Clinician Risk Tolerance and Rates of Admission From the Emergency Department.

Importance: Much remains unknown about the extent of and factors that influence clinician-level variation in rates of admission from the emergency department (ED). In particular, emergency clinician risk tolerance is a potentially important attribute, but it is not well defined in terms of its association with the decision to admit. Objective: To further characterize this variation in rates of admission from the ED and to determine whether clinician risk attitudes are associated with the propensity to admit. Design, Setting, and Participants: In this observational cohort study, data were analyzed from the Massachusetts All Payer Claims Database to identify all ED visits from October 2015 through December 2017 with any form of commercial insurance or Medicaid. ED visits were then linked to treating clinicians and their risk tolerance scores obtained in a separate statewide survey to examine the association between risk tolerance and the decision to admit. Statistical analysis was performed from 2022 to 2023. Main Outcomes and Measures: The ratio between observed and projected admission rates was computed, controlling for hospital, and then plotted against the projected admission rates to find the extent of variation. Pearson correlation coefficients were then used to examine the association between the mean projected rate of admission and the difference between actual and projected rates of admission. The consistency of clinician admission practices across a range of the most common conditions resulting in admission were then assessed to understand whether admission decisions were consistent across different conditions. Finally, an assessment was made as to whether the extent of deviation from the expected admission rates at an individual level was associated with clinician risk tolerance. Results: The study sample included 392 676 ED visits seen by 691 emergency clinicians. Among patients seen for ED visits, 221 077 (56.3%) were female, and 236 783 (60.3%) were 45 years of age or older; 178 890 visits (46.5%) were for patients insured by Medicaid, 96 947 (25.2%) were for those with commercial insurance, 71 171 (18.5%) were Medicare Part B or Medicare Advantage, and the remaining 37 702 (9.8%) were other insurance category. Of the 691 clinicians, 429 (62.6%) were male; mean (SD) age was 46.5 (9.8) years; and 72 (10.4%) were Asian, 13 (1.9%) were Black, 577 (83.5%) were White, and 29 (4.2%) were other race. Admission rates across the clinicians included ranged from 36.3% at the 25th percentile to 48.0% at the 75th percentile (median, 42.1%). Overall, there was substantial variation in admission rates across clinicians; physicians were just as likely to overadmit or underadmit across the range of projected rates of admission (Pearson correlation coefficient, 0.046 [P = .23]). There also was weak consistency in admission rates across the most common clinical conditions, with intraclass correlations ranging from 0.09 (95% CI, 0.02-0.17) for genitourinary/syncope to 0.48 (95% CI, 0.42-0.53) for cardiac/syncope. Greater clinician risk tolerance (as measured by the Risk Tolerance Scale) was associated with a statistically significant tendency to admit less than the projected admission rate (coefficient, -0.09 [P = .04]). The other scales studied revealed no significant associations. Conclusions and Relevance: In this cohort study of ED visits from Massachusetts, there was statistically significant variation between ED clinicians in admission rates and little consistency in admission tendencies across different conditions. Admission tendencies were minimally associated with clinician innate risk tolerance as assessed by this study's measures; further research relying on a broad range of measures of risk tolerance is needed to better understand the role of clinician attitudes toward risk in explaining practice patterns and to identify additional factors that may be associated with variation at the clinician level.

Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department.

Importance: The role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases. Objective: To determine the extent to which patient-level factors are associated with rates of hospital admission from the ED. Design, Setting, and Participants: This cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023. Main Outcomes and Measures: The primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated. Results: A total of 42 392 ED visits by 11 783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7%]) and White (32 148 visits [75.8%]) individuals. The overall percentage of patients admitted was 42.5%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5-percentage point (OR, 1.47; 95% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission. Conclusion and Relevance: Results of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED.

The consequences of emotionally evocative patient behaviors on emergency nurses' patient assessments and handoffs: An experimental study using simulated patient cases.

