cross-sectional review study.

Background: Understanding how to mitigate language barriers is becoming increasingly important for health care providers around the world. Language barriers adversely affect patients in their access to health services; comprehension and adherence; quality of care; and patient and provider satisfaction. In 2003, the United States (US) government made a major change in national policy guidance that significantly affected limited English proficient patients' ability to access language services.

Efficiency Gains for Rheumatology Consultation Using a Novel Electronic Referral System in a Safety-Net Health Setting.

Objective: Health information technology (HIT) holds promise in increasing access to rheumatologists by improving the quality and efficiency of referrals, but few studies have examined its use for this purpose. We evaluated the use and impact of a novel electronic referral (eReferral) system in rheumatology in a safety-net health system.

Methods: We examined eReferrals over 4 years.

Clinicians' views on displaying cost information to increase clinician cost-consciousness.

Objectives: To evaluate 1) clinician attitudes towards incorporating cost information into decision making when ordering imaging studies; and 2) clinician reactions to the display of Medicare reimbursement information for imaging studies at clinician electronic order entry.

Study Design: Focus group study with inductive thematic analysis.

Methods: We conducted focus groups of primary care clinicians and subspecialty physicians (nephrology, pulmonary, and neurology) (N = 50) who deliver outpatient care in 12 hospital-based clinics and community health centers in an urban safety net health system.

Increasing access to specialty care: patient discharges from a gastroenterology clinic.

Objectives: Access to specialty care among safety net patients in the United States is inadequate. Discharging appropriate patients to routine primary care follow-up may improve specialty care access. We sought to identify, by consensus, patients who could safely be discharged from a gastroenterology (GI) clinic, and to evaluate the impact of the discharges on GI clinic work flow.

Electronic Preconsultation as a Method of Quality Improvement for Urological Referrals.

Introduction: Preconsultation exchange is a method to promote expedited care among health care providers through communication between primary care providers and specialists before a clinic visit. We evaluated the efficacy of a preconsultation exchange in streamlining patient visits to the urology clinic with an emphasis on resource efficiency in a safety net hospital.

Methods: Between April 1, 2011 and March 31, 2012 there were 1,705 electronic referrals to our urology department.

Assessment of HBV preventive services in a medically underserved Asian and Pacific Islander population using provider and patient data.

Background: Hepatitis B (HBV) represents a significant health disparity among medically underserved Asian and Hawaiian/Pacific Islander (API) populations. Studies evaluating adherence to HBV screening and vaccination guidelines in this population are limited.

Objective: The purpose of this study was to evaluate HBV screening and vaccination practices using both provider self-report and patient records.

"Choosing wisely" in an academic department of medicine.

The "Choosing Wisely" campaign seeks to reduce unnecessary care in the United States through self-published recommendations by professional societies. The research team sought to identify factors related to low-value care in the Department of Medicine at the University of California San Francisco, using a subset of clinical scenarios published by the American College of Physicians. The team further explored respondents' values on cost consciousness.

Clinician perspectives on considering radiation exposure to patients when ordering imaging tests: a qualitative study.

Background And Objectives: Increased computer tomography (CT) scan use has contributed to a rise in medically-associated radiation exposure. The extent to which clinicians consider radiation exposure when ordering imaging tests is unknown. We examined (1) outpatient clinician attitudes towards considering radiation exposure when ordering CT scans; and (2) clinician reactions to displaying radiation exposure information for CT scans at clinician electronic order entry.

Expanding the Universal Medication Schedule: a patient-centred approach.

Objective: Improved drug labelling for chronic pill-form medications has been shown to promote patient comprehension, adherence and safety. We extended health literacy principles and included patients' perspectives to improve instructions for: (1) non-pill form, (2) short term, (3) 'as needed,' (4) tapered and (5) escalating dose medications.

Setting: Participants were recruited via convenience sampling from primary care clinics in Chicago, Illinois and San Francisco, California, USA.

Hepatitis B management in vulnerable populations: gaps in disease monitoring and opportunities for improved care.

Background: Hepatitis B (HBV) is prevalent in certain US populations and regular HBV disease monitoring is critical to reducing associated morbidity and mortality. Adherence to established HBV monitoring guidelines among primary care providers is unknown.

Aims: The purpose of this study was to evaluate HBV disease monitoring patterns and factors associated with adherence to HBV management guidelines in the primary care setting.

Chemokine receptor-like 2 is involved in ischemic brain injury.

We examined the role of CCRL2 in ischemic brain injury using both and mouse stroke models. The expression of CCRL2 was enhanced at both the RNA and protein levels in cultured brain slices under ischemic conditions. Ischemia-induced cell death was reduced in brain slices derived from CCRL2 knockout (KO) mice in comparison with those from wild type (WT) mice.