Randell K. Wexler

Connecting Emergency Department Patients to Primary Care

Background: Inappropriate emergency department (ED) use among Medicaid enrollees is considered a problem because of cost. We developed and evaluated a system change innovation designed to remove system barriers to primary care access for Medicaid patients. Methods: Patients who presented to the ED without an identified primary care provider were randomized to the intervention (n = 72) or comparison group (n = 68) for a 12-month study designed to connect these patients to primary care offices. Evaluation was mixed quantitative/qualitative. Results: Significantly more intervention participants attended at least 1 primary care visit 3 months after the intervention (odds ratio [OR], 2.52; 95% confidence interval [CI], 1.06–6.02), though this difference was not significant by 12 months (OR, 1.74; 95% CI, 0.79–3.84). The intervention participants also did not have lower odds of returning to the ED for nonurgent reasons by the 12-month follow-up (OR, 1.27; 95% CI, 0.65–2.48). Patient-reported barriers to attending a primary care appointment were primarily social and health system–related factors. Conclusion: The intervention did not decrease ED visits nor increase primary care use over the 12 months of the study period. The qualitative results provide insight into nonurgent ED utilization by patients with Medicaid, suggesting potential future interventions.

Therapeutic Lifestyle Changes for Cardiovascular Disease

Abstract Cardiovascular disease, including hypertension, coronary artery disease, and heart failure, is common in the general US population. The mainstay of treatment for this cohort is implementing therapeutic lifestyle changes (TLCs). Therapeutic lifestyle changes include a reduced-sodium diet, the Dietary Approaches to Stop Hypertension (DASH) diet, weight loss, moderation of alcohol consumption, and increased aerobic exercise. It is important to emphasize that exercise should be recommended to all patients, even for those who historically were told not do so, such as those with heart failure. When prescribing harmacotherapy, physical activity should be taken into account. Athletes competing at the top level warrant adherence to the restrictions of the World Anti-Doping Agency.

Renal laceration in a high school football player

Renal laceration, though uncommon, is a danger for any active person, particularly in collision or contact sports. A traumatic blow to the abdomen or flank can cause kidney damage, and, if left untreated, renal injury may lead to hypertension. Hematuria is often the most obvious sign that alerts clinicians to a renal laceration. The extent of the damage can be evaluated with CT. Conservative treatment of monitoring vital signs is recommended for managing lesser injuries, but intraperitoneal trauma or injury to the renal pedicle may require surgical intervention.