BACKGROUND: Engaging with human emotions is an integral but poorly understood part of the work of emergency healthcare providers. Patient factors (e.g., irritable behavior; mental illness) can evoke strong emotions, and evidence suggests that these emotions can impact care quality and patient safety. Given that nurses play a critical role in providing high quality care, efforts to identify and remedy factors that may compromise care are needed. Yet to date, few experiments have been conducted. OBJECTIVE: To examine the effects of emotionally evocative patient behavior as well as the presence of mental illness on emergency nurses' emotions, patient assessments, testing advocacy, and written handoffs. DESIGN: Experimental vignette research. SETTING: Online experiment distributed via email between October and December 2020. PARTICIPANTS: Convenience sample of 130 emergency nurses from seven hospitals in the Northeastern United States and one hospital in the mid-Atlantic region in the United States. METHODS: Nurses completed four multimedia computer-simulated patient encounters in which patient behavior (irritable vs. calm) and mental illness (present vs. absent) were experimentally varied. Nurses reported their emotions and clinical assessments, recommended diagnostic tests, and provided written handoffs. Tests were coded for whether the test would result in a correct diagnosis, and handoffs were coded for negative and positive patient descriptions and the presence of specific clinical information. RESULTS: Nurses experienced more negative emotions (anger, unease) and reported less engagement when assessing patients exhibiting irritable (vs. calm) behavior. Nurses also judged patients with irritable (vs. calm) behavior as more likely to exaggerate their pain and as poorer historians, and as less likely to cooperate, return to work, and recover. Nurses' handoffs were more likely to communicate negative descriptions of patients with irritable (vs. calm) behavior and omit specific clinical information (e.g., whether tests were ordered, personal information). The presence of mental illness increased unease and sadness and resulted in nurses being less likely to recommend a necessary test for a correct diagnosis. CONCLUSIONS: Emergency nurses' assessments and handoffs were impacted by patient factors, particularly irritable patient behavior. As nurses are central to the clinical team and experience regular, close contact with patients, the effects of irritable patient behavior on nursing assessments and care practices have important implications. We discuss potential approaches to address these ill effects, including reflexive practice, teamwork, and standardization of handoffs. TWEETABLE ABSTRACT: Simulated experimental study found that despite having received identical clinical information, emergency nurses believed that patients displaying irritable behaviours were less likely to return to work soon and were less likely to recover than patients who displayed calm behaviour.

Perspectives of Emergency Clinicians About Medical Errors Resulting in Patient Harm or Malpractice Litigation.

This cross-sectional study analyzes responses to a survey about medical error outcomes completed by emergency department attending physicians and advanced practice clinicians.

US emergency care patterns among nurse practitioners and physician assistants compared with physicians: a cross-sectional analysis.

OBJECTIVES: Nurse practitioners and physician assistants (NPs/PAs) increasingly practice in emergency departments (EDs), yet limited research has compared their practice patterns with those of physicians. DESIGN, SETTING AND PARTICIPANTS: Using nationally representative data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), we analysed ED visits among NPs/PAs and physicians between 1 January 2009 and 31 December 2017. To compare NP/PA and physician utilisation, we estimated propensity score-weighted multivariable regressions adjusted for clinical/sociodemographic variables, including triage acuity score (1=sickest/5=healthiest). Because NPs/PAs may preferentially consult physicians for more complex patients, we performed sensitivity analyses restricting to EDs with >95% of visits including the NP/PA-physician combination. EXPOSURES: NPs/PAs. MAIN OUTCOME MEASURES: Use of hospitalisations, diagnostic tests, medications, procedures and six low-value services, for example, CT/MRI for uncomplicated headache, based on Choosing Wisely and other practice guidelines. RESULTS: Before propensity weighting, we studied visits to 12 410 NPs/PAs-alone, 21 560 to the NP/PA-physician combination and 143 687 to physicians-alone who saw patients with increasing age (41, 45 and 47 years, p<0.001) and worsening triage acuity scores (3.03, 2.85 and 2.67, p<0.001), respectively. After weighting, NPs/PAs-alone used fewer medications (2.62 vs 2.80, p=0.002), diagnostic tests (3.77 vs 4.66, p<0.001), procedures (0.67 vs 0.77, p<0.001), hospitalisations (OR 0.35 (95% CI 0.26 to 0.46)) and low-value CT/MRI studies (OR 0.65 (95% CI 0.53 to 0.80)) than physicians. Contrastingly, the NP/PA-physician combination used more medications (3.08 vs 2.80, p<0.001), diagnostic tests (5.07 vs 4.66, p<0.001), procedures (0.86 vs 0.77, p<0.001), hospitalisations OR 1.33 (95% CI 1.17 to 1.51) and low-value CT/MRI studies (OR 1.23 (95% CI 1.07 to 1.43)) than physicians-results were similar among EDs with >95% of NP/PA visits including the NP/PA-physician combination. CONCLUSIONS AND RELEVANCE: While U.S. NPs/PAs-alone used less care and low-value advanced diagnostic imaging, the NP/PA-physician combination used more care and low-value advanced diagnostic imaging than physicians alone. Findings were reproduced among EDs where nearly all NP/PA visits were collaborative with physicians, suggesting that NPs/PAs seeing more complex patients used more services than physicians alone, but the converse might be true for more straightforward patients.

