Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models.

The Centers for Medicare & Medicaid Services Innovation Center (CMMI) has set the goal for 100% of traditional Medicare beneficiaries to be part of an accountable care relationship by 2030. Lack of meaningful financial incentives, intolerable or unpredictable risk, infrastructure costs, patient engagement, voluntary participation, and operational complexity have been noted by the provider and health care delivery community as barriers to participation or reasons for exiting programs. In addition, most piloted and implemented population-based total cost of care (PB-TCOC) payment models have focused on the role of the primary care physician being the accountability (that is, attributable) leader of a patient's multifaceted care team as well as acting as the mayor of the "medical neighborhood," leaving the role of specialty care physicians undefined. Successful provider specialist integration into PB-TCOC models includes meaningful participation of specialists in achieving whole-person, high-value care where all providers are financially motivated to participate; there is unambiguous prospective attribution and clearly defined accountability for each participating party throughout the care journey or episode; there is a known care attribution transition accountability plan; there is actionable, transparent, and timely data available with appropriate data development and basic analytic costs covered; and there is advanced payment to the accountable person or entity for management of the care episode that is part of a longitudinal care plan. Payment models should be created to address the 7 challenges raised here if specialists are to be incented to join TCOC models that achieve CMMI's goal.

Emergency department hospice care pathway associated with decreased ED and hospital length of stay.

INTRODUCTION: While increasing evidence shows that hospice and palliative care interventions in the ED can benefit patients and systems, little exists on the feasibility and effectiveness of identifying patients in the ED who might benefit from hospice care. Our aim was to evaluate the effect of a clinical care pathway on the identification of patients who would benefit from hospice in an academic medical center ED setting. METHODS: We instituted a clinical pathway for ED patients with potential need for or already enrolled in hospice. This pathway was digitally embedded in the electronic health record and made available to ED physicians, APPs and staff in a non-interruptive fashion. Patient and visit characteristics were evaluated for the six months before (05/04/2021-10/4/2021) and after (10/5/2021-05/04/2022) implementation. RESULTS: After pathway implementation, more patients were identified as appropriate for hospice and ED length of stay (LOS) for qualifying patients decreased by a median of 2.9 h. Social work consultation for hospice evaluation increased, and more patients were discharged from the ED with hospice. As more patients were identified with end-of-life care needs, the number of patients admitted to the hospital increased. However, more patients were admitted under observation status, and admission LOS decreased by a median of 18.4 h. CONCLUSION: This non-interruptive, digitally embedded clinical care pathway provided guidance for ED physicians and APPs to initiate hospice referrals. More patients received social work consultation and were identified as hospice eligible. Those patients admitted to the hospital had a decrease in both ED and hospital admission LOS.

Successful Implementation of Workflow-Embedded Clinical Pathways During the COVID 19 Pandemic.

BACKGROUND AND OBJECTIVES: Clinical pathways have been found effective for improving adherence to evidence-based guidelines, thus providing better patient outcomes. As coronavirus disease-2019 (COVID-19) clinical guidance changed rapidly and evolved, a large hospital system in Colorado established clinical pathways within the electronic health record to guide clinical practice and provide the most up-to-date information to frontline providers. METHODS: On March 12, 2020, a system-wide multidisciplinary committee of specialists in emergency medicine, hospital medicine, surgery, intensive care, infectious disease, pharmacy, care management, virtual health, informatics, and primary care was recruited to develop clinical guidelines for COVID-19 patient care based on the limited available evidence and consensus. These guidelines were organized into novel noninterruptive digitally embedded pathways in the electronic health record (Epic Systems, Verona, Wisconsin) and made available to nurses and providers at all sites of care. Pathway utilization data were analyzed from March 14 to December 31, 2020. Retrospective pathway utilization was stratified by each care setting and compared with Colorado hospitalization rates. This project was designated as a quality improvement initiative. RESULTS: Nine unique pathways were developed, including emergency medicine, ambulatory, inpatient, and surgical care guidelines. Pathway data were analyzed from March 14 to December 31, 2020, and showed that COVID-19 clinical pathways were used 21 099 times. Eighty-one percent of pathway utilization occurred in the emergency department setting, and 92.4% applied embedded testing recommendations. A total of 3474 distinct providers employed these pathways for patient care. CONCLUSIONS: Noninterruptive digitally embedded clinical care pathways were broadly utilized during the early part of the COVID-19 pandemic in Colorado and influenced care across many care settings. This clinical guidance was most highly utilized in the emergency department setting. This shows an opportunity to leverage noninterruptive technology at the point of care to guide clinical decision-making and practice.

Differences in cardiac testing resource utilization using two different risk stratification schemes.

