published_or_final_version / Community Medicine / Doctoral / Doctor of Philosophy

The primary purpose of this dissertation was to understand if emergency department utilization patterns are associated with subsequent drug overdose death. Specifically, it was hypothesized that that increasing emergency department (ED) utilization (as measured by such indices as two or more visits in 72-hours, two or more visits in a 30-day period, four or more visits in a 365-day period) was associated with increasing risk of fatal unintentional drug overdose compared with patients without two or more visits in a given time frame. Using ED data from the New York State Department of Health's (NYSDOH) Statewide Planning and Research Cooperative System (SPARCS) for the years 2006-2010 linked with unintentional fatal prescription drug overdose data from death certificates and medical examiner case files from the New York City Department of Health and Mental Hygiene (NYC DOHMH) and the NYSDOH for the years 2006-2010, a retrospective dynamic cohort of ED encounter data was conducted. In the first study, the patient population consisted of 1,755,734 New York State residents who were 18-64 years of age and had selected diagnoses on their entry visit. Extended Cox proportional hazards regression models were conducted to estimate the association of ED utilization patterns and subsequent drug overdose death. Compared to time periods in which patients had no visits within a year, patients who had 3, 4-10, or > 10 visits in a year had elevated risks of prescription drug overdose death after adjustment for demographic characteristics: 3 visits (adjusted hazard ratio (aHR 4.77, 95% CI 3.60, 6.15)), 4 - 10 (aHR 7.39, 95%CI 5.81, 9.41), and > 10 ED (aHR 18.37, 95% CI 13.38, 25.23). ED utilization patterns are strong predictors of subsequent overdose death. Understanding the timing of overdose death in relation to ED utilization is essential to recognizing which patients to target with overdose prevention interventions. Identifying time-periods of increased risk may be used as an indicator for developing prediction tools to classify patients at increased risk for overdose.

Emergency departments (ED) provide access to care for large numbers of patients who have nonemergent medical needs. More than half of the patients presenting to the ED at Salem Hospital in Salem, Oregon, were found to be seeking care for nonemergent medical needs. In an effort to provide an alternative location for receiving this medical care, the hospital opened an Urgent Care Center (UCC) a few blocks from the ED. The purpose of this study was to determine who uses the ED, why, and what effect the UCC had on providing an alternative to the ED. My anthropological methodology uses both quantitative and qualitative techniques. Included in the study is a random retrospective chart review of 462 patients who utilized the ED and 183 patients who utilized the UCC. The collected data were analyzed and compared with information found in the literature review. Interviews with hospital staff and patients using the two facilities are integrated into the analysis. My own experience as a nurse allows me a certain insider's perspective which was useful in interpreting data, while doing observation, and during the interview process. Findings from my research show that the Urgent Care Clinic does provide an alternative source of health care to the ED for many people. This is particularly true for those whose usual source of care is unavailable and for those who are unable to find a primary care provider to accept them. The emergency department provides nonemergent care for large numbers of patients, some of whom have psycho-social problems which differ as compared to the general population. Some of these patients have moderate psychiatric dysfunction and/or addiction problems or homelessness as well as underlying medical problems, all of which are barriers to obtaining care in a regular office setting. In some cases, the emergency department provides the best option of available care. / Graduation date: 1999

This paper explains the increased use of hospital-based emergency facilities for primary care. The analysis identifies socio-demographic characteristics, individual resources and selected access variables which influence use of physician services or emergency rooms. The selection of variables is based on a model of facility use which has been derived from the literature on medical care. The results from the analysis concluded that socio-demographic characteristics are both directly and indirectly related to facility use, but there is no apparent association between health insurance as an individual resource and access variables, and use of health care services. Suggestions of further research ar:e proposed based upon a theoretical model of health care choice behavior. / Master of Urban Affairs

Strong earthquakes are frequent catastrophic disasters occurring worldwide and often lead to structural collapse of buildings. Urban Search and Rescue (USAR) is the specialised process of locating, extricating and providing immediate medical treatment to victims trapped in collapsed structures. This research project aimed to identify the key preparedness efforts necessary by an earthquake affected country to ensure best coordinated use of international USAR assistance.

Strong earthquakes are frequent catastrophic disasters occurring worldwide and often lead to structural collapse of buildings. Urban Search and Rescue (USAR) is the specialised process of locating, extricating and providing immediate medical treatment to victims trapped in collapsed structures. This research project aimed to identify the key preparedness efforts necessary by an earthquake affected country to ensure best coordinated use of international USAR assistance.

Indiana University-Purdue University Indianapolis (IUPUI) / In 2009, Indianapolis Emergency Medical Service (I-EMS, formerly Wishard Ambulance Service) launched an electronic medical record system within their ambulances and started to exchange patient data with the Indiana Network for Patient Care (INPC). This unique system allows EMS personnel in an ambulance to get important medical information prior to the patient’s arrival to the accepting hospital from incident scene. In this retrospective cohort study, we found EMS personnel made 3,021 patient data requests (14%) of 21,215 EMS transports during a one-year period, with a “success” match rate of 46%, and a match “failure” rate of 17%. The three major factors for causing match “failure” were (1) ZIP code 55%, (2) Patient Name 22%, and (3) Birth Date 12%. This study shows that the ZIP code is not a robust identifier in the patient identification process and Non-ZIP code identifiers may be a better choice due to inaccuracies and changes of the ZIP code in a patient’s record.