RESUMEN
BACKGROUND: The NEXUS Chest CT clinical decision rules (CDRs) have been proposed to safely guide selective chest CT use in blunt trauma evaluation. We conducted a cost-effectiveness analysis of the NEXUS Chest CT CDR to determine its impact on missed injuries, cost, and radiation exposure. METHODS: We constructed a decision model comparing two strategies: implementation of the NEXUS Chest CDR vs. usual care in the evaluation of adults with blunt trauma. We derived probabilities, clinical outcomes, effective radiation dose (ERD) from the NEXUS Chest CT validation cohort and costs from the Charge-master at the primary study site. Our primary outcomes were cost and effective radiation dose (ERD) per missed clinically significant injury (CSI). RESULTS: Using a hypothetical cohort of 1000 adults with blunt chest trauma in each arm, the base case model projected that the implementation of the CDR would result in 161 fewer chest CTs, 0.08 additional missed CSIs, a cost savings of $136,432 and a decrease in 1435â¯mSv, as compared to Usual Care. To detect one additional CSI, the Usual Care strategy would require 2015 more chest CTs with a cost of $1.8 million and 17,934â¯mSv more radiation. CONCLUSIONS: Compared to usual care, implementation of the NEXUS Chest CT Major CDR in the evaluation of adults with blunt trauma would greatly reduce CT associated costs and radiation exposure with a slight increased risk of missed CSIs.
Asunto(s)
Reglas de Decisión Clínica , Análisis Costo-Beneficio , Traumatismos Torácicos/diagnóstico por imagen , Tomografía Computarizada por Rayos X/economía , Heridas no Penetrantes/diagnóstico por imagen , Árboles de Decisión , Humanos , Estudios Prospectivos , Tórax/diagnóstico por imagenRESUMEN
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.
Asunto(s)
Asignación de Recursos/estadística & datos numéricos , Triaje/clasificación , Adolescente , Niño , Preescolar , Costos y Análisis de Costo , Servicio de Urgencia en Hospital/organización & administración , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Hospitalización/estadística & datos numéricos , Humanos , Lactante , Masculino , Medicina de Urgencia Pediátrica/métodos , Medicina de Urgencia Pediátrica/estadística & datos numéricos , Asignación de Recursos/economía , Índice de Severidad de la Enfermedad , Triaje/métodos , Triaje/estadística & datos numéricosRESUMEN
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.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Alta del Paciente/estadística & datos numéricos , Adolescente , Adulto , Alcoholismo/epidemiología , Diagnóstico , Femenino , Encuestas de Atención de la Salud , Humanos , Masculino , Persona de Mediana Edad , Trastornos del Humor/epidemiología , Estudios Retrospectivos , Enfermedades Estomatognáticas/epidemiología , Estados UnidosRESUMEN
BACKGROUND: There is substantial interest in identifying low-acuity visits to emergency departments (EDs) that could be treated more appropriately in other settings. Systematic differences in illness severity between ED patients and comparable patients elsewhere could make such strategies unsafe, but little evidence exists to guide policy makers. OBJECTIVE: To compare illness severity between patients visiting EDs and outpatient clinics, by comparing short-term mortality and hospitalization, controlling for patient demographics, comorbidity, and visit acuity. RESEARCH DESIGN: Cross-sectional study of outcomes after medical encounters. SUBJECTS: Nationally representative 20% sample of Medicare fee-for-service beneficiaries discharged home from ED or clinic visit in 2011, and enrolled continuously for 1 year before the visit. MEASURES: All-cause mortality and hospitalization in the 8, 15, and 30 days after discharge home from ED or clinic visits. RESULTS: After risk-adjusting for patient demographic, comorbidity, disability, and dual-eligibility status, as well as visit acuity as measured by a commonly used algorithm, we found that ED patients were more likely to die (risk-adjusted odds ratio=2.75; 95% confidence interval, 2.56-2.96) or be hospitalized (odds ratio=1.97; 95% confidence interval, 1.95-2.00) after discharge than clinic patients. Differences in short-term outcomes were observed even when comparing patients with the same discharge diagnoses after risk adjustment. CONCLUSIONS: Patients presenting to EDs have worse risk-adjusted short-term outcomes than those presenting to outpatient clinics, even after controlling for acuity level of visit or discharge diagnosis. Existing measures of acuity using administrative data may not adequately capture severity of illness, making judgments of the appropriate setting for care difficult.