OBJECTIVE: Assess whether changing an emergency department (ED) chest pain pathway from utilizing the Thrombolysis in Myocardial Infarction (TIMI) score for risk stratification to an approach utilizing the History, EKG, Age, Risk, Troponin (HEART) score was associated with reductions in healthcare resource utilization. METHODS: A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications evaluated all ED patients with a chest pain encounter from 8/2015 to 7/2019 at a large academic medical center. We included patients age ≥ 18 with negative troponin testing discharged from the ED. Our standardized care pathway utilized TIMI for risk stratification until 09/2017 and HEART thereafter. We evaluated patients undergoing hospital-based cardiac diagnostic testing (CDT), length of stay (LOS), and 30-day Major Adverse Cardiovascular Events (MACE) at the intervention site before and after the pathway change and compared these outcomes to a similar control site within the health system for the difference-in-differences specification. RESULTS: During the study period, 6.3% (450 of 7117) of patients in the TIMI cohort and 7.2% (546 of 7623) in the HEART cohort among 400,965 total ED visits underwent CDT. In a multivariable analysis, transition to the HEART pathway was associated with greater odds of receiving CDT (odds ratio 2.88 [95% CI 1.21 to 6.86]), a reduction in LOS of 34 min (95% CI 2.2 to 67.6), and no significant difference in 30-day MACE. CONCLUSION: The transition from TIMI to HEART was associated with mixed consequences for healthcare resource utilization, including increased CDT but reduced length of stay.

The Role of Academic Health Systems in Leading the "Third Wave" of Digital Health Innovation.

Investors, entrepreneurs, health care pundits, and venture capital firms all agree that the health care sector is awaiting a digital revolution. Steven Case, in 2016, predicted a "third wave" of innovation that would leverage big data, artificial intelligence, and machine learning to transform medicine and finally achieve reduced costs, improved efficiency, and better patient outcomes. Academic medical centers (AMCs) have the infrastructure and resources needed by digital health intrapreneurs and entrepreneurs to innovate, iterate, and optimize technology solutions for the major pain points of modern medicine. With large unique patient data sets, strong research programs, and subject matter experts, AMCs have the ability to assess, optimize, and integrate new digital health tools with feedback at the point of care and research-based clinical validation. As AMCs begin to explore digital health solutions, they must decide between forming internal teams to develop these innovations or collaborating with external companies. Although each has its drawbacks and benefits, AMCs can both benefit from and drive forward the digital health innovations that will result from this journey. This viewpoint will provide an explanation as to why AMCs are ideal incubators for digital health solutions and describe what these organizations will need to be successful in leading this "third wave" of innovation.

Revisits After Emergency Department Discharge for Conditions with High Disposition-Decision Variability at Hospitals with High and Low Discharge Rates.

INTRODUCTION: The first proposed emergency care alternative payment model seeks to reduce avoidable admissions from the emergency department (ED), but this initiative may increase risk of adverse events after discharge. Our study objective was to describe variation in ED discharge rates and determine whether higher discharge rates were associated with more ED revisits. METHODS: Using all-payer inpatient and ED administrative data from the California Office of Statewide Health Planning and Development (OSHPD) 2017 database, we performed a retrospective cohort study of hospital-level ED discharge rates and ED revisits using conditions that have been previously described as having variability in discharge rates: abdominal pain; altered mental status; chest pain; chronic obstructive pulmonary disease exacerbation; skin and soft tissue infection; syncope; and urinary tract infection. We categorized hospitals into quartiles for each condition based on a covariate-adjusted discharge rate and compared the rate of ED revisits between hospitals in the highest and lowest quartiles. RESULTS: We found a greater than 10% difference in the between-quartile median adjusted discharge rate for each condition except for abdominal pain. There was no significant association between adjusted discharge rates and ED revisits. Altered mental status had the highest revisit rate, at 34% for hospitals in the quartile with the lowest and 30% in hospitals with the highest adjusted discharge rate, although this was not statistically significant. Syncope had the lowest rate of revisits at 16% for hospitals in both the lowest and highest adjusted discharge rate quartiles. CONCLUSION: Our findings suggest that there may be opportunity to increase ED discharges for certain conditions without resulting in higher rates of ED revisits, which may be a surrogate for adverse events after discharge.

Salary disparities based on gender in academic emergency medicine leadership.

OBJECTIVE: There are significantly fewer women than men in leadership roles in health care. Previous studies have shown that, overall, male physicians earn nearly $20,000 more annually than their female physician colleagues after adjusting for confounding factors. However, there has not been a description of physician leadership compensation in relation to gender. METHODS: This was a successive cross-sectional observation study design of 154 emergency departments in the United States from 5 years (2013, 2015-2018) using Association of Academic Chairs in Emergency Medicine and Academy of Administrators in Academic EM survey data. The primary variable of interest, leadership role, was attained by recoding the survey responses to assign primary job duty into four main categories: no leadership role, operations leadership, education leadership, and executive leadership. RESULTS: Overall, 8820 responses were included. Across all survey years, the mean (±SD) percentage of women in any leadership role was significantly less than men (44.5% [95% CI: 42.8, 46.2%] vs. 55.3% [95% CI: 54.1, 56.5%]). Women in leadership roles worked more clinical hours than men in the same position (female median = 1008, male median = 960). Women also had significantly lower salaries than men at each of the 5-year time points that data are reported, with unadjusted mean salary differences of -$54,409 per year for executives, -$27,803 for operational leaders, and -$17,803 for education leaders. CONCLUSIONS: Female physicians hold fewer leadership roles in academic emergency medicine (EM), and when they do, they work more clinical hours and are paid less than male physicians. As a specialty, EM should continue to investigate and report on gender achievement disparities as work is done to rectify the system inequalities.

