Objectives

The purpose of this study was to describe the associations between individual health insurance and ambulance utilization using a national sample of patients who receive emergency department (ED) care.

Methods

The data source was the National Hospital Ambulatory Medical Care Survey, years 2004 through 2006. Non-institutionalized patients between ages 18 and 65 years were included. The primary dependant variable was ambulance use. Multivariable logistic regression methods were used to assess the associations between health insurance status and ambulance use, and to adjust for confounders.

Results

A total of 61,013 ED visits were included, representing a national sample of approximately 70 million annual ED visits over three years. Ambulance transport was used in 11% of private insurance visits, 16% of Medicaid visits, and 13% of uninsured visits. In the adjusted model, visits by patients with Medicaid (aOR 1.60, 99% confidence interval (CI) = 1.37 to 1.86) and the uninsured (aOR 1.43, 99% CI = 1.23 to 1.66) were more likely to arrive by ambulance than visits by patients with private insurance. Ambulance use among the uninsured was most pronounced in metropolitan areas.

Conclusions

Ambulance use varies by health insurance status. Medicaid coverage and lack of insurance are each independently associated with increased odds of ambulance use, suggesting a disproportionate role for EMS in the care of patients with limited financial resources.

Background

Recent epidemiologic and clinical data suggest men and racial and ethnic minorities may receive lower-quality care for osteoporosis and fragility fractures than female and nonminority patients. The causes of such differences and optimal strategies for their reduction are unknown.

Questions/purposes

A panel was convened at the May 2010 American Academy of Orthopaedic Surgeons/Orthopaedic Research Society/Association of Bone and Joint Surgeons Musculoskeletal Healthcare Disparities Research Symposium to (1) assess current understanding of sex/gender and racial/ethnic disparities in the care of osteoporosis and after fragility fractures, (2) define goals for improving the equity and quality of care, and (3) identify strategies for achieving these goals.

Where are we now?

Participants identified shortcomings in the quality of care for osteoporosis and fragility fractures among male and minority populations and affirmed a need for novel strategies to improve the quality and equity of care.

Where do we need to go?

Participants agreed opportunities exist for health professionals to contribute to improved osteoporosis management and secondary fracture prevention. They agreed on a need to define standards of care and management for osteoporosis and fragility fractures and develop strategies to involve physicians and other health professionals in improving care.

How do we get there?

The group proposed strategies to improve the quality and equity of osteoporosis and care after fragility fractures. These included increased patient and physician education, with identification of “champions” for osteoporosis care within and outside of the healthcare workforce; creation of incentives for hospitals and physicians to improve care; and research comparing the effectiveness of approaches to osteoporosis screening and fracture management.

Objective To determine the association of resting echocardiography before elective intermediate to high risk non-cardiac surgery with survival and length of hospital stay.

Design Population based retrospective cohort study.

Setting Acute care hospitals in Ontario, Canada, between 1 April 1999 and 31 March 2008.

Participants Patients aged over 40 years who had elective intermediate to high risk non-cardiac surgery.

Intervention Resting echocardiography within 6 months before surgery.

Main outcome measures Postoperative survival (30 days and 1 year) and length of hospital stay; postoperative surgical site infection as an outcome for which no association with echocardiography would be expected.

Results Of the 264 823 patients in the entire cohort, 15.1% (n=40 084) had echocardiography. After use of propensity score methods to assemble a matched cohort (n=70 996) that reduced differences between patients who had or had not had echocardiography, echocardiography was associated with increases in 30 day mortality (relative risk 1.14, 95% confidence interval 1.02 to 1.27), 1 year mortality (1.07, 1.01 to 1.12), and length of hospital stay but no difference in surgical site infections (1.03, 0.98 to 1.06). The association with mortality was influenced (P=0.02) by whether patients had had stress testing or had risk factors for cardiac complications. No association existed between echocardiography and mortality among patients who had stress testing (relative risk 1.01, 0.92 to 1.11) or among patients at high risk who had not had stress testing (1.00, 0.87 to 1.13). However, echocardiography was associated with mortality in patients at low risk (relative risk 1.44, 1.14 to 1.82) and intermediate risk (1.10, 1.02 to 1.18) who had not had stress testing.

Conclusions Preoperative echocardiography was not associated with improved survival or shorter hospital stay after major non-cardiac surgery. These findings highlight the need for further research to guide better use of this common preoperative test.