Asunto(s)
Instituciones de Atención Ambulatoria/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Hospitalización/estadística & datos numéricos , Mortalidad , Anciano , Algoritmos , Estudios Transversales , Femenino , Humanos , Masculino , Medicare/estadística & datos numéricos , Oportunidad Relativa , Gravedad del Paciente , Índice de Severidad de la Enfermedad , Estados UnidosRESUMEN
OBJECTIVE: To assess the effects of the Medicare Care Choices Model (MCCM) on disparities in hospice use and quality of end-of-life care for Medicare beneficiaries from underserved groups-those from racial and ethnic minority groups, dually eligible for Medicare and Medicaid, or living in rural areas. DATA SOURCES AND STUDY SETTING: Medicare enrollment and claims data from 2013 to 2021 for terminally ill Medicare fee-for-service beneficiaries nationwide. STUDY DESIGN: Through MCCM, terminally ill enrolled Medicare beneficiaries received supportive and palliative care services from hospice providers concurrently with curative treatments. Using a matched comparison group, we estimated subgroup-specific effects on hospice use, days at home, and aggressive treatment and multiple emergency department visits in the last 30 days of life. DATA COLLECTION/EXTRACTION METHODS: The sample included decedent Medicare beneficiaries enrolled in MCCM and a matched comparison group from the same geographic areas who met model eligibility criteria at time of enrollment: having a diagnosis of cancer, congestive heart failure, chronic obstructive pulmonary disease, or HIV/AIDS; living in the community; not enrolled in the Medicare hospice benefit in the previous 30 days; and having at least one hospital stay and three office visits in the previous 12 months. PRINCIPAL FINDINGS: Eligible beneficiaries from underserved groups were underrepresented in MCCM. MCCM increased enrollees' hospice use and the number of days at home and reduced aggressive treatment among all subgroups analyzed. MCCM also reduced disparities in hospice use by race and ethnicity and dual eligibility by 4.1 (90% credible interval [CI]: 1.3-6.1) and 2.4 (90% CI: 0.6-4.4) percentage points, respectively. It also reduced disparities in having multiple emergency department visits for rural enrollees by 1.3 (90% CI: 0.1-2.7) percentage points. CONCLUSIONS: MCCM increased hospice use and quality of end-of-life care for model enrollees from underserved groups and reduced disparities in hospice use and having multiple emergency department visits.
Asunto(s)
Disparidades en Atención de Salud , Cuidados Paliativos al Final de la Vida , Medicare , Humanos , Estados Unidos , Medicare/estadística & datos numéricos , Masculino , Femenino , Anciano , Cuidados Paliativos al Final de la Vida/estadística & datos numéricos , Anciano de 80 o más Años , Disparidades en Atención de Salud/estadística & datos numéricos , Disparidades en Atención de Salud/etnología , Cuidado Terminal/estadística & datos numéricos , Planes de Aranceles por Servicios/estadística & datos numéricos , Enfermo Terminal/estadística & datos numéricos , Cuidados Paliativos/estadística & datos numéricosRESUMEN
The Medicare Care Choices Model (MCCM) tested a new option for eligible Medicare beneficiaries to receive conventional treatment for terminal conditions along with supportive and palliative care from participating hospice providers. Using claims data, we estimated differences in average outcomes from enrollment to death between deceased MCCM enrollees and matched comparison beneficiaries who received usual services covered by original Medicare. Enrollees were 15 percentage points less likely to receive an aggressive life-prolonging treatment at the end of life and spent more than five more days at home. MCCM also reduced net Medicare expenditures by 13 percent, decreased inpatient admissions by 26 percent, reduced outpatient emergency department visits by 12 percent, and increased hospice use by 18 percentage points. Although the Centers for Medicare and Medicaid Services did not expand the model, given concerns about generalizability, these results provide evidence that MCCM is a promising approach to transforming care delivery at the end of life.
