Methods: The multiethnic cohort consists of 35,102 blacks and 47,078 Latinos in

Los Angeles, CA. Subjects in the cohort were mailed a first questionnaire asking

whether they had a history of hypertension and had taken or were taking

antihypertension medications. A second questionnaire was mailed in which patients

were queried about their hypertension status. Finally, during biologic specimen

collection, each subject was requested to produce actual current medications of all

types that were recorded by name (generic or brand), dose, and frequency. We

reviewed a random sample of 200 blacks and 200 Latinos and compared their

responses to the criterion standard of hypertension as defined by the documented

presence of an antihypertension medication on home visit.

Results: A single ‘‘Y’’ or ‘‘N’’ on the first questionnaire was associated with

a PPV of self-reported hypertension of 91% and a NPV of 44% for blacks and

a PPV of 79% and NPV of 56% for Latinos (390 subjects). After the addition of

the second questionnaire, 3 ‘‘Y’’ or 3 ‘‘N’’ led to a PPV of 94% and a NPV of 59%

in blacks and a PPV of 98% and NPV of 69% in Latinos (N=278; 145 blacks and

133 Latinos). The NPV was lower mostly because individuals did not classify

themselves as hypertensive when taking diuretics, a-adrenergic blockers, or

digoxin.

Conclusion: Increasing the number of items needed for a self-report of chronic

hypertension allowed better PPV and NPV in this cohort, especially in the Latino

population. These results may underrepresent those with undiagnosed hypertension

but do allow identification of those with confirmed disease.

371 The Nonrandom Occurrence of Visits to the EmergencyDepartment

Graber MA, Dly JW, Dawson JD/University of Iowa, Iowa City, IA

Study objectives: We determine whether variation in the frequency of emergency

department (ED) visits is beyond what would be expected by chance after adjusting

for known confounders such as calendar and weather variables.

Methods: The Poisson goodness-of-fit test was used to determine whether

emergency visits in a Midwestern teaching hospital occurred randomly over time.

Total visits, as well as selected diagnoses, were analyzed. Final diagnosis was

determined using the physicians’ final chart diagnosis, which was assigned an

International Classification of Diseases, Ninth Revision code by one of the

investigators. Data on appendicitis were obtained for 6 years to check for

randomness of distribution; only cases of operatively confirmed appendicitis were

included in the analysis. We also looked at the distribution of specific diagnoses that

might be expected to occur randomly (eg, atrial fibrillation, urinary retention,

headache). Multivariable Poisson regression was used to control for calendar and

weather variables. Autocorrelation coefficients were used to detect ‘‘contagion’’ from

one period to the next.

Results: There were 24,100 ED visits in 1998, with 2,054 distinct final diagnoses.

Forty-six visits were laboratory tests only, and 5 records were lacking a final

diagnosis. The most common diagnoses were ‘‘abdominal pain’’ (643 visits), upper

respiratory infection (548 visits), and open wound of finger (544 visits). Overall,

visits did not occur randomly, even after controlling for time of day, day of week,

academic calendar, season, and weather variables (P\.001). Visits were more

common on Sundays, in the fall, and on warm days. Of 32 diagnoses we predicted

would occur randomly (eg, have a Poisson distribution), 29 did so, including

appendicitis, congestive heart failure, chest pain, venous thrombosis, reflux

esophagitis, intestinal obstruction, gastrointestinal foreign body, gastrointestinal

hemorrhage, hypertension, right-lower-quadrant abdominal pain, subarachnoid

hemorrhage, transient ischemic attack, atrial fibrillation, angina, cerebral

hemorrhage, constipation, seizure, intermediate coronary syndrome, dizziness,

hematuria, kidney stone, migraine, acute pancreatitis, rectal hemorrhage, blood in

stool, syncope, tension headache, Tietze syndrome, and urticaria. The other 3,

cerebrovascular accident, migraine headache, and back pain, were not randomly

distributed.

