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Tuesday, September 16, 2014

A new report from the Medicaid and CHIP Payment and Access Commission (MACPAC) found that Medicaid enrollees have generally more complex health needs than their privately insured counterparts, and those needs can only be addressed in the emergency department.


Nearly all Medicaid enrollees reported having a regular care center other than the ED, but about one-third of adult and 13 percent of child enrollees said they encountered barriers to finding a physician or delays in receiving care. The lack of access to primary care was even more acute for Medicaid patients with disabilities, who are disproportionately represented on Medicaid rolls. The lack of access to primary care contributes to Medicaid patients’ use of the ED, but even having a primary care physician is no bar against emergency department use for those patients with serious mental illness, multiple illnesses, and homelessness, the study said.


MACPAC found that nonurgent visits accounted for just 10 percent of Medicaid visits to the ED, which is close to the general population’s eight percent. A report from the Centers for Studying Health System Change in 2012 also found that most emergency visits by Medicaid patients are for urgent or serious symptoms.

Monday, September 15, 2014

A study funded by the National Institute on Drug Abuse (NIDA) shows that one-third of ED patients who initially declined to be tested for HIV changed their minds after watching a short video.


Researchers showed the 16-minute video to 160 patients who declined testing in a high volume, urban ED. It outlined the importance of testing, and demonstrated how an HIV test can be done orally instead of through blood work, and can yield results in about 20 minutes.


Participants were randomly put into four groups and shown different videos. Patients saw either a white health care provider speaking with a white patient about the importance of HIV testing, or a black health care provider speaking with a black patient. The study also randomized participants to see health care providers describing the benefits of testing and dangers of not testing.


Differences in treatment groups emerged based on the race of participants. The study found significantly greater increases in knowledge and intent to use a condom during vaginal sex among black participants who watched videos depicting white people, compared with black participants randomly assigned to see black people onscreen. The study also found white participants were significantly more likely to accept an HIV test after viewing videos with positive emotional content, compared with white participants who watched negative emotional content.


Interviews with 40 of the patients found that many were unaware that HIV testing could be done without drawing blood or that results could be delivered within 20 minutes. Read the full study at

Friday, September 12, 2014

Emergency department visits have increased in states that expanded Medicaid, according to a Colorado Hospital Association’s (CHA) nationwide study.


The average number of ED visits to hospitals in states that expanded Medicaid grew to 5.6 percent from second quarter 2013 to second quarter 2014, the report said. In comparison, hospitals in states that refused expansion reported a 1.8 percent increase in ED visits in the same period.


CHA also conducted a Colorado-specific analysis that indicated that the newly-insured Medicaid patients have more complex conditions than the average Medicaid patient previously seen in EDs. The case mix index, which measures complexity and resource needs, increased 10 percent for Medicaid patients in the first quarter of 2014 as compared with first quarter 2013. Moreover, the number of Medicaid-covered ED visits increased 38 percent in first quarter 2014.


On the other side of the spectrum, a study in Health Affairs found a drop in ED use among young adults who are now eligible for health insurance under the ACA. This study looked at 2009-2011 state administrative records from California, Florida, and New York to compare changes in ED use in patients ages 19-25 before and after the ACA provision took effect. The younger group had a decrease of 2.7 ED visits per 1,000 people after ACA implementation.



Thursday, September 11, 2014

By Alex Mohseni, MD


Context and challenge are two features that make learning fun and more effective, which is why I have always preferred to learn through difficult case studies. I am always on the lookout for challenging case studies with detailed explanatory narratives, and so I came upon McGraw-Hill’s Case Files Emergency Medicine app on iOS. Available for $29.99, it’s a bit pricey as apps go, and offers no real discount compared with the paperback version.

The app itself is nicely designed, and has a simple and useful interface to browse cases randomly or by topic. Each case is followed by thought-provoking questions, answers, and then relatively detailed analyses, algorithms, pearls, and a quiz. The material seems perfect for first- and second-year emergency medicine residents, but probably a bit too basic for more seasoned attendings. Case studies include staples like acute coronary syndrome, DKA, febrile seizure, and pharyngitis. I picked up an interesting new pearl with every third case or so, but most ED attendings would find the work:reward ratio unsuitable.

To compound the high price and the low reward, many readers have noted an embarrassing number of typos and misspellings in the app and the original text. Check out the reviews for this app on the iOS App Store if you want to see something really fishy. A bunch of five-star reviews all originated within 48 hours of each other on the App Store with poor English syntax and spelling; hopefully they are not representative of emergency physicians’ writing skills. We can also hope McGraw-Hill is spending its to create better content, not to buy five-star reviews.


Dr. Mohseni is an emergency physician in the Washington, D.C., metropolitan area and the counsel to the president for innovation and technology of Emergency Medicine Associates. He is the editor of his own blog, Follow him @amohseni, and read his past columns at


Wednesday, September 10, 2014

The United States will need to produce 1.1 million new registered nurses by 2022 to fill newly created jobs and replace retirees; one in five nurses is expected to retire soon, according to an announcement from the American Nurses Association (ANA).


Demand for health care services is growing largely because of the aging Baby Boomer generation and health care reforms that increase access to care, transform the system to pay for quality, and increase the focus on prevention and primary care services.


The ANA suggested thwarting the nursing shortage by increasing federal funding for Title VIII by 12 percent for 2015, bolstering nurse education by developing and recruiting more educators and increasing capacity of nursing programs, and highlighting the importance of transitioning from education to practice.