Patient satisfaction surveys and quality of care: an information paper.

With passage of the Patient Protection and Affordable Care Act of 2010, payment incentives were created to improve the "value" of health care delivery. Because physicians and physician practices aim to deliver care that is both clinically effective and patient centered, it is important to understand the association between the patient experience and quality health outcomes. Surveys have become a tool with which to quantify the consumer experience. In addition, results of these surveys are playing an increasingly important role in determining hospital payment. Given that the patient experience is being used as a surrogate marker for quality and value of health care delivery, we will review the patient experience-related pay-for-performance programs and effect on emergency medicine, discuss the literature describing the association between quality and the patient-reported experience, and discuss future opportunities for emergency medicine.

A novel approach to identifying targets for cost reduction in the emergency department.

This article introduces a novel framework that classifies emergency department (ED) visits according to broad categories of severity, identifying those categories of visits that present the most potential for reducing costs associated with the ED. Although cost savings directly attributable to the ED are apt to be an important emphasis of organizations operating under reformed payment systems, our framework suggests that a focus on diverting low-acuity visits away from the ED would result in far less savings compared with strategies aimed at reducing admissions and to a lesser extent improving the efficiency of ED care for intermediate or complex conditions. We conclude that targeting these categories, rather than minor injuries/illnesses, should be the primary focus of cost-reduction strategies from the ED. Given this understanding, we then discuss the implications of these findings on the financing of an emergency care system that needs to account for the required fixed costs of "stand-by capacity" of the ED and explore ways in which the ED can be better integrated into a patient-centered health care system.

National Study of Non-urgent Emergency Department Visits and Associated Resource Utilization.

INTRODUCTION: Reducing non-urgent emergency department (ED) visits has been targeted as a method to produce cost savings. To better describe these visits, we sought to compare resource utilization of ED visits characterized as non-urgent at triage to immediate, emergent, or urgent (IEU) visits. METHODS: We performed a retrospective, cross-sectional analysis of the 2006-2009 National Hospital Ambulatory Medical Care Survey. Urgency of visits was categorized using the assigned 5-level triage acuity score. We analyzed resource utilization, including diagnostic testing, treatment, and hospitalization within each acuity categorization. RESULTS: From 2006-2009, 10.1% (95% confidence interval [CI], 9.2-11.2) of United States ED visits were categorized as non-urgent. Most (87.8% [95% CI, 86.3-89.2]) non-urgent visits had some diagnostic testing or treatment in the ED. Imaging was common in non-urgent visits (29.8% [95% CI, 27.8-31.8]), although not as frequent as for IEU visits (52.9% [95% CI, 51.6-54.2]). Similarly, procedures were performed less frequently for non-urgent (34.1% [95% CI, 31.8-36.4]) compared to IEU visits (56.3% [95% CI, 53.5-59.0]). Medication administration was similar between the 2 groups (80.6% [95% CI, 79.5-81.7] vs. 76.3% [95% CI, 74.7-77.8], respectively). The rate of hospital admission was 4.0% (95% CI, 3.3-4.8) vs. 19.8% (95% CI, 18.4-21.3) for IEU visits, with admission to a critical care setting for 0.5% of non-urgent visits (95% CI, 0.3-0.6) vs. 3.4% (95% CI, 3.1-3.8) of IEU visits. CONCLUSIONS: For most non-urgent ED visits, some diagnostic or therapeutic intervention was performed. Relatively low, but notable proportions of non-urgent ED visits were admitted to the hospital, sometimes to a critical care setting. These data call into question non-urgent ED visits being categorized as "unnecessary," particularly in the setting of limited access to timely primary care for acute illness or injury.

Activity-dependent release of tissue plasminogen activator from the dendritic spines of hippocampal neurons revealed by live-cell imaging.

Tissue plasminogen activator (tPA) has been implicated in a variety of important cellular functions, including learning-related synaptic plasticity and potentiating N-methyl-D-aspartate (NMDA) receptor-dependent signaling. These findings suggest that tPA may localize to, and undergo activity-dependent secretion from, synapses; however, conclusive data supporting these hypotheses have remained elusive. To elucidate these issues, we studied the distribution, dynamics, and depolarization-induced secretion of tPA in hippocampal neurons, using fluorescent chimeras of tPA. We found that tPA resides in dense-core granules (DCGs) that traffic to postsynaptic dendritic spines and that can remain in spines for extended periods. We also found that depolarization induced by high potassium levels elicits a slow, partial exocytotic release of tPA from DCGs in spines that is dependent on extracellular Ca(+2) concentrations. This slow, partial release demonstrates that exocytosis occurs via a mechanism, such as fuse-pinch-linger, that allows partial release and reuse of DCG cargo and suggests a mechanism that hippocampal neurons may rely upon to avoid depleting tPA at active synapses. Our results also demonstrate release of tPA at a site that facilitates interaction with NMDA-type glutamate receptors, and they provide direct confirmation of fundamental hypotheses about tPA localization and release that bear on its neuromodulatory functions, for example, in learning and memory.