Objectives The goal of this study was to examine 2006 to 2010 emergency department (ED) admission rates, hospital procedures, lengths of stay, and costs for acute heart failure (AHF). Background Patients with AHF are often admitted and are associated with high readmissions and cost. Methods We utilized Nationwide Emergency Department Sample AHF data from 2006 to 2010 to describe admission proportion, hospital length of stay (LOS), and ED charges as a surrogate for resource utilization. Results were compared across U.S. regions, patient insurance status, and hospital characteristics. Results There were 958,167 mean yearly ED visits for AHF in the United States. Fifty-one percent of the patients were female, and the median age was 75.1 years (interquartile range [IQR]: 62.5 to 83.7 years). Overall, 83.7% (95% confidence interval: 83.1% to 84.2%) were admitted; the median LOS was 3.4 days (IQR: 1.9 to 5.8 days). Comparing 2006 with 2010, there was a small decrease in median LOS (0.09 days), but the proportion admitted did not change. Odds of admission, adjusting for age, sex, hospital characteristic (academic and safety net status), and insurance (Medicare, Medicaid, private, self-pay/no charge) were highest in the Northeast. Median ED charges were $1,075 (IQR: $679 to $1,665) in 2006 and $1,558 (IQR: $1,018 to $2,335) in 2010. Patients without insurance were more likely to be discharged from the ED, but when admitted, were more likely to receive a major diagnostic or therapeutic procedure. Conclusions A very high proportion of ED patients with AHF are admitted nationally, with significant variation in disposition and procedural decisions based on region of the country and type of insurance, even after adjusting for potential confounding.

The BHLS, administered by nurses during routine clinical care, demonstrates adequate reliability and validity to be used as a health literacy measure.

Objective To evaluate the diagnostic performance of chest x-ray (CXR) compared to computed tomography (CT) for detection of pulmonary opacities in adult emergency department (ED) patients. Methods We conducted an observational cross sectional study of adult patients presenting to 12 EDs in the United States from July 1, 2003 through November 30, 2006 who underwent both CXR and chest CT for routine clinical care. CXRs and CT scans performed on the same patient were matched. CXRs and CT scans were interpreted by attending radiologists and classified as containing pulmonary opacities if the final radiologist report noted opacity, infiltrate, consolidation, pneumonia, or bronchopneumonia. Using CT as a criterion standard, the diagnostic test characteristics of CXR to detect pulmonary opacities were calculated. Results The study cohort included 3,423 patients. Shortness of breath, chest pain and cough were the most common complaints, with 96.1% of subjects reporting at least one of these symptoms. Pulmonary opacities were visualized on 309 (9.0%) CXRs and 191 (5.6 %) CT scans. CXR test characteristics for detection of pulmonary opacities included: sensitivity 43.5% (95% CI: 36.4%–50.8%); specificity 93.0% (95% CI: 92.1%–93.9%); positive predictive value 26.9% (95% CI: 22.1%–32.2%); and negative predictive value 96.5% (95% CI: 95.8%–97.1%). Conclusion In this multicenter cohort of adult ED patients with acute cardiopulmonary symptoms, CXR demonstrated poor sensitivity and positive predictive value for detecting pulmonary opacities. Reliance on CXR to identify pneumonia may lead to significant rates of misdiagnosis.

Background and Objective Efficiency in scale design reduces respondent burden. A brief but reliable measure of numeracy may provide a useful research tool eligible for integration into large epidemiological studies or clinical trials. Our goal was to validate a 3-item version of the Subjective Numeracy Scale (SNS-3). Design and Setting We examined seven separate cross-sectional datasets (patients in the emergency department (n=208), clinic (n=205), and hospital (n=460; n=2,053); patients with chronic kidney disease (n=147), diabetes (n=318), and on hemodialysis (n=143)). Measurements Internal reliability of the SNS-3 was assessed with Cronbach’s alpha. Criterion validity was determined by nonparametric correlations of the SNS-3 with SNS-8 and other measures of numeracy; construct validity was determined by correlations with measures of health literacy and education. Results The SNS-3 had good internal reliability (median Cronbach’s alpha = 0.78) and correlated highly with the full SNS (median rho = 0.91). The SNS-3 was significantly correlated with other measures of numeracy (e.g., median rho = 0.57 with the WRAT), health literacy (e.g., median rho = 0.35 with the S-TOFHLA), and education (median rho = 0.41), providing good evidence of criterion and construct validity. Conclusion The SNS-3 is sufficiently reliable and valid to be used as a measure of subjective numeracy.

BackgroundMore than 30% of patients hospitalized for heart failure are rehospitalized or die within 90 days of discharge. Lower health literacy is associated with mortality among outpatients with chronic heart failure; little is known about this relationship after hospitalization for acute heart failure.Methods and ResultsPatients hospitalized for acute heart failure and discharged home between November 2010 and June 2013 were followed through December 31, 2013. Nurses administered the Brief Health Literacy Screen at admission; low health literacy was defined as Brief Health Literacy Screen ≤9. The primary outcome was all-cause mortality. Secondary outcomes were time to first rehospitalization and, separately, time to first emergency department visit within 90 days of discharge. Cox proportional hazards models determined their relationships with health literacy, adjusting for age, gender, race, insurance, education, comorbidity, and hospital length of stay. For the 1379 patients, average age was 63.1 years, 566 (41.0%) were female, and 324 (23.5%) had low health literacy. Median follow-up was 20.7 months (interquartile range 12.8 to 29.6 months), and 403 (29.2%) patients died. Adjusted hazard ratio for death among patients with low health literacy was 1.34 (95% CI 1.04, 1.73, P=0.02) compared to Brief Health Literacy Screen >9. Within 90 days of discharge, there were 415 (30.1%) rehospitalizations and 201 (14.6%) emergency department visits, with no evident association with health literacy.ConclusionsLower health literacy was associated with increased risk of death after hospitalization for acute heart failure. There was no evident relationship between health literacy and 90-day rehospitalization or emergency department visits.