The effect of malpractice reform on emergency department care.

BACKGROUND: Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice. METHODS: Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions. RESULTS: For eight of the nine state-outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges. CONCLUSIONS: Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.).

Impact of Risk Adjustment for Socioeconomic Status on Risk-adjusted Surgical Readmission Rates.

OBJECTIVE: To assess whether differences in readmission rates between safety-net hospitals (SNH) and non-SNHs are due to differences in hospital quality, and to compare the results of hospital profiling with and without SES adjustment. BACKGROUND: In response to concerns that quality measures unfairly penalizes SNH, NQF recently recommended that performance measures adjust for socioeconomic status (SES) when SES is a risk factor for poor patient outcomes. METHODS: Multivariate regression was used to examine the association between SNH status and 30-day readmission after major surgery. The results of hospital profiling with and without SES adjustment were compared using the CMS Hospital Compare and the Hospital Readmissions Reduction Program (HRRP) methodologies. RESULTS: Adjusting for patient risk and SES, patients admitted to SNHs were not more likely to be readmitted compared with patients in in non-SNHs (AOR 1.08; 95% CI:0.95-1.23; P = 0.23). The results of hospital profiling based on Hospital Compare were nearly identical with and without SES adjustment (ICC 0.99, κ 0.96). Using the HRRP threshold approach, 61% of SNHs were assigned to the penalty group versus 50% of non-SNHs. After adjusting for SES, 51% of SNHs were assigned to the penalty group. CONCLUSIONS: Differences in surgery readmissions between SNHs and non-SNHs are due to differences in the patient case mix of low-SES patients, and not due to differences in quality. Adjusting readmission measures for SES leads to changes in hospital ranking using the HRRP threshold approach, but not using the CMS Hospital Compare methodology. CMS should consider either adjusting for the effects of SES when calculating readmission thresholds for HRRP, or replace it with the approach used in Hospital Compare.

Association of neighborhood characteristics with bystander-initiated CPR.

BACKGROUND: For persons who have an out-of-hospital cardiac arrest, the probability of receiving bystander-initiated cardiopulmonary resuscitation (CPR) may be influenced by neighborhood characteristics. METHODS: We analyzed surveillance data prospectively submitted from 29 U.S. sites to the Cardiac Arrest Registry to Enhance Survival between October 1, 2005, and December 31, 2009. The neighborhood in which each cardiac arrest occurred was determined from census-tract data. We classified neighborhoods as high-income or low-income on the basis of a median household income threshold of $40,000 and as white or black if more than 80% of the census tract was predominantly of one race. Neighborhoods without a predominant racial composition were classified as integrated. We analyzed the relationship between the median income and racial composition of a neighborhood and the performance of bystander-initiated CPR. RESULTS: Among 14,225 patients with cardiac arrest, bystander-initiated CPR was provided to 4068 (28.6%). As compared with patients who had a cardiac arrest in high-income white neighborhoods, those in low-income black neighborhoods were less likely to receive bystander-initiated CPR (odds ratio, 0.49; 95% confidence interval [CI], 0.41 to 0.58). The same was true of patients with cardiac arrest in neighborhoods characterized as low-income white (odds ratio, 0.65; 95% CI, 0.51 to 0.82), low-income integrated (odds ratio, 0.62; 95% CI, 0.56 to 0.70), and high-income black (odds ratio, 0.77; 95% CI, 0.68 to 0.86). The odds ratio for bystander-initiated CPR in high-income integrated neighborhoods (1.03; 95% CI, 0.64 to 1.65) was similar to that for high-income white neighborhoods. CONCLUSIONS: In a large cohort study, we found that patients who had an out-of-hospital cardiac arrest in low-income black neighborhoods were less likely to receive bystander-initiated CPR than those in high-income white neighborhoods. (Funded by the Centers for Disease Control and Prevention and others.).

The impact of anesthesiologists on coronary artery bypass graft surgery outcomes.

