Heterogeneity of State Stroke Center Certification and Designation Processes.

BACKGROUND: Stroke centers are critical for the timely diagnosis and treatment of acute stroke and have been associated with improved treatment and outcomes; however, variability exists in the definitions and processes used to certify and designate these centers. Our study categorizes state stroke center certification and designation processes and provides examples of state processes across the United States, specifically in states with independent designation processes that do not rely on national certification. METHODS: In this cross-sectional study from September 2022 to April 2023, we used peer-reviewed literature, primary source documents from states, and communication with state officials in all 50 states to capture each state's process for stroke center certification and designation. We categorized this information and outlined examples of processes in each category. RESULTS: Our cross-sectional study of state-level stroke center certification and designation processes across states reveals significant heterogeneity in the terminology used to describe state processes and the processes themselves. We identify 3 main categories of state processes: No State Certification or Designation Process (category A; n=12), State Designation Reliant on National Certification Only (category B; n=24), and State Has Option for Self-Certification or Independent Designation (category C; n=14). Furthermore, we describe 3 subcategories of self-certification or independent state designation processes: State Relies on Self-Certification or Independent Designation for Acute Stroke Ready Hospital or Equivalent (category C1; n=3), State Has Hybrid Model for Acute Stroke Ready Hospital or Equivalent (category C2; n=5), and State Has Hybrid Model for Primary Stroke Center and Above (category C3; n=6). CONCLUSIONS: Our study found significant heterogeneity in state-level processes. A better understanding of how these differences may impact the rigor of each process and clinical performance of stroke centers is worthy of further investigation.

Characterizing emergency department and inpatient health care utilization after seizure-related hospitalization: A retrospective cohort study.

OBJECTIVE: Seizure care is a significant driver of health care costs in both emergency department (ED) and inpatient settings, but the majority of studies have focused on inpatient admissions as the only metric of health care utilization. This study aims to better characterize ED and inpatient encounters among patients with seizure to inform care and policy. METHODS: Using statewide administrative data from the Healthcare Cost and Utilization Project State Inpatient Databases and State Emergency Department Databases from Florida and New York, we identified patients with a seizure-related index hospitalization between January 1, 2016, and December 31, 2018. Among this cohort, we examined the incidence and characteristics of subsequent acute care visits in the ED and inpatient settings for 365 days after initial hospital discharge. RESULTS: A total of 54 456 patients had an eligible seizure-related hospitalization. Patients were 49% female, predominantly White (64%) and non-Hispanic (84%), and used a public primary payer (68%). There were 36 838 (68%) patients with at least one acute care visit in the year following discharge. Overall, patients had a median of 2 (interquartile [IQR] = 1-5) subsequent acute care visits and the median time to first acute care visit was 53 days (IQR = 15-138). Of the 154 369 subsequent acute care visits, 97 399 (63%) were ED-only visits, 56 970 (37%) were readmissions, and 37 176 (24%) were seizure-related. There were 18 786 patients (35%) with four or more acute care visits over 365 days of follow-up. Patients with four or more visits contributed 84% of acute care visits and 78% of costs after initial hospitalization. SIGNIFICANCE: The majority of patients hospitalized for seizure return to the ED or hospital at least once in the year after discharge. A small portion of patients account for the majority of ED and inpatient visits as well as health care costs associated with this population, identifying a subgroup of patients who may benefit from improved inpatient and outpatient management.

Trends in Inequities in the Treatment of and Outcomes for Women and Minorities with Myocardial Infarction.

