A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks.

Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism. CONTEXT: Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. METHODS: To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. FINDINGS: The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. CONCLUSIONS: The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.

Racial disparities in opioid administration and prescribing in the emergency department for pain.

STUDY OBJECTIVE: To investigate the holistic characteristics of patients administered or prescribed opioids to treat pain in the emergency department (ED). METHODS: We used National Hospital Ambulatory Medical Care Survey (NHAMCS) data for 2018 to examine the administration and prescribing of opioids for pain-related ED visits. Weighted logistic regression models were developed to evaluate the association between opioid administration and prescribing (OAP) in the ED and patients' pain/severity of conditions, demographic/socioeconomic factors, behavioral factors, contextual factors, and organizational factors. Then, subgroup analyses were conducted by type of pain. RESULTS: Nearly 55% of the ED visits in 2018 involved pain as a main reason for visiting the ED. The odds of receiving opioids were 45% less in black patients than in white patients when other covariates were adjusted (OR: 0.55; CI: 0.430-0.703). Compared to patients with private insurance, Medicaid beneficiaries and uninsured/self-pay patients had a 45% (OR: 0.55; CI: 0.423-0.706) and 44% (OR: 0.56; CI: 0.386-0.813) lower chance of receiving or being prescribed opioids for a pain-related ED visit when all covariates were adjusted. Other significant predictors of OAP for pain in EDs included older age, higher pain level, ED arrival by ambulance, admission to hospital, ED arrival during a night shift, geographic region of the ED. Behavioral factors, such as ED return within 72 h and whether a patient has substance/alcohol abuse or dependence, were not significantly associated with OAP. The subgroup analysis indicated that black patients had lower odds of OAP than their white counterparts only for certain pain categories. CONCLUSION: Despite increasing awareness of potential implicit bias in managing pain in the ED, racial disparities in OAP still existed. More education and training on implicit bias would help with reduce the disparities. Also, our study result indicated that non-clinical factors may play a role in emergency physicians' decision making in OAP. Increased recognition of the variation and systemic efforts to address factors affecting the variability are needed.

Racial and ethnic disparities in emergency department transfers to public hospitals.

OBJECTIVE: To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. DATA SOURCES AND STUDY SETTING: ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018). STUDY DESIGN: Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means. DATA COLLECTION/EXTRACTION METHODS: We examined 1,265,588 adult ED patients transferred from 187 hospitals. PRINCIPAL FINDINGS: Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. CONCLUSIONS: Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.

The opioid epidemic: Mobilizing an academic health center to improve outcomes.

Since 2000, opioid use disorder (OUD) has become an epidemic in the United States with more than 600,000 total deaths and a $51 billion annual cost. Patients with OUD require services from community-based organizations, local and state health departments, and health systems, all of which necessitate communication and collaboration among these groups to develop an effective strategy for diagnosis, treatment, and coordination of care. Academic health centers (AHCs) are poised to make significant contributions to the care of patients with OUD given in-house expertise across multiple medical specialties and the mission to care for patients in need. Despite the potential for AHCs to provide necessary services and address this public health crisis, progress has been slow. Many AHCs lack a clear roadmap for moving this agenda forward in their local regions. In response to rising deaths due to OUD, the authors' AHC undertook a significant redesign effort to facilitate the necessary processes and interdepartmental collaboration to provide patient-centered, comprehensive care for patients with OUD. In this article, using an organizational development framework (McKinsey 7S model), the authors describe their transformation process, and articulate strategies and potential barriers to implementing this framework. The goal of the article is to highlight the structural, procedural, and cultural changes that have occurred in one AHC so we can assist other AHCs in addressing the opioid epidemic.

Rabies Vaccination Compliance and Reasons for Incompletion.

INTRODUCTION: Rabies is a fatal disease with a 91% mortality rate in the United States. Current treatment of rabies consists of post-exposure prophylaxis treatment involving a complicated vaccination regimen. Studies conducted in other countries have found that patients do not complete their rabies vaccination treatment due to forgetting about their treatment, lack of time for visits, and the financial burden of treatment. However, little is known about why patients do not complete the rabies series in the US. The objective of this study was to determine the reasons why patients in the US do not complete rabies treatment. METHODS: We performed a retrospective study to evaluate rabies post-exposure prophylaxis completion in the emergency department of an academic suburban hospital between June 2014- July 2017. Further review was performed for patients who received inadequate vaccination to determine the cause of treatment incompletion. We conducted additional follow-up by phone survey for those patients who did not complete their rabies treatment but had no explanation for discontinuation available in the medical chart review. RESULTS: Results indicated 198 patients received rabies post-exposure treatment during the inclusion period. Of these, 145 patients completed the rabies vaccination regimen. Reasons for treatment incompletion were found for 29 patients, and 24 patients were lost to follow-up. Of the 29 patients for which discontinuation was assessed, 23 patients (79.3%) stopped treatment due to appropriate reasons - either the animal involved tested negative for the rabies virus or the patient had prior rabies treatment and only required two booster shots. Reasons for not completing the series when medically indicated included the patient deciding to not return for treatment, lack of awareness of the full vaccination regimen, and the patient declining initiation of rabies vaccination. CONCLUSION: Most patients in the US discontinue their rabies vaccination treatment for appropriate reasons; however, there is a proportion of patients who discontinue rabies vaccination when further treatment is medically indicated. This subset of patients is particularly at risk of rabies-related mortality, and additional measures need to be taken to ensure increased treatment compliance.