Asunto(s)
Cuidados Paliativos al Final de la Vida , Hospitales para Enfermos Terminales , Medicare Part C , Cuidado Terminal , Anciano , Humanos , Estados Unidos , Gastos en Salud , MuerteRESUMEN
OBJECTIVE: To examine whether randomization to permanent supportive housing (PSH) versus usual care reduces the use of acute health care and other services among chronically homeless high users of county-funded services. DATA SOURCES: Between 2015 and 2019, we assessed service use from Santa Clara County, CA, administrative claims data for all county-funded health care, jail and shelter, and mortality. STUDY DESIGN: We conducted a randomized controlled trial among chronically homeless high users of multiple systems. We compared postrandomization outcomes from county-funded systems using multivariate regression analysis. DATA COLLECTION: We extracted encounter data from an integrated database capturing health care at county-funded facilities, shelter and jails, county housing placement, and death certificates. PRINCIPAL FINDINGS: We enrolled 423 participants (199 intervention; 224 control). Eighty-six percent of those randomized to PSH received housing compared with 36 percent in usual care. On average, the 169 individuals housed by the PSH intervention have remained housed for 28.8 months (92.9 percent of the study follow-up period). Intervention group members had lower rates of psychiatric ED visits IRR 0.62; 95% CI [0.43, 0.91] and shelter days IRR 0.30; 95% CI [0.17, 0.53], and higher rates of ambulatory mental health services use IRR 1.84; 95% CI [1.43, 2.37] compared to controls. We found no differences in total ED or inpatient use, or jail. Seventy (37 treatment; 33 control) participants died. CONCLUSIONS: The intervention placed and retained frequent user, chronically homeless individuals in housing. It decreased psychiatric ED visits and shelter use, and increased outpatient mental health care, but not medical ED visits or hospitalizations. Limitations included more than one-third of usual care participants received another form of subsidized housing, potentially biasing results to the null, and loss of power due to high death rates. PSH can house high-risk individuals and reduce emergent psychiatric services and shelter use. Reductions in hospitalizations may be more difficult to realize.
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Personas con Mala Vivienda/estadística & datos numéricos , Servicios de Salud Mental/estadística & datos numéricos , Aceptación de la Atención de Salud/estadística & datos numéricos , Vivienda Popular/estadística & datos numéricos , Adulto , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Estado de Salud , Humanos , Masculino , Persona de Mediana Edad , Factores SocioeconómicosRESUMEN
INTRODUCTION: After having an acute myocardial infarction (AMI), racial and ethnic minorities have less access to care, decreased rates of invasive treatments such as percutaneous coronary intervention (PCI), and worse outcomes compared with white patients. The objective of this study was to determine whether the Affordable Care Act's expansion of Medicaid eligibility was associated with changes in racial disparities in access, treatments, and outcomes after AMI. METHODS: Quasi-experimental, difference-in-differences-in-differences analysis of non-Hispanic white and minority patients with acute myocardial infarction in California and Florida from 2010-2015, using linear regression models to estimate the difference-in-differences. This population-based sample included all Medicaid and uninsured patients ages 18-64 hospitalized with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act beginning as early as July 2011 in certain counties, and Florida, which did not expand Medicaid. The main outcomes included rates of admission to hospitals capable of performing PCI, rates of transfer for patients who first presented to hospitals that did not perform PCI, rates of PCI during hospitalization and rates of early (within 48 hours of admission) PCI, rates of readmission to the hospital within 30 days, and rates of in-hospital mortality. RESULTS: A total of 55,991 hospital admissions met inclusion criteria, 32,540 of which were in California and 23,451 were in Florida. Among patients with AMI who initially presented to a non-PCI hospital, the likelihood of being transferred increased by 12 percentage points (95% CI 2 to 21) for minority patients relative to white patients after the Medicaid expansion. The likelihood of undergoing PCI increased by 3 percentage points (95% CI 0 to 5) for minority patients relative to white patients after the Medicaid expansion. We did not find an association between the Medicaid expansion and racial disparities in overall likelihood of admission to a PCI hospital, hospital readmissions, or in-hospital mortality. CONCLUSIONS: The Medicaid expansion was associated with a decrease in racial disparities in transfers and rates of PCI after AMI. We did not find an association between the Medicaid expansion and admission to a PCI hospital, readmissions, and in-hospital mortality. Additional factors outside of insurance coverage likely continue to contribute to disparities in outcomes after AMI. These findings are crucial for policy makers seeking to reduce racial disparities in access, treatment and outcomes in AMI.