STUDY OBJECTIVE: To test whether the differences across sex and race in the treatment of and outcomes for ST-segment elevation myocardial infarction (STEMI) and non-ST-segment elevation myocardial infarction (NSTEMI) have changed over a recent decade. METHODS: We conducted a retrospective analysis of patients with a diagnosis of STEMI or NSTEMI in California from 2005 to 2015 using the Office of State Health Planning and Development dataset. Using multivariable linear regression with county-fixed effects, we measured the baseline and change over time in the proportions of patients with STEMI or NSTEMI who underwent appropriately-timed coronary angiography (day of admission and within 3 days of admission, respectively) and survived at 1 year according to sex and race (Asian, Black, Hispanic, and White) and adjusting for comorbidities, payor, and hospital characteristics. RESULTS: We analyzed 159,068 STEMI and 294,068 NSTEMI presentations. In 2005, 50.0% of 12,329 men and 35.7% of 6,939 women with STEMI and 45.0% of 14,379 men and 33.1% of 10,674 women with NSTEMI underwent timely angiography. In 2015, 76.7% of 6,257 men and 66.8% of 2,808 women with STEMI underwent timely angiography and 56.3% of 13,889 men and 45.9% of 9,334 women with NSTEMI underwent timely angiography. In 2005, 1-year survival was 82.3% for men and 69.6% for women after STEMI; in 2013, 1-year survival was 88.1% for men and 79.1% for women. In the multivariable model, the baseline difference was 1.1 percentage points (95% confidence interval [CI] 0.2 to 1.9), and survival increased for women compared with men by 0.3 percentage points per year (95% CI 0.2 to 0.5). In 2005, 46.0% (5,878) of 12,789 White patients and 31.2% (330) of 1,057 Black patients with STEMI underwent timely angiography; in 2015 75.2% of 3,928 White patients and 69.2% of 522 Black patients underwent timely angiography for STEMI. In the multivariable model, this difference was 6.4 percentage points at baseline (95% CI 4.5 to 8.3), and the probability of undergoing timely angiography for Black patients increased by 0.3 percentage points per year (95% CI -0.1 to 0.6). CONCLUSION: Despite overall improvements in the treatment of and outcomes for STEMI and NSTEMI, disparities persist in the treatment of and outcomes for both the conditions, particularly for women.

Association of STEMI regionalization of care with de facto NSTEMI regionalization.

The regionalization of care for ST elevation myocardial infarction (STEMI) may unintentionally concentrate patients with non-ST elevation myocardial infarction (NSTEMI) into percutaneous coronary intervention (PCI) capable hospitals. This could lead to benefits such as increased access to PCI-capable hospitals, but could cause harms such as crowding in some hospitals with decreased patient volume and revenue in others. We set out to assess whether STEMI regionalization programs concentrated patients with NSTEMI at STEMI-receiving hospitals.

Changes in Mental Health Following the 2016 Presidential Election.

BACKGROUND: The 2016 presidential election and the controversial policy agenda of its victor have raised concerns about how the election may have impacted mental health. OBJECTIVE: Assess how mental health changed from before to after the November 2016 election and how trends differed in states that voted for Donald Trump versus Hillary Clinton. DESIGN: Pre- versus post-election study using monthly cross-sectional survey data. PARTICIPANTS: A total of 499,201 adults surveyed in the Behavioral Risk Factor Surveillance System from May 2016 to May 2017. EXPOSURE: Residence in a state that voted for Trump versus state that voted for Clinton and the candidate's margin of victory in the state. MAIN MEASURES: Self-reported days of poor mental health in the last 30 days and depression rate. KEY RESULTS: Compared to October 2016, the mean days of poor mental health in the last 30 days per adult rose from 3.35 to 3.85 in December 2016 in Clinton states (0.50 days difference, p = 0.005) but remained statistically unchanged in Trump states, moving from 3.94 to 3.78 days (- 0.17 difference, p = 0.308). The rises in poor mental health days in Clinton states were driven by older adults, women, and white individuals. The depression rate in Clinton states began rising in January 2017. A 10-percentage point higher margin of victory for Clinton in a state predicted 0.41 more days of poor mental health per adult in December 2016 on average (p = 0.001). CONCLUSIONS: In states that voted for Clinton, there were 54.6 million more days of poor mental health among adults in December 2016, the month following the election, compared to October 2016. Clinicians should consider that elections could cause at least transitory increases in poor mental health and tailor patient care accordingly, especially with the 2020 election upon us.