BACKGROUND: One of every 150 hospitalized patients experiences a lethal adverse event; nearly half of these events involves surgical patients. Although variations in surgeon performance and quality have been reported in the literature, less is known about the influence of anesthesiologists on outcomes after major surgery. Our goal of this study was to determine whether there is significant variation in outcomes between anesthesiologists after controlling for patient case mix and hospital quality. METHODS: Using clinical data from the New York State Cardiac Surgery Reporting System, we conducted a retrospective observational study of 7920 patients undergoing isolated coronary artery bypass graft surgery. Multivariable logistic regression modeling was used to examine the variation in death or major complications (Q-wave myocardial infarction, renal failure, stroke) across anesthesiologists, controlling for patient demographics, severity of disease, comorbidities, and hospital quality. RESULTS: Anesthesiologist performance was quantified using fixed-effects modeling. The variability across anesthesiologists was highly significant (P < 0.001). Patients managed by low-performance anesthesiologists (corresponding to the 25th percentile of the distribution of anesthesiologist risk-adjusted outcomes) experienced nearly twice the rate of death or serious complications (adjusted rate 3.33%; 95% confidence interval [CI], 3.09%-3.58%) as patients managed by high-performance anesthesiologists (corresponding to the 75th percentile) (adjusted rate 1.82%; 95% CI, 1.58%-2.10%). This performance gap was observed across all patient risk groups. CONCLUSIONS: The rate of death or major complications among patients undergoing coronary artery bypass graft surgery varies markedly across anesthesiologists. These findings suggest that there may be opportunities to improve perioperative management to improve outcomes among high-risk surgical patients.

Should payment policy be changed to allow a wider range of EMS transport options?

The Institute of Medicine and other national organizations have asserted that current payment policies strongly discourage emergency medical services (EMS) providers from transporting selected patients who call 911 to non-ED settings (eg, primary care clinics, mental health centers, dialysis centers) or from treating patients on scene. The limited literature available is consistent with the view that current payment policies incentivize transport of all 911 callers to a hospital ED, even those who might be better managed elsewhere. However, the potential benefits and risks of altering existing policy have not been adequately explored. There are theoretical benefits to encouraging EMS personnel to transport selected patients to alternate settings or even to provide definitive treatment on scene; however, existing evidence is insufficient to confirm the feasibility or safety of such a policy. In light of growing concerns about the high cost of emergency care and heavy use of EDs, assessing EMS transport options should be a high-priority topic for outcomes research.

The state of innovative emergency medical service programs in the United States.

BACKGROUND: The primary objective of this study was to determine how EMS organizations that are piloting patient-centered treatment and transport protocols are approaching the challenges of implementation, reimbursement, and quality assurance. We were particularly interested in determining if these pilot efforts have raised any patient safety concerns. METHODS: We conducted a set of discussions with a small group of key EMS stakeholders regarding the status of pioneering efforts to develop and evaluate innovative approaches to EMS in the United States. RESULTS: We had discussions with 9 EMS agencies to better understand their innovative programs, including: the history of their service policy and procedure for transports that do not require emergency department care; the impact of their innovative program on service costs and/or cost savings; any reimbursement issues or changes; patient safety; patient satisfaction; and overall impression as well as recommendations for other EMS systems considering adoption of this policy. CONCLUSIONS: In general, EMS systems are not reimbursed for service unless the patient is transported to an ED. Spokespersons for all nine sites covered by this project said that this policy creates a powerful disincentive to implementing pilot programs to safely reduce EMS use by directing patients to more appropriate sites of care or proactively treating them in their homes. Even though private and public hospitals and payers typically benefit from these programs, they have been generally reluctant to offer support. This raises serious questions about the long-term viability of these programs.

Systematic review of strategies to manage and allocate scarce resources during mass casualty events.

