1698 Correspondence / American Journal of Emergency Medicine 36 (2018) 1693-1715

months after ED CG initiation; the number of primary care provider en- counters 12 months prior-to, and 3 months after ED CG initiation; chief complaint at time of CG initiation, and number of previous visits for that

Table 1

Chief complaints leading to CG initiation, and change-per-month after initiation. Positive value in visit change indicates an increase in the number of visits for that specific com- plaint after the CG initiation, and a negative value indicates a decrease.

same complaint prior to initiation; and finally, demographic informa-

tion such as age, gender and insurance provider. These data were ana- lyzed with respect to the number of ED and primary care visits both prior-to and after the initiation of each CG.

There were 287 patients with a CG included in this study. Of those, 80 patients (27.8%) were male and 207 patients (72.2%) were female. Mean age of subjects was 38.3 +- 11.9 years. Only 19.4% of patients with CGs had private insurance. Overall, 75.3% of CGs belonged to pa- tients with either government sponsored or government subsidy insur- ance plans. Mean ED visits/month before CG was 1.20 +- 0.66, and after CG assignment was 0.71 +- 0.54. This represents approximately a 41% (95% CI, 43.2% to 54.8%) Decrease in ED visits per month. Mean PCP visits/month before CG was 0.31 +- 0.64, and after assignment was

0.28 +- 0.68 (p = .30). The chief complaints leading to CG initiation, as well as the change-per-month of these complaints after initiation of the CG can be seen in the Table 1. Overall, 42% of patients had CG initi- ated for pain-related complaints. The visit change analysis showed that visits for pain-related complaints decreased by 0.51 visits/month.

These results demonstrate that CG initiation reduces ED utilization

by at least 40% for chronic non-emergent complaints, but fails to show that these patients are being redirected back to primary care resources. Care managing strategies have been implemented at multiple other fa- cilities and have shown varying degrees of improvED patient care, de- creased radiation, decreased unnecessary testing, and decreased costs, in addition to directing patients to the most appropriate care setting for their complaints [4-10]. There are several limitations of this study which may contribute to these findings. One is the inability to track pa- tients PCP visits outside of this hospital-specific system. Also, there are no universal criteria for establishing a CG. Therefore, there may be many patients who could benefit from a CG who have not been assigned one, and others that may not have had an impactful decline in visit numbers because they were prematurely assigned a CG.

Case management follows up with every patient with a CG every time they are seen in the ED. This encourages correct use of the ED and ensures patients have appropriate primary care follow-up and resources. While there was a statistically significant decrease in ED visits after CG initiation this may be due in part to the diminished prescription of opioids in the ED. Often times CGs specify that no narcotics be given until acute pathology be proved or alternative treatments to opiates offered. Breaking the cycle of treating chronic pain complaints with opiates may have lead pa- tients to stop seeking these medications in the ED, but did not result in any more follow-up with their primary care physician.

Kristin Shnowske, DO¹ David D. Berg, DO* Patti Guntern, DO² Dana Hop, DO³

Metro Health Hospital-University of Michigan Hospital, Department of

Emergency Medicine, United States

*Corresponding author at: 4669 Canterwood Ct NE, Ada, MI 49301,

United States.

E-mail address: [email protected] (D.D. Berg).

9 January 2018

https://doi.org/10.1016/j.ajem.2018.01.036

¹ 4203 Avalanche Ave, Yakima, WA, 98908.

² 7819 GRACEmore Ct, Alto, MI 49302.

³ 10275 Eastern Ave SE, Wayland, MI 49348.

References

1. Gutherz C, Baron S. Why patients with primary care physicians use the emergency department for non-urgent care. Einstein Q J Biol Med 2001;18:171-6.
2. Davidson S. Understanding the growth of emergency department utilization. Med

   Care 1978;16:122-32.

   Enard KR, Ganelin DM. Reducing preventable emergency department utilization and costs by using community health workers as patient navigators. J Healthc Manag 2014;58(6):412-28.

3. Shumway M, Boccellari A, O’Brien K, et al. Cost-effectiveness of clinical case manage-

   ment for ED frequent fliers: results of a randomized trial. Am J Emerg Med 2008; 26(2):155-64.

   care plans for frequent flyers save money, cut costs, Hosp Case Manag 2006;14(2):22 (30-31).