Conclusion: ED visits did not occur randomly over time. Most diagnoses that

would be expected to occur randomly did so, but a few exhibited nonrandom

variation. ED staff should be alert to nonrandom occurrence of disease as

a mechanism for finding unsuspected causes or associations of different

diseases.

372 Racial and Economic Composition of Emergency DepartmentVisitors and Privacy Values: Are First-Time Visitors DifferentFrom Repeat Visitors?

Nelson BP, Hurwitz S, Hutson H/Mount Sinai School of Medicine, New York, NY;

Brigham and Women’s Hospital, Boston, MA

Study objectives: Studies of patient satisfaction after an emergency department

(ED) visit often focus on methods of improving willingness to return for further care

or postvisit satisfaction measures. However, up to half of ED visits are by first-time

visitors, and such measures are not applicable to their initial appearance in the ED.

Thus, interventions targeted toward improved satisfaction may not be relevant in

addressing the preferences of a large segment of the ED population. This study is

undertaken to determine the factors first-time visitors value most when choosing an

ED, compared with repeat visitors. In addition, demographic factors affecting ED

utilization between these groups were assessed.

Methods: An observational, prospective survey at an urban Level I trauma center

(annual census 64,000) was undertaken. A convenience sample of 346 patients

visiting the ED during July and August 2003 was surveyed. Demographics on age,

sex, race, insurance status, primary care access, and income were collected. Before

their ED encounter, patients quantified the importance of the following aspects of

their care a priori from 1 (not important) to 5 (very important): privacy, attentive

nurse, diagnosis, informed of delays, wait time, pain relief, trust in providers, and

having concerns addressed. These categories have previously been linked to patient

satisfaction. A subset of first-time visitors was contacted several weeks after their

initial visit to reevaluate their scores on these criteria. First-time visitors and repeat

visitors were compared by Wilcoxon rank-sum test, with statistical significance

criteria adjusted for multiple tests.

Results: First-time visitors comprised 46% of total visits. Between first-time

visitors and repeat visitors, median age was 37 years, 56% were women, 84% were

insured, and 77% had a primary care physician. Repeat visitors averaged 2.7 visits

per year (95% confidence interval [CI] 1.5 to 3.82) and reported lower median

annual income than first-time visitors ($34,000 versus $60,000, P=.002). A greater

proportion of repeat visitors were black (23% versus 13%, P=.02) and Hispanic

(26% versus 13%, P=.007). Both groups valued ‘‘trust in providers’’ most (mean

4.5, 95% CI 4.4 to 4.7). First-time visitors valued privacy less than repeat visitors

(3.8 versus 4.3, P=.0001) but were otherwise similar in their preferences. At

follow-up, values of first-time visitors were no longer different from those of repeat

visitors.

Conclusion: Despite similarities in age, sex, and markers for access to care

(insurance and a primary care physician), there are significant differences in the

racial and economic backgrounds of repeat visitors compared with first-time visitors,

which suggests that other factors contribute to increased utilization in this

population. Although first-time visitors initially value privacy less than repeat

visitors, this changed after experiencing a complete ED visit, which may reflect an

initial naivete on the part of first-time visitors about what to expect during a typical

ED stay. We conclude that commonly used categories to score patient satisfaction

may be used in first-time visitor and repeat visitor populations.

R E S E A R C H F O R U M A B S T R A C T S

O C T O B E R 2 0 0 4 4 4 : 4 A N N A L S O F E M E R G E N C Y M E D I C I N E

373 Emergency Department Overcrowding: Patient Preference forBoarding Hallway Location

McNamee CS, Kolb J/University of Mississippi Medical Center, Jackson, MS

Study objectives: An unfortunate nationwide hospital patient flow epidemic

exists. Emergency department (ED) outflow of admitted patients awaiting inpatient

ward room placement contributes to this problem. One solution recognized in New

York that was withdrawn from the Joint Commission on Accreditation of Healthcare

Organizations (JCAHO) 2004 Hospital Accreditation Manual (draft version) was for

admitted patients to wait outside the ED. We wish to learn what location patients

prefer.