Asunto(s)
Medicaid , Infarto del Miocardio/terapia , Adulto , California , Femenino , Florida , Mortalidad Hospitalaria , Humanos , Masculino , Persona de Mediana Edad , Patient Protection and Affordable Care Act , Intervención Coronaria Percutánea , Estados Unidos , Adulto JovenRESUMEN
INTRODUCTION: Uninsured patients have decreased access to care, lower rates of percutaneous coronary intervention (PCI), and worse outcomes after acute myocardial infarction (AMI). The aim of this study was to determine whether expanding insurance coverage through the Affordable Care Act's expansion of Medicaid eligibility affected access to PCI hospitals, rates of PCI, 30-day readmissions, and in-hospital mortality after AMI. METHODS: Quasi-experimental, difference-in-differences analysis of Medicaid and uninsured patients with acute myocardial infarction in California, which expanded Medicaid through the Affordable Care Act, and Florida, which did not, from 2010-2015. This study accounts for the early expansion of Medicaid in certain California counties that began as early as July 2011. Main outcomes included rates of admission to PCI hospitals, rates of transfer for patients who initially presented to non-PCI hospitals, rates of PCI, rates of early PCI defined as within 48 hours of hospital admission, in-hospital mortality, and 30-day readmission. RESULTS: 55,991 hospital admissions between 2010-2015 met inclusion criteria. Of these, 32,540 were in California, which expanded Medicaid, and 23,451 were in Florida, which did not. 30-day readmission rates after AMI decreased by an absolute difference of 1.22 percentage points after the Medicaid expansion (95% CI -2.14 to -0.30, P < 0.01). This represented a relative decrease in readmission rates of 9.5% after AMI. No relationship between the Medicaid expansion and admission to PCI hospitals, transfer to PCI hospitals, rates of PCI, rates of early PCI, or in-hospital mortality were observed. CONCLUSIONS: Hospital readmissions decreased by 9.5% after the Affordable Care Act expanded Medicaid eligibility, although there was no association found between Medicaid expansion and access to PCI hospitals or treatment with PCI. Better understanding the ways that Medicaid expansion might affect care for vulnerable populations with AMI is important for policymakers considering whether to expand Medicaid eligibility in their state.
Asunto(s)
Accesibilidad a los Servicios de Salud/estadística & datos numéricos , Cobertura del Seguro/legislación & jurisprudencia , Cobertura del Seguro/estadística & datos numéricos , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea/estadística & datos numéricos , Adulto , California , Estudios de Casos y Controles , Determinación de la Elegibilidad , Femenino , Mortalidad Hospitalaria , Hospitalización/estadística & datos numéricos , Humanos , Masculino , Medicaid , Pacientes no Asegurados/estadística & datos numéricos , Persona de Mediana Edad , Infarto del Miocardio/mortalidad , Patient Protection and Affordable Care Act , Readmisión del Paciente/estadística & datos numéricos , Transferencia de Pacientes/estadística & datos numéricos , Resultado del Tratamiento , Estados UnidosRESUMEN
PURPOSE: Changing market forces increasingly are leading academic medical centers (AMCs) to form or join health systems. But it is unclear how this shift is affecting the tripartite academic mission of education, research, and high-quality patient care. To explore this topic, the authors identified and characterized the types of health systems that owned or managed AMCs in the United States in 2016. METHOD: The authors identified AMCs as any general acute care hospitals that had a resident-to-bed ratio of at least 0.25 and that were affiliated with at least one MD- or DO-granting medical school. Using the Agency for Healthcare Research and Quality 2016 Compendium of U.S. Health Systems, the authors also identified academic-affiliated health systems (AHSs) as those health systems that owned or managed at least one AMC. They compared AMCs and other general acute care hospitals, AHSs and non-AHSs, and AHSs by type of medical school relationship, using health system size, hospital characteristics, undergraduate and graduate medical education characteristics, services provided, and ownership. RESULTS: Health systems owned or managed nearly all AMCs (361, 95.8%). Of the 626 health systems, 230 (36.7%) met the definition of an AHS. Compared with other health systems, AHSs included more hospitals, provided more services, and had a lower ratio of primary care doctors to specialists. Most AHSs (136, 59.1%) had a single, shared medical school relationship, whereas 38 (16.5%) had an exclusive medical school relationship and 56 (24.3%) had multiple medical school relationships. CONCLUSIONS: These findings suggest that several distinct types of relationships between AHSs and medical schools exist. The traditional vision of a medical school having an exclusive relationship with a single AHS is no longer prominent.