STUDY OBJECTIVE: Efficient management and allocation of scarce medical resources can improve outcomes for victims of mass casualty events. However, the effectiveness of specific strategies has never been systematically reviewed. We analyze published evidence on strategies to optimize the management and allocation of scarce resources across a wide range of mass casualty event contexts and study designs. METHODS: Our literature search included MEDLINE, Scopus, EMBASE, Cumulative Index to Nursing and Allied Health Literature, Global Health, Web of Science, and the Cochrane Database of Systematic Reviews, from 1990 through late 2011. We also searched the gray literature, using the New York Academy of Medicine's Grey Literature Report and key Web sites. We included both English- and foreign-language articles. We included studies that evaluated strategies used in actual mass casualty events or tested through drills, exercises, or computer simulations. We excluded studies that lacked a comparison group or did not report quantitative outcomes. Data extraction, quality assessment, and strength of evidence ratings were conducted by a single researcher and reviewed by a second; discrepancies were reconciled by the 2 reviewers. Because of heterogeneity in outcome measures, we qualitatively synthesized findings within categories of strategies. RESULTS: From 5,716 potentially relevant citations, 74 studies met inclusion criteria. Strategies included reducing demand for health care services (18 studies), optimizing use of existing resources (50), augmenting existing resources (5), implementing crisis standards of care (5), and multiple categories (4). The evidence was sufficient to form conclusions on 2 strategies, although the strength of evidence was rated as low. First, as a strategy to reduce demand for health care services, points of dispensing can be used to efficiently distribute biological countermeasures after a bioterrorism attack or influenza pandemic, and their organization influences speed of distribution. Second, as a strategy to optimize use of existing resources, commonly used field triage systems do not perform consistently during actual mass casualty events. The number of high-quality studies addressing other strategies was insufficient to support conclusions about their effectiveness because of differences in study context, comparison groups, and outcome measures. Our literature search may have missed key resource management and allocation strategies because of their extreme heterogeneity. Interrater reliability was not assessed for quality assessments or strength of evidence ratings. Publication bias is likely, given the large number of studies reporting positive findings. CONCLUSION: The current evidence base is inadequate to inform providers and policymakers about the most effective strategies for managing or allocating scarce resources during mass casualty events. Consensus on methodological standards that encompass a range of study designs is needed to guide future research and strengthen the evidence base. Evidentiary standards should be developed to promote consensus interpretations of the evidence supporting individual strategies.

Military Medicine's Value to US Health Care and Public Health: Bringing Battlefield Lessons Home.

Importance: Military medicine in the US was established to treat wounded and ill service members and to protect the health and well-being of our military forces at home and abroad. To accomplish these tasks, it has developed the capacity to rapidly adapt to the changing nature of war and emerging health threats; throughout our nation's history, innovations developed by military health professionals have been quickly adopted by civilian medicine and public health for the benefit of patients in the US and around the world. Observations: From the historical record and published studies, we cite notable examples of how military medicine has advanced civilian health care and public health. We also describe how military medicine research and development differs from that done in the civilian world. During the conflicts in Afghanistan and Iraq, military medicine's focused approach to performance improvement and requirements-driven research cut the case fatality rate from severe battlefield wounds in half, to the lowest level in the history of warfare. Conclusions and Relevance: Although innovations developed by military medicine regularly inform and improve civilian health care and public health, the architects of these advances and the methods they use are often overlooked. Enhanced communication and cooperation between our nation's military and civilian health systems would promote reciprocal learning, accelerate collaborative research, and strengthen our nation's capacity to meet a growing array of health and geopolitical threats.

Graduate Medical Education in the Military Health System: Strategic Analysis and Options.