The rising cost of commonly used emergency department medications (2006-15).

OBJECTIVE: We determine how aggregate costs have changed for commonly used emergency department (ED) medications, and assess drivers of cost increases. METHODS: Using the National Hospital Ambulatory Medical Care Survey (NHAMCS), we identified the top 150 ED medications administered and prescribed at discharge in 2015. We used average wholesale prices (AWP) for each year from 2006 to 15 from the Red Book (Truven Health Analytics Inc.). Average wholesale price per patient (AWPP) was calculated by dividing AWP by drug uses. This was then multiplied by the total drug administrations or prescriptions to estimate the total cost in a given the year. All prices were converted to 2015 dollars. RESULTS: Aggregate costs of drugs administered in the ED increased from $688.7 million in 2006 to $882.4 million in 2015. For discharge prescriptions, aggregate costs increased from $2.031 billion in 2006 to $4.572 billion in 2015. AWPP for drugs administered in the ED in 2015 was 14.5% higher than in 2006 and 24.3% higher at discharge. The largest absolute increase in AWPP for drugs administered was for glucagon, which increased from $111 in 2006 to $235 in 2015. The largest AWPP increase at discharge was for epinephrine auto-injector, which increased from $124 in 2006 and to $481 in 2015. CONCLUSION: Over the course of the study period, the aggregate costs of the most common medications administered in the ED increased by 28% while the costs of medications prescribed at discharge increased 125%.

Early Do-Not-Resuscitate Orders and Outcome After Intracerebral Hemorrhage.

BACKGROUND: Do-not-resuscitate (DNR) orders are commonly used after intracerebral hemorrhage (ICH) and have been shown to be a predictor of mortality independent of disease severity. We determined the frequency of early DNR orders in ICH patients and whether a previously reported association with increased mortality still exists. METHODS: We performed a retrospective analysis of patients discharged from non-federal California hospitals with a primary diagnosis of ICH from January 2013 through December 2014. Characteristics included hospital ICH volume and type and whether DNR order was placed within 24 h of admission (early DNR order). The risk of in-hospital mortality was evaluated both on the individual and hospital level using multivariable analyses. A case mix-adjusted hospital DNR index was calculated for each hospital by comparing the actual number of DNR cases with the expected number of DNR cases from a multivariate model. RESULTS: A total of 9,958 patients were treated in 180 hospitals. Early DNR orders were placed in 20.1% of patients and 54.2% of these patients died during their hospitalization compared to 16.0% of patients without an early DNR order. For every 10% increase in a hospital's utilization of early DNR orders, there was a corresponding 26% increase in the likelihood of in-hospital mortality. Patients treated in hospitals within the highest quartile of adjusted DNR use had a higher relative risk of death compared to the lowest quartile (RR 3.9 vs 5.2) though the trend across quartiles was not statistically significant. CONCLUSIONS: The use of early DNR orders for ICH continues to be a strong predictor of in-hospital mortality. However, patients treated at hospitals with an overall high or low use of early DNR had similar relative risks of death whether or not there was an early DNR order, suggesting that such orders may not be a proxy for less aggressive care as seen previously.

Factors Associated With Geriatric Frequent Users of Emergency Departments.

STUDY OBJECTIVE: Frequent users of the emergency department (ED) are often associated with increased health care costs. Limited research is devoted to frequent ED use within the increasing senior population, which accounts for the highest use of health care resources. We evaluate patient characteristics and patterns of ED use among geriatric patients. METHODS: This was a multicenter, retrospective, longitudinal, cohort study of ED visits among geriatric patients older than 65 years in 2013 and 2014. Logistic regression analysis was used to identify independent associations with frequent users. The setting was a nonpublic statewide database in California, which includes 326 licensed nonfederal hospitals. We included all geriatric patients within the database who were older than 65 years and had an ED visit in 2014, for a total of 1,259,809 patients with 2,792,219 total ED visits. The main outcome was frequent users, defined as having greater than or equal to 6 ED visits in a 1-year period, starting from their last visit in 2014. RESULTS: Overall, 5.7% of geriatric patients (n=71,449) were identified as frequent users of the ED. They accounted for 21.2% (n=592,407) of all ED visits. The associations of frequent ED use with the largest magnitude were patients with an injury-related visit (odds ratio 3.8; 95% confidence interval 3.8 to 3.9), primary diagnosis of pain (odds ratio 5.5; 95% confidence interval 5.4 to 5.6), and comorbidity index score greater than or equal to 3 (odds ratio 7.2; 95% confidence interval 7.0 to 7.5). CONCLUSION: Geriatric frequent users are likely to have comorbid conditions and be treated for conditions related to pain and injuries. These findings provide evidence to guide future interventions to address these needs that could potentially decrease frequent ED use among geriatric patients.

