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The American Journal of Managed Care December 2018
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Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems
Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
Risk Adjusting Medicare Advantage Star Ratings for Socioeconomic Status
Margaret E. O’Kane, MHA, President, National Committee for Quality Assurance
Reducing Disparities Requires Multiple Strategies
Melony E. Sorbero, PhD, MS, MPH; Susan M. Paddock, PhD; and Cheryl L. Damberg, PhD
Cost Variation and Savings Opportunities in the Oncology Care Model
James Baumgardner, PhD; Ahva Shahabi, PhD; Christopher Zacker, RPh, PhD; and Darius Lakdawalla, PhD
Patient Attribution: Why the Method Matters
Rozalina G. McCoy, MD, MS; Kari S. Bunkers, MD; Priya Ramar, MPH; Sarah K. Meier, PhD; Lorelle L. Benetti, BA; Robert E. Nesse, MD; and James M. Naessens, ScD, MPH
Patient Experience During a Large Primary Care Practice Transformation Initiative
Kaylyn E. Swankoski, MA; Deborah N. Peikes, PhD, MPA; Nikkilyn Morrison, MPPA; John J. Holland, BS; Nancy Duda, PhD; Nancy A. Clusen, MS; Timothy J. Day, MSPH; and Randall S. Brown, PhD
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Natasha Parekh, MD, MS; Inmaculada Hernandez, PharmD, PhD; Thomas R. Radomski, MD, MS; and William H. Shrank, MD, MSHS
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James O. Breen, MD
Adalimumab Persistence for Inflammatory Bowel Disease in Veteran and Insured Cohorts
Shail M. Govani, MD, MSc; Rachel Lipson, MSc; Mohamed Noureldin, MBBS, MSc; Wyndy Wiitala, PhD; Peter D.R. Higgins, MD, PhD, MSc; Sameer D. Saini, MD, MSc; Jacqueline A. Pugh, MD; Dawn I. Velligan, PhD; Ryan W. Stidham, MD, MSc; and Akbar K. Waljee, MD, MSc
The Value of Novel Immuno-Oncology Treatments
John A. Romley, PhD; Andrew Delgado, PharmD; Jinjoo Shim, MS; and Katharine Batt, MD
Medicare Advantage Control of Postacute Costs: Perspectives From Stakeholders
Emily A. Gadbois, PhD; Denise A. Tyler, PhD; Renee R. Shield, PhD; John P. McHugh, PhD; Ulrika Winblad, PhD; Amal Trivedi, MD; and Vincent Mor, PhD
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David H. Howard, PhD; Brad Herring, PhD; John Graves, PhD; and Erin Trish, PhD
Mixed Messages to Consumers From Medicare: Hospital Compare Grades Versus Value-Based Payment Penalty
Jennifer Meddings, MD, MSc; Shawna N. Smith, PhD; Timothy P. Hofer, MD, MSc; Mary A.M. Rogers, PhD, MS; Laura Petersen, MHSA; and Laurence F. McMahon Jr, MD, MPH

Feasibility of Expanded Emergency Department Screening for Behavioral Health Problems

Mamata Kene, MD, MPH; Christopher Miller Rosales, MS; Sabrina Wood, MS; Adina S. Rauchwerger, MPH; David R. Vinson, MD; and Stacy A. Sterling, DrPH, MSW
This feasibility study of expanded emergency department screening identified a high prevalence of behavioral health conditions. Screening was successfully integrated into emergency visit idle times.

Electronic health record. Patient age, race/ethnicity, gender, and psychiatric and medical comorbidities based on International Classification of Diseases, Ninth Revision and Tenth Revision diagnosis codes were extracted from the electronic health record (EHR). We identified psychiatric diagnoses (eg, alcohol or drug use disorders, depression, anxiety, and psychotic disorders; specific codes available on request) and other chronic disease diagnoses (Charlson Comorbidity Index [CCI]) in the year prior to each patient’s index ED visit. To ensure accurate ascertainment of these demographic and comorbidity variables, we included only patients without prolonged health plan membership gaps.