Weak correlations in health services research: Weak relationships or common error?

OBJECTIVE: To examine whether the correlation between a provider's effect on one population of patients and the same provider's effect on another population is underestimated if the effects for each population are estimated separately as opposed to being jointly modeled as random effects, and to characterize how the impact of the estimation procedure varies with sample size. DATA SOURCES: Medicare claims and enrollment data on emergency department (ED) visits, including patient characteristics, the patient's hospitalization status, and identification of the doctor responsible for the decision to hospitalize the patient. STUDY DESIGN: We used a three-pronged investigation consisting of analytical derivation, simulation experiments, and analysis of administrative data to demonstrate the fallibility of stratified estimation. Under each investigation method, results are compared between the joint modeling approach to those based on stratified analyses. DATA COLLECTION/EXTRACTION METHODS: We used data on ED visits from administrative claims from traditional (fee-for-service) Medicare from January 2012 through September 2015. PRINCIPAL FINDINGS: The simulation analysis demonstrates that the joint modeling approach is generally close to unbiased, whereas the stratified approach can be severely biased in small samples, a consequence of joint modeling benefitting from bivariate shrinkage and the stratified approach being compromised by measurement error. In the administrative data analyses, the estimated correlation of doctor admission tendencies between female and male patients was estimated to be 0.98 under the joint model but only 0.38 using stratified estimation. The analogous correlations for White and non-White patients are 0.99 and 0.28 and for Medicaid dual-eligible and non-dual-eligible patients are 0.99 and 0.31, respectively. These results are consistent with the analytical derivations. CONCLUSIONS: Joint modeling targets the parameter of primary interest. In the case of population correlations, it yields estimates that are substantially less biased and higher in magnitude than naive estimators that post-process the estimates obtained from stratified models.

Attitudes toward risk among emergency physicians and advanced practice clinicians in Massachusetts.

OBJECTIVE: Risk aversion is a personality trait influential to decision making in medicine. Little is known about how emergency department (ED) clinicians differ in their attitudes toward risk taking. METHODS: We conducted a cross-sectional survey of practicing ED clinicians (physicians and advanced practice clinicians [APCs]) in Massachusetts using the following 4 existing validated scales: the Risk-Taking Scale (RTS), Stress from Uncertainty Scale (SUS), the Fear of Malpractice Scale (FMS), and the Need for (Cognitive) Closure Scale (NCC). We used Cronbach's α to assess the reliability of each scale and performed multivariable linear regressions to analyze the association between the score for each scale and clinician characteristics. RESULTS: Of 1458 ED clinicians recruited for participation, 1116 (76.5%) responded from 93% of acute care hospitals in Massachusetts. Each of the 4 scales demonstrated high internal consistency reliability with Cronbach's αs ranging from 0.76 to 0.92. The 4 scales also were moderately correlated with one another (0.08 to 0.54; all P < 0.05). The multivariable results demonstrated differences between physicians and APCs, with physicians showing a greater tolerance for risk or uncertainty (NCC difference, -3.58 [95% confidence interval, CI, -5.26 to -1.90]; SUS difference, -3.14 [95% CI: -4.99 to -1.29]) and a higher concern about malpractice (FMS difference, 1.14 [95% CI, 0.11-2.17]). Differences were also observed based on clinician age (a proxy for years of experience), with greater age associated with greater tolerance of risk or uncertainty (age older than 50 years compared with age 35 years and younger; NCC difference, -2.84 [95% CI, -4.69 to -1.00]; SUS difference, -4.71 [95% CI, -6,74 to -2.68]) and less concern about malpractice (FMS difference, -3.19 [95% CI, -4.31 to -2.06]). There were no appreciable differences based on sex, and there were no consistent associations between scale scores and the practice and payment characteristics assessed. CONCLUSION: We found that risk attitudes of ED clinicians were associated with type of training (physician vs APC) and age (experience). These differences suggest one possible explanation for the observed differences in decision making.