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Educación de Postgrado en Medicina/organización & administración , Educación de Pregrado en Medicina/organización & administración , Hospitales de Enseñanza/organización & administración , Centros Médicos Académicos/organización & administración , Investigación Biomédica , Hospitales Generales/organización & administración , Hospitales Pediátricos/organización & administración , Hospitales con Fines de Lucro/organización & administración , Hospitales Públicos/organización & administración , Hospitales Filantrópicos/organización & administración , Humanos , Calidad de la Atención de Salud , Proveedores de Redes de Seguridad/organización & administración , Facultades de Medicina/organización & administraciónRESUMEN
OBJECTIVE: To test the hypothesis that the earned income tax credit (EITC)-the largest US poverty alleviation program-affects short-term health care expenditures among US adults. DATA SOURCES: Adult participants in the 1997-2012 waves of the US Medical Expenditure Panel Survey (MEPS) (N = 1 282 080). STUDY DESIGN: We conducted difference-in-differences analyses, comparing health care expenditures among EITC-eligible adults in February (immediately following EITC refund receipt) with expenditures during other months, using non-EITC-eligible individuals to difference out seasonal variation in health care expenditures. Outcomes included total out-of-pocket expenditures as well as spending on specific categories such as outpatient visits and inpatient hospitalizations. We conducted subgroup analyses to examine heterogeneity by insurance status. PRINCIPAL FINDINGS: EITC refund receipt was not associated with short-term changes in total expenditures, nor any expenditure subcategories. Results were similar by insurance status and robust to numerous alternative specifications. CONCLUSIONS: EITC refunds are not associated with short-term changes in health care expenditures among US adults. This may be because the refund is spent on other expenses, because of income smoothing, or because of similar refund-related variation in health care expenditures among noneligible adults. Future studies should examine whether other types of income supplementation affect health care expenditures, particularly among individuals in poverty.
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Gastos en Salud/estadística & datos numéricos , Impuesto a la Renta/legislación & jurisprudencia , Impuesto a la Renta/estadística & datos numéricos , Vigilancia de la Población , Pobreza/estadística & datos numéricos , Adulto , Femenino , Humanos , Masculino , Factores Socioeconómicos , Estados UnidosRESUMEN
Little is known about mortality risk among frequent emergency department (ED) users. Using California hospital data for 2005-13 linked to vital statistics data, we found that frequent ED use in the past year was predictive of mortality among the nonelderly in both the short and longer terms.
Asunto(s)
Servicio de Urgencia en Hospital/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Mortalidad , Adolescente , Adulto , California , Femenino , Humanos , Masculino , Trastornos Mentales/terapia , Persona de Mediana Edad , Estudios Retrospectivos , Trastornos Relacionados con Sustancias/terapia , Adulto JovenRESUMEN
Frequent emergency department (ED) users often have complex behavioral health and social needs. However, policy makers often focus on this population's medical system use without examining its use of behavioral health and social services systems. To illuminate the wide-ranging needs of frequent ED users, we compared medical, mental health, substance use, and social services use among nonelderly nonfrequent, frequent, and superfrequent ED users in San Francisco County, California. We linked administrative data for fiscal years 2013-15 for beneficiaries of the county's Medicaid managed care plan to a county-level integrated data system. Compared to nonfrequent users, frequent users were disproportionately female, white or African American/black, and homeless. They had more comorbidities and annual outpatient mental health visits (11.93 versus 4.16), psychiatric admissions (0.73 versus 0.07), and sobering center visits (0.17 versus <0.01), as well as disproportionate use of housing and jail health services. Our findings point to the need for shared knowledge across domains, at the patient and population levels. Integrated data can serve as a systems improvement tool and help identify patients who might benefit from coordinated care management. To deliver whole-person care, policy makers should prioritize improvements in data sharing and the development of integrated medical, behavioral, and social care systems.