4. Grover C, Close R, Villarreal K, et al. Emergency department frequent user: pilot study of intensive case management to reduce visits and computed tomography. West J Emerg Med 2010;11(4):336-43.
5. Okin RL, Boccellari A, Azocar F, et al. The effects of clinical case management on hos- pital service use among ED frequent users. Am J Emerg Med 2000;18(5):603-8.
6. Skinner J, Carter L, Haxton C. The effects of clinical case management on hospital ser-

   vice use among ED frequent users. Am J Emerg Med 2009;26(2):103-5.

   Spillane LL, Lumb EW, Cobaugh DJ, et al. Frequent users of the emergency depart- ment: can we intervene? Academy Emerg Med 1997;4(6):574-80.

7. Stokes-Buzzelli S, Peltzer-Jones J, Martin B, et al. Use of health information technol-

   ogy to manage frequently presenting emergency department patients. West J Emerg Med 2010;11(4):348-53.

   Effect of rivaroxaban starter packs on emergency department throughput

   1. Rivaroxaban starter packs and ED throughput

   Emergency department (ED) overcrowding impedes delivery of high quality, efficient care [1]. One solution is improving ED throughput, which is measured by ED length of stay [2]. This study examined the impact of rivaroxaban starter packs for treatment of venous thromboembolism in patients discharged from the ED. Starter packs contain a 30-day supply of rivaroxaban for initial treatment of VTE. The primary outcome was ED LOS for patients treated with the starter pack compared to alterna- tive anticoagulation. Secondary outcomes included ED or hospital readmis- sion within 7 and 30 days and outpatient follow-up within 30 days.

   This retrospective study included patients from four University of Pittsburgh Medical Center (UPMC) hospitals in Pittsburgh, PA and was approved by the University of Pittsburgh Institutional Review Board. We included patients 18 years and older with an ED visit from January 01, 2014 to December 31, 2016 and primary diagnosis of VTE confirmed with diagnostic imaging. Exclusion criteria included anticoagulation with- in one week before the ED visit or admission from ED to the hospital.

   The starter pack was prescribed at the discretion of the ED physician and dispensed from the ED in accordance with legal requirements for

   Correspondence / American Journal of Emergency Medicine 36 (2018) 1693-1715 1699

   dispensing an outpatient prescription. Patients were counseled on all discharge medications per the EDs’ policies and procedures.

   A total of 255 individuals were included: 86 individuals received a start- er pack and 169 individuals received alternative anticoagulation. Of the 169 individuals, 87 received a dose of enoxaparin, 22 received a dose of both enoxaparin and warfarin, 1 received a dose of warfarin only, 1 received an intravenous (IV) heparin infusion, 50 received a single dose of rivaroxaban, and 8 received a dose of apixaban. The individual who received an IV hep- arin infusion was given an outpatient prescription for rivaroxaban.

   There were no significant differences in baseline characteristics (Table 1). Additionally, there were 103 physicians for the 255 patient visits.

   There were no statistically significant differences in ED LOS, return ED visits, or Hospital readmissions (Table 2). Initial outpatient 30-day follow- up was similar between both groups. A sub-group analysis comparing the individual anticoagulants to the starter pack showed no statistical differ- ences in ED LOS.

   There was no difference in ED LOS with use of the starter pack compared to alternative anticoagulation. The Average ED LOS was comparable to other studies [3,4]. We hypothesized that ED LOS would be longer with enoxaparin due to weight-based dosing and education related to injection technique and warfarin bridging. Furthermore, treatment with either enoxaparin or a single dose of a direct oral anticoagulant often requires de- termination of outpatient costs to ensure medication access post-discharge. ED LOS may have been similar between groups as standard ED practice is to provide patient education for any new medications prescribed. Additional- ly, our ED providers often discuss initial anticoagulation selection with the patient’s primary care physician, which could impact ED LOS.

   Secondary outcomes support previous findings that use of rivaroxaban starter packs in the ED is both safe and effective [5]. Hospital readmissions and ED visits regarding VTE and/or bleeding were similar between groups. Patients were no less likely to seek outpatient follow- up within 30 days. Patient satisfaction was not measured; however, an additional benefit of the starter pack is improved medication access. Thus, challenges with delays in filling prescriptions or problems with ini- tial insurance coverage may be avoided, especially during the period of highest VTE recurrence [6]. Use of rivaroxaban starter packs is likely to in- crease as rivaroxaban is recommended as a first-line option for VTE treat- ment [7]. This study supports rivaroxaban starter packs as a safe and effective choice for initial VTE treatment in patients discharged from the ED to the community.

