PubMed · 14983638
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Cindy Levine. 2004-02-06. I was dead wrong.. https://pubmed.ncbi.nlm.nih.gov/14983638/
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BACKGROUND: The lack of valid classification methods for emergency department (ED) visit urgency has resulted in large variation in reported rates of nonurgent ED utilization. OBJECTIVES: To compare four methods of defining ED visit urgency with the criterion standard, implicit criteria, for infant ED visits. METHODS: This was a secondary data analysis of a prospective birth cohort of Medicaid-enrolled infants who made at least one ED visit in the first six months of life. Complete ED visit data were reviewed to assess urgency via implicit criteria. The explicit criteria (adherence to prespecified criteria via complete ED charts), ED triage, diagnosis, and resources methods were also used to categorize visit urgency. Concordance and agreement (kappa) between the implicit criteria and alternative methods were measured. RESULTS: A total of 1,213 ED visits were assessed. Mean age was 2.8 (SD +/- 1.78) months, and the most common diagnosis was upper respiratory infection (21.0%). Using implicit criteria, 52.3% of ED visits were deemed urgent. Urgent visits using other methods were as follows: explicit criteria, 51.8%; ED triage, 60.6%; diagnosis, 70.3%; and resources, 52.7%. Explicit criteria had the highest concordance (78.3%) and agreement (kappa = 0.57) with implicit criteria. Of limited data methods, resources demonstrated the best concordance (78.1%) and agreement (kappa = 0.56), while ED triage (67.9%) and diagnosis (71.6%) exhibited lower concordance and agreement (kappa = 0.35 and kappa = 0.42, respectively). Explicit criteria and resources equally misclassified urgency for 11.1% of visits; ED triage and diagnosis tended to overclassify visits as urgent. CONCLUSIONS: The explicit criteria and resources methods best approximate implicit criteria in classifying ED visit urgency in infants younger than six months of age. If confirmed in further studies, resources utilized has the potential to be an inexpensive, easily applicable method for urgency classification of infant ED visits when limited data are available.
In many medical conditions subjects can experience recurrent incidents. A common feature for the recurrent events data and multi-stage failure time observations is that the events are naturally ordered and occur in a certain sequence over time. To analyze such data, conventional methods based on either the frequency of events or the time to the first event or overall survival time is often inefficient and unsophisticated. If data have repeated events over a period with censored failure time in longitudinal studies, more complex analytic approaches are needed to obtain accurate estimates and efficient inferences, because adjustment is necessary for existing correlation between recurrent failure times within a subject. For analyzing different kinds of recurrent event data we review the existing models-multiple failure time models and frailty models, which allow use of all the available information to accurately estimate the relative risks of recurrences in a given dataset. Using the Pediatric Firearm Victim's Emergency Department Visit Study, the results from the proposed models are compared, and applicability and appropriateness of each model are discussed.
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