INTRODUCTION: At the request of then-Assistant Secretary of Defense for Health Affairs, Dr. Jonathan Woodson, Defense Health Horizons (DHH) examined options for shaping Graduate Medical Education (GME) in the Military Health System (MHS) in order to achieve the goals of a medically ready force and a ready medical force. MATERIALS AND METHODS: The DHH interviewed service GME directors, key designated institutional officials, and subject-matter experts on GME in the military and civilian health care systems. RESULTS: This report proposes numerous short- and long-term courses of action in three areas:1. Balancing the allocation of GME resources to suit the needs of active duty and garrisoned troops. We recommend developing a clear, tri-service mission and vision for GME in the MHS and expanding collaborations with outside institutions in order to prepare an optimal mix of physicians and ensure that trainees meet requirements for clinical experience.2. Improving the recruitment and tracking of GME students, as well as the management of accessions. We recommend several measures to improve the quality of incoming students, to track the performance of students and medical schools, and to foster a tri-service approach to accessions.3. Aligning MHS with the tenets of the Clinical Learning Environment Review to advance a culture of safety and to help the MHS become a high reliability organization (HRO). We recommend several actions to strengthen patient care and residency training and to develop a systematic approach to MHS management and leadership. CONCLUSION: Graduate Medical Education (GME) is vital to produce the future physician workforce and medical leadership of the MHS. It also provides the MHS with clinically skilled manpower. Graduate Medical Education (GME) research sows the seeds for future discoveries to improve combat casualty care and other priority objectives of the MHS. Although readiness is the MHS's top mission, GME is also vital to meeting the other three components of the quadruple aim (better health, better care, and lower costs). Properly managed and adequately resourced GME can accelerate the transformation of the MHS into an HRO. Based on our analysis, DHH believes that there are numerous opportunities for MHS leadership to strengthen GME so it is more integrated, jointly coordinated, efficient, and productive. All physicians emerging from military GME should understand and embrace team-based practice, patient safety, and a systems-oriented focus. This will ensure that those we prepare to be the military physicians of the future are prepared to meet the needs of the line, to protect the health and safety of deployed warfighters, and to provide expert and compassionate care to garrisoned service members, families, and military retirees.

National trends in emergency department occupancy, 2001 to 2008: effect of inpatient admissions versus emergency department practice intensity.

STUDY OBJECTIVE: We evaluate recent trends in emergency department (ED) crowding and its potential causes by analyzing ED occupancy, a proxy measure for ED crowding. METHODS: We analyzed data from the annual National Hospital Ambulatory Medical Care Surveys from 2001 to 2008. The surveys abstract patient records from a national sample of hospital EDs to generate nationally representative estimates of visits. We used time of ED arrival and length of ED visit to calculate mean and hourly ED occupancy. RESULTS: During the 8-year study period, the number of ED visits increased by 1.9% per year (95% confidence interval 1.2% to 2.5%), a rate 60% faster than population growth. Mean occupancy increased even more rapidly, at 3.1% per year (95% confidence interval 2.3% to 3.8%), or 27% during the 8 study years. Among potential factors associated with crowding, the use of advanced imaging increased most, by 140%. But advanced imaging had a smaller effect on the occupancy trend than other more common throughput factors, such as the use of intravenous fluids and blood tests, the performance of any clinical procedure, and the mention of 2 or more medications. Of patient characteristics, Medicare payer status and the age group 45 to 64 years accounted for small disproportionate increases in occupancy. CONCLUSION: Despite repeated calls for action, ED crowding is getting worse. Sociodemographic changes account for some of the increase, but practice intensity is the principal factor driving increasing occupancy levels. Although hospital admission generated longer ED stays than any other factor, it did not influence the steep trend in occupancy.

Small area variations in out-of-hospital cardiac arrest: does the neighborhood matter?

BACKGROUND: The incidence and outcomes of out-of-hospital cardiac arrest vary widely across cities. It is unknown whether similar differences exist at the neighborhood level. OBJECTIVE: To determine the extent to which neighborhoods have persistently high rates of cardiac arrest but low rates of bystander cardiopulmonary resuscitation (CPR). DESIGN: Multilevel Poisson regression of 1108 cardiac arrests from 161 census tracts as captured by the Cardiac Arrest Registry to Enhance Survival (CARES). SETTING: Fulton County, Georgia, between 1 October 2005 to 30 November 2008. MEASUREMENTS: Incidence of cardiac arrest, by census tract and year and by rates of bystander CPR. RESULTS: Adjusted rates of cardiac arrest varied across neighborhoods (interquartile range [IQR], 0.57 to 0.73 per 1000 persons; mean, 0.64 per 1000 persons [SD, 0.11]) but were stable from year to year (intraclass correlation, 0.36 [95% CI, 0.26 to 0.50]; P < 0.001). Adjusted bystander CPR rates also varied by census tract (IQR, 19% to 29%; mean, 25% [SD, 10%]). LIMITATION: Analysis was based on data from a single county. CONCLUSION: Surveillance data can identify neighborhoods with a persistently high incidence of cardiac arrest and low rates of bystander CPR. These neighborhoods are promising targets for community-based interventions. PRIMARY FUNDING SOURCE: Robert Wood Johnson Foundation Clinical Scholars Program, National Institutes of Health, and Centers for Disease Control and Prevention.