Screening instrument. All participants completed the same screening tool (eAppendix [available at]). Questions from the National Institute on Alcoholism and Alcohol Abuse’s validated clinician screening guide were used,24 including the number of heavy drinking days (≥4 drinks for women, ≥5 drinks for men) in the past 3 months, drinking days per week, and typical number of drinks per drinking day. Drug use questions were based on the National Institute on Drug Abuse (NIDA)–validated NIDA Quick Screen25 and assessed past-year frequency (never, less than monthly, monthly, weekly, daily/almost daily) of marijuana use and of illegal drug use or prescription drug misuse.

The Patient Health Questionnaire (PHQ-2) is a validated 2-item symptom-based screening instrument based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition depression criteria, asking patients about mood symptoms in the prior 2 weeks.26 The General Anxiety Disorder questionnaire (GAD-2) is a validated 2-item anxiety symptom screening instrument.27

Questions about IPV were informed by validated instruments such as the HARK (Humiliation, Afraid, Rape, Kick) and the HITS (Hurt, Insulted, Threatened with harm, Screamed at them) and recommended by the health system’s Director of Family Violence Prevention. These questions included whether the patient was currently in a relationship in which their partner hit, slapped, kicked, choked, or hurt them, or had threatened them, and whether they had ever had a partner who physically hurt or threatened them.28-30

Chronic pain items included whether they had experienced chronic pain during the previous 6 months, and if so, whether they felt able to manage their pain well. Sleep questions included the average number of hours of sleep per night and whether they felt that amount was adequate. Because validated tools to assess sleep, IPV, and chronic pain are limited, we relied on questions recommended by KPNC clinical leaders for these domains.

Statistical Analysis

Chi-square tests were performed to assess baseline differences in demographics and comorbidities between screened patients and the full cohort. All analyses were performed using SAS 9.3 (SAS Institute, Inc; Cary, North Carolina).


Over the study period, 598 of 773 patients who completed the ED screener met eligibility criteria and had complete data. We also identified from the EHR a group of 14,919 patients evaluated in the ED during the study period who met eligibility criteria (age ≥18 years, membership gaps <3 months, ESI level 2 or 3) but were not screened (Figure 1). Screened patients were largely similar to the eligible group with regard to psychiatric comorbidities, as indicated by EHR data, although they had slightly higher rates of depression (22% vs 18%, respectively; P = .009), panic disorder (4% vs 3%; P = .03), chronic pain (30% vs 26%; P = .018), and several chronic medical conditions (Table).

Self-reported Symptoms Compared With Diagnoses

Except for IPV, the prevalence of self-reported behavioral health symptoms among those screened was higher than that of diagnoses made in the year prior to the index ED visit (Figure 2). Notably, almost half (45%) of patients endorsed anxiety symptoms, although only 19% had an anxiety diagnosis in the year prior (P <.001). Similarly, 40% of patients endorsed depressive symptoms, although only 22% had a related diagnosis (P <.001). Self-reported drug use (7%) and hazardous alcohol use (12%) were approximately double the prevalence of associated diagnoses (4% [P = .011] and 5% [P <.001], respectively). The largest disparity between endorsed symptoms and clinical diagnoses was recorded for sleep disorders and associated symptoms (sleep disorder diagnosis, 4.2% vs self-reported sleep problems, 47%; P <.001). Chronic pain was the most common past-year diagnosis of all conditions assessed (30%), although self-reported chronic pain was significantly higher, in 47% of patients (P <.001).


The RA was able to approach patients and offer screening for common behavioral health conditions within the workflow and timing of the ED visit. Communication with clinical providers (nurses and physicians) was important in identifying suitable times to approach patients and ascertaining that patients were medically stable and appropriate for screening. The RA either left the screener with the patient, returning for the completed survey at a later time, or, for patients who preferred it, would read the questions to the patient. The RA reviewed the responses and discussed questions with unclear or unmarked answers, as well as affirmative answers, with the patient.

Because our study examined feasibility of screening, we did not collect data on occurrence, rates, and outcomes of physician-initiated referrals. The total time per patient screened was approximately 15 minutes, including the time from introducing the screener, allowing time for self-administration, and reviewing results with the patient.

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