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Servicio de Urgencia en Hospital , Mal Uso de los Servicios de Salud/tendencias , Bases de Datos Factuales , Servicio de Urgencia en Hospital/estadística & datos numéricos , Femenino , Accesibilidad a los Servicios de Salud , Vivienda , Humanos , Masculino , Medicaid , Persona de Mediana Edad , San Francisco , Estados UnidosRESUMEN
BACKGROUND: The Affordable Care Act has provided health insurance to a large portion of the uninsured in the United States. However, different types of health insurance provide varying amounts of reimbursements to providers, which may lead to different types of treatment, potentially worsening health outcomes in patients covered by low-reimbursement insurance plans, such as Medicaid. The objective was to determine differences in access, treatment, and health outcomes by insurance type, using hospital fixed effects. METHODS AND RESULTS: We conducted a multivariate regression analysis using patient-level data for nonelderly adult patients with acute myocardial infarction in California from January 1, 2001, to December 31, 2014, as well as hospital-level information to control for differences between hospitals. The probability of Medicaid-insured and uninsured patients having access to catheterization laboratory was higher by 4.50 and 3.75 percentage points, respectively, relative to privately insured patients. When controlling for access to percutaneous coronary intervention facilities, however, Medicaid-insured and uninsured patients had a 4.24- and 0.85-percentage point lower probability, respectively, in receiving percutaneous coronary intervention treatment compared with privately insured patients. They also had higher mortality and readmission rates relative to privately insured patients. CONCLUSIONS: Although Medicaid-insured and uninsured patients with acute myocardial infarction had better access to catheterization laboratories, they had significantly lower probabilities of receiving percutaneous coronary intervention treatment and a higher likelihood of death and readmission compared with privately insured patients. This provides empirical evidence that treatment received and health outcomes strongly vary between Medicaid-insured, uninsured, and privately insured patients, with Medicaid-insured patients most disproportionately affected, despite having better access to cardiac technology.
Asunto(s)
Cateterismo Cardíaco/economía , Accesibilidad a los Servicios de Salud/economía , Disparidades en Atención de Salud/economía , Cobertura del Seguro/economía , Seguro de Salud/economía , Infarto del Miocardio/economía , Infarto del Miocardio/terapia , Intervención Coronaria Percutánea/economía , Cateterismo Cardíaco/efectos adversos , Cateterismo Cardíaco/mortalidad , Femenino , Humanos , Masculino , Medicaid/economía , Pacientes no Asegurados , Persona de Mediana Edad , Infarto del Miocardio/diagnóstico , Infarto del Miocardio/mortalidad , Readmisión del Paciente , Intervención Coronaria Percutánea/efectos adversos , Intervención Coronaria Percutánea/mortalidad , Sector Privado/economía , Infarto del Miocardio con Elevación del ST/diagnóstico , Infarto del Miocardio con Elevación del ST/economía , Infarto del Miocardio con Elevación del ST/mortalidad , Infarto del Miocardio con Elevación del ST/terapia , Resultado del Tratamiento , Estados UnidosRESUMEN
OBJECTIVE: To examine current trends in the characteristics of patients visiting California emergency departments (EDs) in order to better direct the allocation of acute care resources. DESIGN: A retrospective study. SETTING: We analysed ED utilisation trends between 2005 and 2015 in California using non-public patient data from California's Office of Statewide Health Planning and Development. PARTICIPANTS: We included all ED visits in California from 2005 to 2015. PRIMARY AND SECONDARY OUTCOME MEASURES: We analysed ED visits and visit rates by age, sex, race/ethnicity, payer and urban/rural trends. We further examined age, sex, race/ethnicity and urban/rural trends within each payer group for a more granular picture of the patient population. Additionally, we looked at the proportion of patients admitted from the ED and distribution of diagnoses. RESULTS: Between 2005 and 2015, the annual number of ED visits increased from 10.2 to 14.2 million in California. ED visit rates increased by 27.8% (p<0.001), with the greatest increases among patients aged 5-19 (37.4%, p<0.001) and 45-64 years (41.1%, p<0.001), non-Hispanic Black and Hispanic patients (56.8% and 48.8%, p<0.001), the uninsured and Medicaid-insured (36.1%, p=0.002; 28.6%, p<0.001) and urban residents (28.3%, p<0.001). The proportion of ED visits resulting in hospitalisation decreased by 18.3%, with decreases across all payer groups. CONCLUSIONS: Our findings reveal an increasing demand for emergency care and may reflect current limitations in accessing care in other parts of the healthcare system. Policymakers may need to recognise the increasingly vital role that EDs are playing in the provision of care and consider ways to incorporate this changing reality into the delivery of health services.