Methods: A convenience sample of patients from the ED and inpatient ward in

a tertiary urban center completed a survey differentiating boarding location

preference, the degree they objected to boarding in each location, and rationale for

their preference. None of the patients were actually in the hallway at the survey. The

study was conducted from January to March 2004 after an institutional review

board–expedited review.

S 1 1 5

Table, abstract 374.

TransferHospitals (683 Cases)

ReceivingHospitals (673 Cases)

NotTransferred

TransferredOut

TransferredIn

NotTransferred

Mean age, y (SD) 82 (8) 76 (6) 75 (7) 78 (8)Female sex, % 60 42 45 54Frail, % 33 6 7 19Previous stroke, % 22 12 11 15Diabetes, % 36 25 26 33Creatinine >2.5

mg/dL, %25 8 11 18

Heart failureon admission, %

44 32 21 44

QOCAspirin on

admission, %88 94 NA 87

b-blocker onadmission, %

70 82 NA 66

Aspirin atdischarge, %

85 NA 87* 88*

b-blocker atdischarge, %

73 NA 92* 80*

R E S E A R C H F O R U M A B S T R A C T S

Results: Three hundred thirty-seven (96%) of 352 patients surveyed voiced

a boarding location preference. Two hundred twenty-three (66.2%) patients

preferred boarding in the inpatient ward hallway versus 114 (33.8%) in the ED.

Two hundred sixty-four (75.9%) patients were surveyed on the ward and 88 (25%)

in the ED. Boarding location preference was not affected by interview site. Less

than a 1.8% absolute difference existed across sites for ward and ED hallway

preferences. A rationale for hallway preference was supplied by 146 (65.5%) who

favored boarding in the ward and 80 (70.2%) who favored the ED. Of those

preferring the ward, 74 (50.7%) patients desired to avoid the ED’s high level of

traffic, noise, commotion, or low level of privacy. Forty-three (29.5%) patients

cited physical proximity to their room, to ‘‘get in faster,’’ or ‘‘see your room.’’

Seventeen (11.6%) pro-ward hallway patients’ justification could be grouped under

a common category characterized by feeling uncomfortable in the ED because it

was ‘‘too dangerous’’ or ‘‘rough,’’ made them nervous, had more germs or weird

people, and had less cosmetic appeal. Of the patients opting for boarding in the

ED, 46 (57.5%) patients justified their decision by reporting that health care and

treatment would be quicker or better or involve physicians. Fourteen (17.5%)

patients thought that the ED was more comfortable, safer, private, and spacious,

with less traffic and fewer people to ‘‘look at me funny.’’ The next most common

justification was by 5 (6.3%) patients who believed they would reach their room in

less time. When asked to choose their degree of objection, those desiring boarding

in the ward and ED chose ‘‘no problem’’ (27.4 versus 21.9%), ‘‘minor

inconvenience’’ (30.9% versus 31.6%), ‘‘dissatisfied’’ (23.4% versus 26.3%), ‘‘very

dissatisfied but understand’’ (7.2% versus 7.9%), ‘‘very dissatisfied and angry’’

(10.8% versus 9.6%), or had no answer (0.4% versus 2.7%).

Conclusion: Nearly twice as many patients would prefer to be boarded in an

inpatient hallway in contrast to the ED hallway. In suboptimal situations when there

is no other care location than the hallway, administrators and the JCAHO should

also consider the admitted patient’s preference. Patients in our hospital were

surprisingly forgiving of the potential of being placed in the hallway.