Characterizing pediatric high frequency users of California emergency departments.

OBJECTIVE: Emergency department (ED) utilization has increased for the last several decades. Despite a focus on adult frequent ED users, little research has examined pediatric frequent ED users. The purpose of this study was to assess pediatric ED utilization in California and to describe those identified as frequent ED users. METHODS: This was a retrospective multi-facility study of ED visits by children 1-17 years of age using statewide data from the California Office of Statewide Health Planning and Development. Patients were classified into utilization groups by the number of ED visits in a one-year period prior to their last visit in 2016: occasional (1-5 visits) vs. frequent (>5 visits). Differences in patient characteristics were compared between occasional and frequent users. RESULTS: There were 690,130 patients between 1 and 17 years of age with 1,238,262 visits during the study period. Children with ≥6 visits (2.3%) accounted for 9.3% of all visits. 67% of frequent users had no visits to a pediatric ED. Over 40% (41.4%) of frequent users visited 2 or more hospitals, compared to 7.7% of occasional users. In multivariate analysis, the characteristics with the largest associations with frequent ED use were age, payer, and being admitted/transferred. CONCLUSIONS: The majority of pediatric frequent users do not seek care in pediatric EDs. Age, prior admission, and Medicare/Medicaid appear to have the largest associations with pediatric patient frequent ED utilization.

Comparing resource use between paediatric emergency department visits by triage level.

OBJECTIVE: The majority of paediatric ED visits result in discharge but little is known about what ED resources are deployed for these visits. The goal of this study was to understand the utilisation of diagnostic testing, procedures and hospital admission for paediatric ED visits triaged as 'non-urgent'. STUDY DESIGN: We examined US ED visits for children aged 0-17 years from 1 January 2009 to 31 December 2011 in the National Hospital Ambulatory Medical Care Survey. Visits triaged on arrival as 'non-urgent' (level 5) were compared with urgent visits (triage levels 1-4) for resource use and disposition. Sensitivity and specificity of triage for predicting resource use and disposition were assessed. RESULTS: Among 21 052 observations, representing 86 620 988 visits, 11.1% were triaged as 'non-urgent'. Diagnostic services were provided during 37.6% (95% CI 33.9% to 41.4%) of non-urgent and 55.2% (95% CI 53.3% to 57.2%) of urgent visits. Procedures were performed in 23.9% (95% CI 20.4% to 27.3%) of non-urgent and 33.9% (95% CI 31.2% to 35.9%) of urgent visits. 1.7% (95% CI 0.09% to 2.6%) of the non-urgent visits resulted in admission, with 0.08% (95% CI 0% to 0.2%) to critical care units, compared with 4.4% (95% CI 3.6% to 5.2%) of the urgent visits, with 0.3% (95% CI 0.2% to 0.4%) to critical care. Despite some substantial differences in the rates of resource use, triage score had poor sensitivity for identifying patients who did not receive ED tests, procedures or admission. CONCLUSION: A significant percentage of ED patients with non-urgent ED triage scores received ED testing and procedures. More work is needed to improve methods of prospectively identifying patients with low acuity complaints who do not need significant ED resources.

Geographic Discordance Between Patient Residence and Incident Location in Emergency Medical Services Responses.