Analysis of Consistency in Emergency Department Physician Variation in Propensity for Admission Across Patient Sociodemographic Groups.

Importance: Sociodemographic disparities in health care and variation in physician practice patterns have been well documented; however, the contribution of variation in individual physician care practices to health disparities is challenging to quantify. Emergency department (ED) physicians vary in their propensity to admit patients. The consistency of this variation across sociodemographic groups may help determine whether physician-specific factors are associated with care differences between patient groups. Objective: To estimate the consistency of ED physician admission propensities across categories of patient sex, race and ethnicity, and Medicaid enrollment. Design, Setting, and Participants: This cross-sectional study analyzed Medicare fee-for-service claims for ED visits from January 1, 2016, to December 31, 2019, in a 10% random sample of hospitals. The allocation of patients to ED physicians in the acute care setting was used to isolate physician-level variation in admission rates that reflects variation in physician decision-making. Multi-level models with physician random effects and hospital fixed effects were used to estimate the within-hospital physician variation in admission propensity for different patient sociodemographic subgroups and the covariation in these propensities between subgroups (consistency), adjusting for primary diagnosis and comorbidities. Main Outcomes and Measures: Admission from the ED. Results: The analysis included 4 567 760 ED visits involving 2 334 361 beneficiaries and 15 767 physicians in 396 EDs. The mean (SD) age of the beneficiaries was 78 (8.2) years, 2 700 661 visits (59.1%) were by women, and most patients (3 839 055 [84.1%]) were not eligible for Medicaid. Of 4 473 978 race and ethnicity reports on enrollment, 103 699 patients (2.3%) were Asian/Pacific Islander, 421 588 (9.4%) were Black, 257 422 (5.8%) were Hispanic, and 3 691 269 (82.5%) were non-Hispanic White. Within hospitals, adjusted rates of admission were higher for men (36.8%; 95% CI, 36.8%-36.9%) than for women (33.7%; 95% CI, 33.7%-33.8%); higher for non-Hispanic White (36.0%; 95% CI, 35.9%-36.0%) than for Asian/Pacific Islander (33.6%; 95% CI, 33.3%-33.9%), Black (30.2%; 95% CI, 30.0%-30.3%), or Hispanic (31.1%; 95% CI, 30.9%-31.2%) beneficiaries; and higher for beneficiaries dually enrolled in Medicaid (36.3%; 95% CI, 36.2%-36.5%) than for those who were not (34.7%; 95% CI, 34.7%-34.8%). Within hospitals, physicians varied in the percentage of patients admitted, ranging from 22.4% for physicians at the 10th percentile to 47.6% for physicians at the 90th percentile of the estimated distribution. Physician admission propensities were correlated between men and women (r = 0.99), Black and non-Hispanic White patients (r = 0.98), and patients who were dually enrolled and not dually enrolled in Medicaid (r = 0.98). Conclusions and Relevance: This cross-sectional study indicated that, although overall rates of admission differ systematically by patient sociodemographic factors, an individual physician's propensity to admit relative to other physicians appears to be applied consistently across sociodemographic groups of patients.

National Trends In ED Visits, Hospital Admissions, And Mortality For Medicare Patients During The COVID-19 Pandemic.

Concerns about avoidance or delays in seeking emergency care during the COVID-19 pandemic are widespread, but national data on emergency department (ED) visits and subsequent rates of hospitalization and outcomes are lacking. Using data on all traditional Medicare beneficiaries in the US from October 1, 2018, to September 30, 2020, we examined trends in ED visits and rates of hospitalization and thirty-day mortality conditional on an ED visit for non-COVID-19 conditions during several stages of the pandemic and for areas that were considered COVID-19 hot spots versus those that were not. We found reductions in ED visits that were largest by the first week of April 2020 (52 percent relative decrease), with volume recovering somewhat by mid-June (25 percent relative decrease). These reductions were of similar magnitude in counties that were and were not designated as COVID-19 hot spots. There was an early increase in hospitalizations and in the relative risk for thirty-day mortality, starting with the first surge of the pandemic, peaking at just over a 2-percentage-point increase. These results suggest that patients were presenting with more serious illness, perhaps related to delays in seeking care.

Variation in Rates of Hospital Admission from the Emergency Department Among Medicare Patients at the Regional, Hospital, and Physician Levels.