Asunto(s)
Enfermedad Aguda/epidemiología , Servicios Médicos de Urgencia/estadística & datos numéricos , Cobertura del Seguro/estadística & datos numéricos , Medicaid , Aceptación de la Atención de Salud , Heridas y Lesiones/epidemiología , Enfermedad Aguda/terapia , Adolescente , Adulto , Anciano , California/epidemiología , Niño , Etnicidad , Femenino , Hospitalización/estadística & datos numéricos , Hospitalización/tendencias , Humanos , Lactante , Masculino , Persona de Mediana Edad , Aceptación de la Atención de Salud/estadística & datos numéricos , Estudios Retrospectivos , Estados Unidos , Heridas y Lesiones/terapiaRESUMEN
Importance: An association between frequent use of the emergency department (ED) and mental health diagnoses is frequently documented in the literature, but little has been done to more thoroughly understand why mental illness is associated with increased ED use. Objective: To determine which factors were associated with higher ED use in the near future among patients with and without mental health diagnoses. Design, Setting, and Participants: A retrospective case-control study of all patients presenting to the ED in California in 2013 using past ED data to predict future ED use. Data from January 1, 2012, through December 31, 2014, from California's Office of Statewide Health Planning and Development were analyzed. Main Outcomes and Measures: Factors associated with higher ED use in the year following an index visit for patients with vs without a mental health diagnosis. Results: Among the 3â¯446â¯338 individuals in the study (accounting for 7â¯678â¯706 ED visits), 44.6% (1â¯537â¯067) were male; 31.6% (1â¯089â¯043) were between the ages of 18 and 30 years, 40.3% (1â¯338â¯874) were between the ages of 31 and 50 years, and 28.1% (968â¯421) were between the ages of 51 and 64 years. The mean (SD) number of ED visits per patient per year was 1.69 (2.56), and 29.1% of patients (1â¯002â¯884) had at least 1 mental health diagnosis. Previous hospitalization and high rates of lagged ED visits were associated with higher future ED use. The severity of the mental health diagnosis (mild, moderate, or severe) was associated with increased ED visits (incidence rate ratio [IRR], 1.029; 95% CI, 1.02-1.04 for mild; IRR, 1.121; 95% CI, 1.11-1.13 for moderate; and IRR, 1.226; 95% CI, 1.22-1.24 for severe). Little evidence was found for interaction effects between mental health diagnoses and other diagnoses in predicting increased future ED use. Conclusions and Relevance: Certain classes of mental health diagnoses were associated with higher ED use. The presence of a mental illness diagnosis did not appear to interact with other patient-level factors in a way that meaningfully altered associations with future ED use.