STUDY OBJECTIVE: The location of a patient's residence is often used for emergency medical services (EMS) system planning. Our objective is to evaluate the association between patient residence and emergency incident zip codes for 911 calls. METHODS: We used data from the 2013 National Emergency Medical Services Information System (NEMSIS) Public-Release Research Dataset. We studied all 911 calls with a valid complaint by dispatch, identifying zip codes for both the residence and incident locations (n=12,376,784). The primary outcomes were geographic and distance discordances between patient residence and incident zip codes. We used a multivariate logistic regression model to determine geographic discordance between residence and incident zip codes by dispatch complaint, age, and sex. We also measured distances between locations with geospatial processing. RESULTS: The overall proportion of geographic discordance for all 911 calls was 27.7% (95% confidence interval [CI] 27.7% to 27.8%) and the median distance discordance was 11.5 miles (95% CI 11.5 to 11.5 miles). Lower geographic discordance rates were found among patients aged 65 to 79 years (20.2%; 95% CI 20.1% to 20.2%) and 80 years and older (14.5%; 95% CI 14.5% to 14.6%). Motor vehicle crashes (63.5%; 95% CI 63.5% to 63.6%), industrial accidents (59.3%; 95% CI 58.0% to 60.6%), and mass casualty incidents (50.6%; 95% CI 49.6% to 51.5%) were more likely to occur outside a patient's residence zip code. Median network distance between home and incident zip centroid codes ranged from 8.6 to 23.5 miles. CONCLUSION: In NEMSIS, there was geographic discordance between patient residence zip code and call location zip code in slightly more than one quarter of EMS responses records. The geographic discordance rates between residence and incident zip codes were associated with dispatch complaints and age. Although a patient's residence might be a valid proxy for incident location for elderly patients, this relationship holds less true for other age groups and among different complaints. Our findings have important implications for EMS system planning, resource allocation, and injury surveillance.

Avoidable emergency department visits: a starting point.

OBJECTIVE: To better characterize and understand the nature of a very conservative definition of 'avoidable' emergency department (ED) visits in the United States to provide policymakers insight into what interventions can target non-urgent ED visits. DESIGN/SETTING: We performed a retrospective analysis of a very conservative definition of 'avoidable' ED visits using data from the National Hospital Ambulatory Medical Care Survey from 2005 to 2011. PARTICIPANTS: We examined a total of 115 081 records, representing 424 million ED visits made by patients aged 18-64 years who were seen in the ED and discharged home. MAIN OUTCOME MEASURES: We defined 'avoidable' as ED visits that did not require any diagnostic or screening services, procedures or medications, and were discharged home. RESULTS: In total, 3.3% (95% CI: 3.0-3.7) of all ED visits were 'avoidable.' The top five chief complaints included toothache, back pain, headache, other symptoms/problems related to psychosis and throat soreness. Alcohol abuse, dental disorders and depressive disorders were among the top three ICD-9 discharge diagnoses. Alcohol-related disorders and mood disorders accounted for 6.8% (95% CI: 5.7-8.0) of avoidable visits, and dental disorders accounted for 3.9% (95% CI: 3.0-4.8) of CCS-grouped discharge diagnoses. CONCLUSIONS: A significant number of 'avoidable' ED visits were for mental health and dental conditions, which the ED is not fully equipped to treat. Our findings provide a better understanding of what policy initiatives could potentially reduce these 'avoidable' ED visits to address the gaps in our healthcare system, such as increased access to mental health and dental care.

Validating the Use of ICD-9 Code Mapping to Generate Injury Severity Scores.