STUDY OBJECTIVE: Rates of admission from the emergency department (ED) vary widely across regions of the country, hospitals within regions, and physicians within hospitals. Our objective was to determine the extent to which variation in admission decisions was described by differences in admission rates at these 3 levels. This understanding will serve to better target interventions to modify rates of admission where appropriate. METHODS: In this cross-sectional observational cohort study, we analyzed Medicare fee-for-service claims for ED visits from 2012 to 2015 in a 20% random sample of beneficiaries. We first estimated the total regional-, hospital-, and physician-level variations in rates of admission and their proportions of the total variation after adjusting for patient and each level's covariates. We then estimated the extent to which each level's characteristics accounted for variation at that respective level. RESULTS: Our study sample included 5,778,218 visits with 45,491 physicians at 3,480 EDs across 306 hospital referral regions. The mean rate of admission was 38.9% and ranged from 21.4% to 53.0% for physicians at the 10th and 90th percentile of the distribution, respectively. The residual (unexplained) variations at the regional, hospital, and physician levels were 13.3% (95% confidence interval [CI], 11.2 to 15.5%), 60.1% (57.1 to 62.9%), and 26.7% (26.4 to 26.9%), respectively. Regional, hospital, and physician characteristics accounted for 9.1% (95% CI, -5.6 to 23.8%), 51.1% (48.8 to 53.5%), and 2.7% (1.3 to 4.1%), respectively, of the explained variation at their respective levels. CONCLUSION: Within-area variation, both across hospitals within a region and across physicians within a hospital, is a more substantial component of observed variation in admission rates from the ED than regional level variation. These findings suggest that variation in admission rates is at least in part related to institutional norms and cultures as well as heterogeneity of physician decisionmaking within hospitals, both of which could be targets of interventions to modify rates of admission.

Variation In Emergency Department Admission Rates Among Medicare Patients: Does The Physician Matter?

Hospitalizations account for the largest share of health care spending. New payment models increasingly encourage health care providers to reduce hospital admissions. Although emergency department (ED) physicians play a major role in the decision to admit a patient, the extent to which admission rates vary among ED physicians even within the same hospital remains poorly understood. In this study we examined physician-level variation in ED admission rates for Medicare patients. We found meaningful variation in admission rates: The mean physician-level adjusted admission rate was 38.9 percent and ranged from 32.2 percent to 45.6 percent for physicians at the tenth and ninetieth percentiles, respectively, of the estimated distribution within the same hospital. In contrast, the predicted risk for admission based on patient characteristics varied little among these physicians, suggesting that the variation in admission rates was not due to differences in patients seen. Our results suggest that strategies targeting physician decision making could modify (by either increasing or decreasing when appropriate) rates of admissions.

The Influence of Medicare for All on Reimbursement for Emergency Care Treat-and-Release Visits.

STUDY OBJECTIVE: Single-payer health care is supported by most Americans, but the effect of single payer on any particular sector of the health care market has not been well explored. We examine the effect of 2 potential single-payer designs, Medicare for All and an alternative including Medicare and Medicaid, on total payments and out-of-pocket spending for treat-and-release emergency care (patients discharged after an emergency department [ED] visit). METHODS: We used the 2013 to 2016 Medical Expenditure Panel Survey to determine estimates of payments made for ED visits by insurance type, and the 2015 National Hospital Ambulatory Medical Care Survey to estimate the proportion of ED visits covered by each insurance type. RESULTS: We found that total payments were predicted to increase from $85.5 billion to $89.0 billion (range $81.3 to $99.8 billion) in the Medicare-only scenario and decrease to $79.4 billion (range $71.6 to $87.2 billion) under Medicare/Medicaid, whereas out-of-pocket costs were predicted to decrease from $116 per visit to $45 with Medicare and to $36 with Medicare/Medicaid. CONCLUSION: In this study of ED treat-and-release patients, a transition to a Medicare for All system may increase ED reimbursement and reduce consumer out-of-pocket costs, whereas a system that maintains Medicaid in addition to Medicare could reduce total payments for emergency care.

Reduction of opioid prescribing through the sharing of individual physician opioid prescribing practices.