Factors associated with closures of emergency departments in the United States.

CONTEXT: Between 1998 and 2008, the number of hospital-based emergency departments (EDs) in the United States declined, while the number of ED visits increased, particularly visits by patients who were publicly insured and uninsured. Little is known about the hospital, community, and market factors associated with ED closures. Federal law requiring EDs to treat all in need regardless of a patient's ability to pay may make EDs more vulnerable to the market forces that govern US health care. OBJECTIVE: To determine hospital, community, and market factors associated with ED closures. DESIGN: Emergency department and hospital organizational information from 1990 through 2009 was acquired from the American Hospital Association (AHA) Annual Surveys (annual response rates ranging from 84%-92%) and merged with hospital financial and payer mix information available through 2007 from Medicare hospital cost reports. We evaluated 3 sets of risk factors: hospital characteristics (safety net [as defined by hospitals caring for more than double their Medicaid share of discharges compared with other hospitals within a 15-mile radius], ownership, teaching status, system membership, ED size, case mix), county population demographics (race, poverty, uninsurance, elderly), and market factors (ownership mix, profit margin, location in a competitive market, presence of other EDs). SETTING: All general, acute, nonrural, short-stay hospitals in the United States with an operating ED anytime from 1990-2009. MAIN OUTCOME MEASURE: Closure of an ED during the study period. RESULTS: From 1990 to 2009, the number of hospitals with EDs in nonrural areas declined from 2446 to 1779, with 1041 EDs closing and 374 hospitals opening EDs. Based on analysis of 2814 urban acute-care hospitals, constituting 36,335 hospital-year observations over an 18-year study interval (1990-2007), for-profit hospitals and those with low profit margins were more likely to close than their counterparts (cumulative hazard rate based on bivariate model, 26% vs 16%; hazard ratio [HR], 1.8; 95% confidence interval [CI], 1.5-2.1, and 36% vs 18%; HR, 1.9; 95% CI, 1.6-2.3, respectively). Hospitals in more competitive markets had a significantly higher risk of closing their EDs (34% vs 17%; HR, 1.3; 95% CI, 1.1-1.6), as did safety-net hospitals (10% vs 6%; HR, 1.4; 95% CI, 1.1-1.7) and those serving a higher share of populations in poverty (37% vs 31%; HR, 1.4; 95% CI, 1.1-1.7). CONCLUSION: From 1990 to 2009, the number of hospital EDs in nonrural areas declined by 27%, with for-profit ownership, location in a competitive market, safety-net status, and low profit margin associated with increased risk of ED closure.

Web-based self-triage of influenza-like illness during the 2009 H1N1 influenza pandemic.

The sudden emergence of 2009 H1N1 influenza in the spring of that year sparked a surge in visits to emergency departments in New York City and other communities. A larger, second wave of cases was anticipated the following autumn. To reduce a potential surge of health system utilization without denying needed care, we enlisted the input of experts from medicine, public health, nursing, information technology, and other disciplines to design, test, and deploy clinical algorithms to help minimally trained health care workers and laypeople make informed decisions about care-seeking for influenza-like illness. The product of this collaboration, named Strategy for Off-Site Rapid Triage (SORT) was disseminated in 2 forms. Static algorithms, posted on the Centers for Disease Control and Prevention's Web site, offered guidance to clinicians and telephone call centers on how to manage adults and children with influenza-like illness. In addition, 2 interactive Web sites, http://www.Flu.gov and http://www.H1N1ResponseCenter.com, were created to help adults self-assess their condition and make an informed decision about their need for treatment. Although SORT was anchored in a previously validated clinical decision rule, incorporated the input of expert clinicians, and was subject to small-scale formative evaluations during rapid standup, prospective evaluation is lacking. If its utility and safety are confirmed, SORT may prove to be a useful tool to blunt health system surge and rapidly collect epidemiologic data on future disease outbreaks.