The Injury Severity Score (ISS) is a measure of injury severity widely used for research and quality assurance in trauma. Calculation of ISS requires chart abstraction, so it is often unavailable for patients cared for in nontrauma centers. Whether ISS can be accurately calculated from International Classification of Diseases, Ninth Revision (ICD-9) codes remains unclear. Our objective was to compare ISS derived from ICD-9 codes with those coded by trauma registrars. This was a retrospective study of patients entered into 9 U.S. trauma registries from January 2006 through December 2008. Two computer programs, ICDPIC and ICDMAP, were used to derive ISS from the ICD-9 codes in the registries. We compared derived ISS with ISS hand-coded by trained coders. There were 24,804 cases with a mortality rate of 3.9%. The median ISS derived by both ICDPIC (ISS-ICDPIC) and ICDMAP (ISS-ICDMAP) was 8 (interquartile range [IQR] = 4-13). The median ISS in the registry (ISS-registry) was 9 (IQR = 4-14). The median difference between either of the derived scores and ISS-registry was zero. However, the mean ISS derived by ICD-9 code mapping was lower than the hand-coded ISS in the registries (1.7 lower for ICDPIC, 95% CI [1.7, 1.8], Bland-Altman limits of agreement = -10.5 to 13.9; 1.8 lower for ICDMAP, 95% CI [1.7, 1.9], limits of agreement = -9.6 to 13.3). ICD-9-derived ISS slightly underestimated ISS compared with hand-coded scores. The 2 methods showed moderate to substantial agreement. Although hand-coded scores should be used when possible, ICD-9-derived scores may be useful in quality assurance and research when hand-coded scores are unavailable.

Use of emergency department imaging in patients with minor trauma.

BACKGROUND: Advanced radiographic studies have detrimental risks, yet the prevalence of CT utilization in patients with minor trauma presenting to the emergency department (ED) has never been fully evaluated. Our objective was to evaluate the frequency of CT imaging in patients presenting to the ED for minor trauma. MATERIALS AND METHODS: A retrospective analysis of the California Office of Statewide Health Planning and Development Emergency Department and Ambulatory Surgery Data from 2005 to 2013 was performed. A total of 8,535,831 patients were identified using the following inclusion criteria: adult patients (age ≥18 y); with a traumatic ECODE diagnosis and injury severity score <9; and discharge to home. The primary study outcome measurement was the prevalence of CT imaging for each year in the study period. We performed univariate and multivariate analysis to evaluate clinical and hospital-level factors related to CT use in this population. We also performed a trend analysis using Poisson logistic regression to assess the trend of imaging scans over the study period. RESULTS: Of the study population, 5.9% received at least one CT study during their ED visit. The proportion of patients with at least one CT scan increased from 3.51% in 2005 to 7.17% in 2013 (P < 0.005). Adjusted predictors for CT included age 18-24 y or >45 y (P < 0.005), Medicare and self-pay patients (P < 0.005), fall injuries (P < 0.005), motor vehicle collision injuries (P < 0.005), and patients seen at level I/II trauma centers (P = 0.005). CONCLUSIONS: Even after clinical and demographic predictors were adjusted for, there was a 1.97-fold increase in CT among minor trauma patients from 2005-2013.

Relationship of Affordable Care Act Implementation to Emergency Department Utilization Among Young Adults.

STUDY OBJECTIVE: The 2010 provision of the Patient Protection and Affordable Care Act (ACA) extended eligibility for health insurance for young adults aged 19 to 25 years. It is unclear, however, how expanded coverage changes health care behavior and promotes efficient use of emergency department (ED) services. Our objective was to use population-level emergency department data to characterize any changes in diagnoses seen in ED among young adults since the implementation of the ACA dependent coverage expansion. METHODS: We performed a difference-in-differences analysis of 2009 to 2011 ED visits from California, Florida, and New York, using all-capture administrative data to determine how the use of ED services changed for clinical categories after the ACA provision among young adults aged 19 to 25 years compared with slightly older adults unaffected by the provision, aged 26 to 31 years. RESULTS: We analyzed a total of 10,158,254 ED visits made by 4,734,409 patients. After the implementation of the 2010 ACA provision, young adults had a relative decrease of 0.5% ED visits per 1,000 people compared with the older group. For the majority of diagnostic categories, young adults' rates and risk of visit did not change relative to that of slightly older adults after the implementation of the ACA. However, although young adults' ED visits significantly increased for mental illnesses (2.6%) and diseases of the circulatory system (eg, nonspecific chest pain) (4.8%), visits decreased for pregnancy-related diagnoses and diseases of the skin (eg, cellulitis, abscess) compared with that of the older group (3.7% and 3.1%, respectively). CONCLUSION: Our results indicate that increased coverage has kept young adults out of the ED for specific conditions that can be cared for through access to other channels. As EDs face capacity challenges, these results are encouraging and offer insight into what could be expected under further insurance expansions from health care reform.