   Conflicts of interest

   None declared.

   Gina T. Ayers, PharmD, BCPS*

   Frank D’Amico, PhD Roberta M. Farrah, PharmD, BCPS, BCACP Patricia M. Klatt, PharmD, BCPS Megan A. Baumgartner, PharmD, BCPS

   University of Pittsburgh Medical Center St. Margaret, 815 Freeport Road,

   Pittsburgh, PA 15215, United States

   *Corresponding author at: 815 Freeport Road, Pittsburgh, PA 15215,

   United States.

   E-mail address: [email protected] (G.T. Ayers).

   14 October 2017

   https://doi.org/10.1016/j.ajem.2018.01.043

   References

   Derlet RW, Richards RJ. Overcrowding in the nation’s emergency departments: com- plex causes and disturbing effects. Ann Emerg Med 2000;35(1):63-8.

8. Yoon P, Steiner I, Reinhardt G. Analysis of factors influencing length of stay in the emergency department. Can J Emerg Med 2003;5(3):155-61.
9. Rathley NK, Obendorfer D, White LF, et al. Time series analysis of emergency depart- ment length of stay per 8-hour shift. West J Emerg Med 2012 May;13(2):163-8.
10. Horwitz LI, Green J, Bradley EH. US emergency department performance on wait time

    and length of visit. Ann Emerg Med 2010 Feb;55(2):133-41.

    Chu A, Limberg J. Findings from a rivaroxaban program for acute venous thromboem- bolism upon emergency department discharge, with focus on utility of commercially available dose pack. Am J Emerg Med 2017 Dec;35(12):1910-4.

11. Limone BL, Hernandez AV, Michalak D, Bookhart BK, Coleman CI. Timing of recurrent venous thromboembolism early after the index event: a meta-analysis of randomized controlled trials. Thromb Res 2013;132(4):420-6.
12. Kearon C, Akl EA, Ornelas J, et al. antithrombotic therapy for VTE disease: CHEST guidelines and expert panel report. Chest 2016 Feb;149(2):315-52.

    Cardiac arrest while exercising on mountains

    Letter to the editor,

    Highly interesting data on the risk and outcomes of cardiac arrest while exercising in the mountains have recently been presented in this Journal by Jung et al. [1]. The reported prevalence of cardiac arrest in the mountainous areas of national or provincial parks in Korea was 0.35 per 1,000,000 visits being somewhat higher during the winter season. The prognosis of cardiac arrest in the mountains was poor when com- pared to that not occurring in mountainous areas primarily due to fewer performed defibrillation and significantly longer pre-hospital times. In my opinion, 2 points deserve discussion in more depth. First, 96% of all cardiac arrests in the mountains affected males. This is an

    Table 1

    Baseline characteristics by study group.

    Characteristic	Starter pack (n = 86)	Other (n = 169)	P-value
    Age (yr) - mean (SD)	54.5 (16.4)	54.5 (16.5)	0.99
    Female sex - freq. (%)	43 (50)	74 (43.8)	0.36
    Charlson Comorbidity Index - mean (SD)	2.8 (2.3)	2.9 (2.3)	0.82
    Serum creatinine (mg/dL) - mean (SD)	0.93 (0.29)	0.92 (0.36)	0.78
    DVTa - freq. (%)	78 (91.8)	160 (95.2)	0.27
    Diagnostic imaging prior to ED visit - freq. (%)	52 (60.5)	88 (52.1)	0.23
    Additional diagnostic imaging - freq. (%)	20 (23.3)	23 (13.6)	0.05
    Medical consult - freq. (%)	2 (2.3)	6 (3.6)	0.7

    ^a Sample sizes based on n = 85 in starter pack and n = 168 in other, since one person in each group had a diagnosis for both DVT and PE.

    Table 2

    Primary and secondary outcomes.

    Outcomes		Starter pack (n = 86)	Other (n = 169)	Difference	95% CI for difference
    Primary	ED LOS (hr) - mean (SD)	3.1 (1.3)	3.2 (1.6)	-0.11	[-0.5, 0.27]
    Secondary	7-day readmission - freq. (%)	3 (3.5)	11 (6.5)	-3%	[-8.3%, 3.8%]
    	30-day readmission - freq. (%)	8 (9.3)	17 (10.1)	-0.76%	[-7.8%, 8%]
    	30-day follow-up - freq. (%)	54 (62.8)	113 (66.9)	-5.2%	[-15%, 0.9%]