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Servicio de Urgencia en Hospital/estadística & datos numéricos , Trastornos Mentales/epidemiología , Trastornos Mentales/terapia , Aceptación de la Atención de Salud/estadística & datos numéricos , Adolescente , Adulto , California/epidemiología , Estudios de Casos y Controles , Femenino , Humanos , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Adulto JovenRESUMEN
Importance: Emergency medical services (EMS) provide critical prehospital care, and disparities in response times to time-sensitive conditions, such as cardiac arrest, may contribute to disparities in patient outcomes. Objectives: To investigate whether ambulance 9-1-1 times were longer in low-income vs high-income areas and to compare response times with national benchmarks of 4, 8, or 15 minutes across income quartiles. Design, Setting, and Participants: A retrospective cross-sectional study was performed of the 2014 National Emergency Medical Services Information System data in June 2017 using negative binomial and logistic regressions to examine the association between zip code-level income and EMS response times. The study used ambulance 9-1-1 response data for out-of-hospital cardiac arrest from 46 of 50 state repositories (92.0%) in the United States. The sample included 63â¯600 cardiac arrest encounters of patients who did not die on scene and were transported to the hospital. Main Outcomes and Measures: Four time measures were examined, including response time, on-scene time, transport time, and total EMS time. The study compared response times with EMS response time benchmarks for responding to cardiac arrest calls within 4, 8, and 15 minutes. Results: The study sample included 63â¯600 cardiac arrest encounters of patients (mean [SD] age, 60.6 [19.0] years; 57.9% male), with 37â¯550 patients (59.0%) from high-income areas and 8192 patients (12.9%) from low-income areas. High-income areas had greater proportions of white patients (70.1% vs 62.2%), male patients (58.8% vs 54.1%), privately insured patients (29.4% vs 15.9%), and uninsured patients (15.3% vs 7.9%), while low-income areas had a greater proportion of Medicaid-insured patients (38.3% vs 15.8%). The mean (SD) total EMS time was 37.5 (13.6) minutes in the highest zip code income quartile and 43.0 (18.8) minutes in the lowest. After controlling for urban zip code, weekday, and time of day in regression analyses, total EMS time remained 10% longer (95% CI, 9%-11%; P < .001), translating to 3.8 minutes longer in the poorest zip codes. The EMS response time to patients in high-income zip codes was more likely to meet 8-minute and 15-minute cutoffs compared with low-income zip codes. Conclusions and Relevance: Patients with cardiac arrest from the poorest neighborhoods had longer EMS times compared with those from the wealthiest, and response times were less likely to meet national benchmarks in low-income areas, which may lead to increased disparities in prehospital delivery of care over time.
Asunto(s)
Ambulancias/estadística & datos numéricos , Servicios Médicos de Urgencia/estadística & datos numéricos , Renta/estadística & datos numéricos , Paro Cardíaco Extrahospitalario , Adulto , Anciano , Anciano de 80 o más Años , Estudios Transversales , Femenino , Humanos , Masculino , Persona de Mediana Edad , Paro Cardíaco Extrahospitalario/epidemiología , Paro Cardíaco Extrahospitalario/terapia , Pobreza , Grupos Raciales/estadística & datos numéricos , Características de la Residencia/estadística & datos numéricos , Estudios Retrospectivos , Factores de Tiempo , Estados Unidos/epidemiologíaRESUMEN
BACKGROUND: Standard clinical protocols for repetitive transcranial magnetic stimulation (rTMS) for major depressive disorder (MDD) apply 10â¯Hz pulses over left prefrontal cortex, yet little is known about the effects of rTMS in more diagnostically complex depressed patients. OBJECTIVE/HYPOTHESIS: Posttraumatic stress disorder (PTSD) is commonly comorbid with MDD, and while rTMS has been shown to alleviate PTSD symptoms in preliminary studies, ideal parameters remain unclear. We conducted a prospective, open-label study of 5â¯Hz rTMS for patients with comorbid PTSDâ¯+â¯MDD and hypothesized stimulation would reduce symptoms of both disorders. METHODS: Outpatients (Nâ¯=â¯40) with PTSDâ¯+â¯MDD and at least moderate global severity were enrolled. 5â¯Hz rTMS included up to 40 daily sessions followed by a 5-session taper. Symptoms were measured using the PTSD Checklist (PCL-5) and Inventory of Depressive Symptomatology, Self-Report (IDS-SR). Baseline-to-endpoint changes were analyzed. RESULTS: The intent-to-treat population included 35 participants. Stimulation significantly reduced PTSD symptoms (PCL-5 baseline mean⯱â¯SD score 52.2⯱â¯13.1 versus endpoint 34.0⯱â¯21.6; pâ¯<â¯.001); 23 patients (48.6%) met a pre-defined categorical PTSD response criteria. MDD symptoms also improved significantly (IDS-SR, baseline 47.8⯱â¯11.9 to endpoint 30.9⯱â¯18.9; pâ¯<â¯.001); 15 patients (42.9%) demonstrated categorical response and 12 (34.3%) remitted. PTSD and MDD symptom change was highly correlated (râ¯=â¯0.91, pâ¯<â¯.001). LIMITATIONS: Unblinded single-arm study, with modest sample size. CONCLUSION: Significant and clinically meaningful reductions in both MDD and PTSD symptoms were observed following stimulation. The preliminary efficacy of 5â¯Hz rTMS for both symptom domains in patients with comorbid disorders supports future controlled studies.