Comparison of Mortality and Costs at Trauma and Nontrauma Centers for Minor and Moderately Severe Injuries in California.

STUDY OBJECTIVE: We examine differences in inpatient mortality and hospitalization costs at trauma and nontrauma centers for injuries of minor and moderate severity. METHODS: Inpatient data sets from the California Office of Statewide Health Planning and Development were analyzed for 2009 to 2011. The study population included patients younger than 85 years and admitted to general, acute care hospitals with a primary diagnosis of a minor or moderate injury. Minor injuries were defined as having a New Injury Severity Score less than 5 and moderate injuries as having a score of 5 to 15. Multivariate logistic regression and generalized linear model with log-link and γ distribution were used to estimate differences in adjusted inpatient mortality and costs. RESULTS: A total of 126,103 admissions with minor or moderate injury were included in the study population. The unadjusted mortality rate was 6.4 per 1,000 admissions (95% confidence interval [CI] 5.9 to 6.8). There was no significant difference found in mortality between trauma and nontrauma centers in unadjusted (odds ratio 1.2; 95% CI 0.97 to 1.48) or adjusted models (odds ratio 1.1; 95% CI 0.79 to 1.57). The average cost of a hospitalization was $13,465 (95% CI $12,733 to $14,198) and, after adjustment, was 33.1% higher at trauma centers compared with nontrauma centers (95% CI 16.9% to 51.6%). CONCLUSION: For patients admitted to hospitals for minor and moderate injuries, hospitalization costs in this study population were higher at trauma centers than nontrauma centers, after adjustments for patient clinical-, demographic-, and hospital-level characteristics. Mortality was a rare event in the study population and did not significantly differ between trauma and nontrauma centers.

In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department.

IMPORTANCE: Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care. OBJECTIVE: To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED. DESIGN, SETTING, AND PARTICIPANTS: Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days. EXPOSURES: Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED. MAIN OUTCOMES AND MEASURES: In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs. RESULTS: Among the 9,036,483 index ED visits to 424 hospitals in the study sample, 1,758,359 patients were admitted to the hospital during the index ED visit. Of these patients, 149,214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228,370 (13.0%) within 14 days, and 349,335 (19.9%) within 30 days, and 76,151 (51.0%), 122,040 (53.4%), and 190,768 (54.6%), respectively, were readmitted to the hospital. Among the 7,278,124 patients who were discharged during the index ED visit, 598,404 (8.2%) had a return visit to the ED within 7 days, 839,386 (11.5%) within 14 days, and 1,205,865 (16.6%) within 30 days. Of these patients, 86,012 (14.4%) were admitted to the hospital within 7 days, 121,587 (14.5%) within 14 days, and 173,279 (14.4%) within 30 days. The 86,012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1,609,145 patients who were admitted during the index ED visit without a return ED visit (2.48%) (odds ratio, 0.73 [95% CI, 0.69-0.78]), lower rates of ICU admission (23.3% vs 29.0%, respectively; odds ratio, 0.73 [95% CI, 0.71-0.76]), lower mean costs ($10,169 vs $10,799; difference, $629 [95% CI, $479-$781]), and longer lengths of stay (5.16 days vs 4.97 days; IRR, 1.04 [95% CI, 1.03-1.05]). Similar outcomes were observed for patients returning to the ED within 14 and 30 days of the index ED visit. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit. CONCLUSIONS AND RELEVANCE: Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.

Regional availability of mechanical embolectomy for acute ischemic stroke in California, 2009 to 2010.