BACKGROUND: Drug overdoses are the most common cause of accidental death in the United States, with the majority being attributed to opioids. High per capita opioid prescribing is correlated with higher rates of opioid abuse and death. We aimed to determine the impact of sharing individual prescribing data on the rates of opioid prescriptions written for patients discharged from the emergency department (ED). METHODS: This was a pre-post intervention at a single community ED. We compared opioid prescriptions written on patient discharge before and after an intervention consisting of sharing individual and comparison prescribing data. Clinicians at or over one standard deviation above the mean were notified via standard template electronic communication. RESULTS: For each period, we reported the median number of monthly prescriptions written by each clinician, accounting for the total number of patient discharges. The pre-intervention median was 12.5 prescriptions per 100 patient discharges (IQR 10-19) compared to 9 (IQR 6-11) in the post-intervention period (p < 0.001). This represents a 28% reduction in the overall rate of opioid prescriptions written per patient discharged. Using interrupted time series analysis for monthly rates, this was associated with a reduction in opioid prescriptions, showing a decrease of almost 9 prescriptions for every 100 discharges over the 6 months of the study (p = 0.032). CONCLUSION: Our study demonstrates the sharing of individual opioid prescribing data was associated with a reduction in opioid prescribing at a single institution.

Emergency Department Care for Patients with Limited English Proficiency: a Retrospective Cohort Study.

BACKGROUND: Limited English proficiency (LEP) patients may be particularly vulnerable in the high acuity and fast-paced setting of the emergency department (ED). OBJECTIVE: To compare the care processes of LEP patients in the ED. DESIGN: Retrospective cohort study. SETTING: ED in a large tertiary care academic medical center. PATIENTS: Adult LEP and English Proficient (EP) patients during their index presentation to the ED from September 1, 2013, to August 31, 2015. LEP patients were identified as those who selected a preferred language other than English when registering for care. MAIN MEASURES: Rates of diagnostic studies, admission, and return visits for those originally discharged from the ED. KEY RESULTS: We studied 57,435 visits of which 5241 (9.1%) were for patients with LEP. In adjusted analyses, LEP patients were more likely to receive an X-ray/ultrasound (OR 1.11, CI 1.03-1.19) and be admitted to the hospital (OR 1.09, CI 1.01-1.19). There was no difference in 72-h return visits (OR 0.98, CI 0.73-1.33). LEP patients presenting with complaints related to the cardiovascular system were more likely to receive a stress test (OR 1.51, CI 1.22-1.86), and those with gastrointestinal diagnoses were more likely to have an X-ray/ultrasound (OR 1.31, CI 1.02-1.68). In stratified analyses, Spanish speakers were less likely to be admitted (OR 0.8, CI 0.70-0.91), but those preferring "other" languages, which were all languages with < 500 patients, had a statistically significant higher adjusted rate of admission (OR 1.35, CI 1.17-1.57). CONCLUSIONS: ED patients with LEP experienced both increased rates of diagnostic testing and of hospital admission. Research is needed to examine why these differences occurred and if they represent inefficiencies in care.

Emergency Department Involvement in Accountable Care Organizations in Massachusetts: A Survey Study.

STUDY OBJECTIVE: We assess Massachusetts emergency department (ED) involvement and internal ED constructs within accountable care organization contracts. METHODS: An online survey was distributed to 70 Massachusetts ED directors. Questions attempted to assess involvement of EDs in accountable care organizations and the structures in place in EDs-from departmental resources to physician incentives-to help achieve accountable care organization goals of decreasing spending and improving quality. RESULTS: Of responding ED directors, 79% reported alignment between the ED and an accountable care organization. Almost all ED groups (88%) reported bearing no financial risk as a result of the accountable care organization contracts in which their organizations participated. Major obstacles to meeting accountable care organization objectives included care coordination challenges (62%) and lack of familiarity with accountable care organization goals (58%). The most common cost-reduction strategies included ED case management (85%) and information technology (61%). Limitations of this study include that information was self-reported by ED directors, a focus limited to Massachusetts, and a survey response rate of 47%. CONCLUSION: The ED directors perceived that the majority of physicians were not familiar with accountable care organization goals, many challenges remain in coordinating care for patients in the ED, and most EDs have no financial incentives tied to accountable care organizations. EDs in Massachusetts have begun to implement strategies aimed at reducing admissions, utilization, and overall cost, but these strategies are not widespread apart from case management, even in a state with heavy accountable care organization penetration. Our results suggest that Massachusetts EDs still lack clear directives and direct involvement in meeting accountable care organization goals.