374 Effect of Interhospital Transfer Patterns on Hospitals’ QualityPerformance Measurement Results

Graff LG, Foody J, Galusha D, Tuozzo K, Meehan T, Radford M/Qualidigm,

Middletown, CT

Study objectives: National measures for quality of care (QOC) for acute

myocardial infarction (AMI) are emerging, and results of these measures are used

to communicate and compare hospitals’ QOC. Although the AMI QOC measures

use the ‘‘ideal candidate’’ methodology (theoretically immune to differences in

patient cohort characteristics), underuse among ‘‘ideal candidates’’ is not

independent of patient characteristics. Interhospital transfer patterns are likely to

accentuate differences in cohort characteristics at different hospitals, and these

cohort differences may lead to loss of comparability of QOC measures across

hospitals. We study the difference in cohort characteristics and QOC results

between ‘‘transfer-out’’ (T) hospitals and ‘‘receiving’’ (R) hospitals in Connecticut

(CT).

Methods: Our analysis cohort (n=1,356) was assembled from AMI QOC

assessments by the CT Quality Improvement Organization in 1998 and 2001. We

excluded patients younger than 65 years. Hospitals were divided into those that

transferred out less than 10% (R) and those that transferred out 10% or more of their

AMI patients. We compared AMI cohort characteristics and AMI QOC for

administration to ‘‘ideal candidates’’ of aspirin and b-blocker within the first day

after hospital admission and at hospital discharge, according to transfer pattern of

the hospitals and transfer status of the cases.

Results: Twenty-two T hospitals cared for 683 AMI cases, whereas 7 R hospitals

cared for 673 AMI cases. T hospitals transferred out 221 (32.4%) of their AMI cases,

and 271 (40.3%) were received in transfer to R hospitals. Cases transferred out of T

hospitals or into R hospitals were younger, less often female patients, with fewer

comorbidities than cases not transferred (Table). QOC measures were higher for

cases transferred (Table), particularly for T hospitals, which outperformed R

hospitals on early QOC (P\.05, T versus R hospitals). All differences between

transferred and nontransferred cases were significant to P\.05, except where noted

by an asterisk.

Conclusion: Current QOC measures disadvantage hospitals that transfer out

a substantial portion of AMI cases to tertiary care centers.

375 Does the Evidence Support the Joint Commission onAccreditation of Healthcare Organizations’s Requirement forSpiritual Assessment?

Jang TB, Kryder GD, Tan D, Char DM/Washington University School of Medicine,

St. Louis, MO

Study objectives: Our hospital was recently cited for not obtaining adequate

spiritual assessments on patients presenting to the emergency department (ED), and

obtaining spiritual assessments is required for accreditation by the Joint Commission

on Accreditation of Healthcare Organizations. We assess whether patients presenting

to the ED by ambulance have religious or spiritual needs or want such interactions

with clinicians.

Methods: Fifty consecutive ambulance patients on each of 4 shifts—weekday day,

weekday night, weekend day, and weekend night—were asked to complete and

return questionnaires.

Results: Eighty-six patients consented to participate. Ninety-four women (51%)

and 92 men (49%) participated, with a median age range of 46 to 55 years. Fifty-five

percent thought that their religious or spiritual beliefs affected their health care

choices and decisions, whereas 43% had religious or spiritual needs at presentation

to the ED. Eighty-four percent thought providers should address the spiritual

concerns of patients in the ED, but only 56% actually wanted their providers to ask

about such needs during their current presentation, whereas 52% wanted someone

to pray or meditate with them while in the ED. However, 81% of patients reported

never having a provider ask about their beliefs or needs in the ED.

Conclusion: Most of the ambulance patients in our sample thought that

providers should address the spiritual beliefs and concerns of patients in the ED,

whereas a large portion presented to the ED with concomitant religious or

spiritual needs.

376 Emergency Medicine Workforce Study in Israel: 2003

Drescher MJ, Peleg J, Aharonson-Daniel L, Liebman Y/Sheba Medical Center and

University of Connecticut, Tel Hashomer, Israel; Gertner Institute for Epidemiology and

Health Policy Research, Tel Hashomer, Israel

Study objectives: Emergency medicine was officially recognized as a specialty in

Israel in 1999. In November 2003, the first class of 9 Israeli trained and examined

S 1 1 6 A N N A L S O F E M E R G E N C Y M E D I C I N E 4 4 : 4 O C T O B E R 2 0 0 4