BACKGROUND AND PURPOSE: We sought to assess the geographic proximity of patients with stroke in California to centers that performed specific threshold volumes of mechanical embolectomy procedures each year. METHODS: We identified all patients who were hospitalized for acute ischemic stroke at all nonfederal acute care hospitals in California from 2009 to 2010, and all hospitals that performed any mechanical embolectomy procedures by case volume during the same period, using nonpublic data from the Office of Statewide Health Planning and Development. We computed geographic service areas around each hospital on the basis of prespecified ground transport distance thresholds. We then calculated the proportion of hospitalized patients with stroke who lived within service areas for centers that performed a low volume and high volume of mechanical embolectomy procedures each year. RESULTS: During the 2-year study period, 15% (53/360) of hospitals performed at least 1 mechanical embolectomy for acute stroke, but only 19% (10/53) performed >10 cases per year. Most hospitalized patients with stroke (94%) lived within a 2-hour transport time (65 miles) to a hospital that performed ≥1 procedure during the 2-year period. Approximately 93% of the patients with stroke who received mechanical embolectomy lived within 20 miles from an embolectomy-capable hospital compared with 7% of those who lived >20 miles. CONCLUSIONS: In California, most patients with stroke lived within reasonable ground transport distances from centers that performed ≥1 mechanical embolectomy in a 2-year period. The probability of receiving mechanical embolectomy for acute ischemic stroke was associated with living in close geographic proximity to these hospitals.

Prehospital and Emergency Care: Updates from the Disease Control Priorities, Version 3.

BACKGROUND: It is increasingly understood that emergency care systems can be cost-effective in low- and middle-income countries (LMICs). The development of such systems, however, is still a work in progress. This article updates previous work in providing the most recent estimates of the burden of disease sensitive to emergency care, the current state of knowledge on the feasibility of emergency care, effect on outcomes, and cost-effectiveness in LMICs, and future directions for research, policy, and implementation. METHODS: We calculated the potential impact of prehospital and emergency care systems using updated and revised data based on the global burden of disease study. We then assessed the state of current knowledge and potential future directions for research and policy by conducting a review of the literature on current systems in LMICs. RESULTS: According to these newest updates, 24 million deaths related to emergency medical conditions occur in LMICs annually, accounting for an estimated 932 million years of life lost. Evidence shows that multiple emergency care models can function in different local settings, depending on resources and urbanicity. Emergency care can significantly improve mortality rates from emergent conditions and be highly cost-effective. Further research is needed on implementation of emergency care systems as they become a necessary reality in developing nations worldwide. CONCLUSIONS: Emergency care implementation in LMICs presents both challenges and opportunities. Investment in evidence-based emergency care, research on implementation, and system coordination in LMICs could lead to a more cost- and outcome-effective emergency care system than exists in advanced economies.

The association between community-level insurance coverage and emergency department use.

BACKGROUND: Emergency departments (EDs) nationwide are key entry points into the health care system, and their use may reflect changes in access and need in their communities. However, no studies to date have empirically and longitudinally studied how changes in a community's level of insurance coverage, a key determinant of access, affect ED utilization. OBJECTIVE: To determine the effects of changes in a community's rate of insurance coverage on its population's ED use. METHODS: We conducted a longitudinal analysis of all California counties between 2005 and 2010 using comprehensive ED visit data from the California Office of Statewide Health Planning and Development. Using Poisson regression with county and year fixed effects, we determined how changes in the rate of insurance coverage within a given county affect ED visits per 1000 residents. RESULTS: We found that changes in the rate of insurance coverage within a county had a slight but significant inverse relationship with ED visits per 1000 residents for both adults and children. For example, if a county's rate of insurance coverage among adults jumped from the 10th (73.22%) to the 90th percentile (84.93%), an estimated 2 fewer ED visits would occur per 1000 adult residents. CONCLUSIONS: As the rate of insurance coverage increased within California counties, overall ED utilization declined only slightly. Thus, expanding insurance coverage may not lead to significant decreases in overall ED use.