Timeliness of Care for High-acuity Conditions at Hospital-affiliated Freestanding Emergency Departments.

BACKGROUND: Hospital-affiliated freestanding emergency departments (FREDs) are rapidly proliferating in some states and have been the subject of recent policy debate. As FREDs' role in acute care delivery is expanding in certain regions, little is known about the quality of care that they provide for their sickest patients. Our aim was to compare timeliness of emergent care at FREDs and hospital-based EDs (HEDs) for patient visits with selected high-acuity and time-sensitive conditions. METHODS: We performed a retrospective observational analysis of adult patient visit data from 19 FREDs and five HEDs from one health system over a 1-year period. Median times to events and hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated via Cox regression. RESULTS: The median time to electrocardiogram for visits with chest pain was 10 minutes at FREDs and 9 minutes at HEDs (HR = 0.91 [CI = 0.87 to 0.96]). Time to cardiac catheterization lab for visits with ST-segment elevation myocardial infarction (STEMI) was 78 minutes at FREDs, inclusive of transfer time, and 31 minutes at HEDs (HR = 0.41 [CI = 0.24 to 0.71]). Time to computed tomography for visits with stroke was 37 minutes at FREDs and 29 minutes at HEDs (HR = 0.42 [CI = 0.31 to 0.58]). Among visits with sepsis, FREDs had longer times to lactate collection (HR = 0.41 [CI = 0.30 to 0.56]), blood culture collection (HR = 0.24 [CI = 0.11 to 0.51]), and antibiotic administration (HR = 0.61 [CI = 0.26 to 1.42]). Beta agonists were administered for visits with asthma exacerbations in 24 minutes at FREDs and 44 minutes at HEDs (HR = 2.50 [CI = 2.34 to 2.68]), with similar times for anticholinergic and corticosteroid administration. CONCLUSIONS: Freestanding EDs provided more timely care than HEDs for visits with asthma exacerbation and less timely care for acute chest pain, stroke, and sepsis, although absolute differences were small. Even though STEMI patients at FREDs required transfer for catheterization, they tended to receive care in line with national guidelines.

Effect of Accountable Care Organizations on Emergency Medicine Payment and Care Redesign: A Qualitative Study.

STUDY OBJECTIVE: Accountable care organizations are provider networks aiming to improve quality while reducing costs for populations. It is unknown how value-based care within accountable care organizations affects emergency medicine care delivery and payment. Our objective was to describe how accountable care has impacted emergency care redesign and payment. METHODS: We performed a qualitative study of accountable care organizations, consisting of semistructured interviews with emergency department (ED) and accountable care organization leaders responsible for strategy, care redesign, and payment. We analyzed transcripts for key themes, using thematic analysis techniques. RESULTS: We performed 22 interviews across 7 accountable care organizations. All sites were enrolled in the Medicare Shared Savings Program; however, sites varied in region and maturity with respect to population health initiatives. Nearly all sites were focused on reducing low-value ED visits, expanding alternate venues for acute unscheduled care, and redesigning care to reduce ED admission rates through expanded care coordination, including programs targeting high-risk populations such as older adults and frequent ED users, telehealth, and expanded use of direct transfer to skilled nursing facilities from the ED. However, there has been no significant reform of payment for emergency medical care within these accountable care organizations. Nearly all informants expressed concern in regard to reduced ED reimbursement, given accountable care organization efforts to reduce ED utilization and increase clinician participation in alternative payment contracts. No participants expressed a clear vision for reforming payment for ED services. CONCLUSION: Care redesign within accountable care organizations has focused on outpatient access and alternatives to hospitalization. However, there has been little influence on emergency medicine payment, which remains fee for service. Evidence-based policy solutions are urgently needed to inform the adoption of value-based payment for acute unscheduled care.

Development of an Emergency Department Trigger Tool Using a Systematic Search and Modified Delphi Process.

OBJECTIVE: This study aimed to develop an emergency department (ED) trigger tool to improve the identification of adverse events in the ED and that can be used to direct patient safety and quality improvement. This work describes the first step toward the development of an ED all-cause harm measurement tool by experts in the field. METHODS: We identified a multidisciplinary group of emergency medicine safety experts from whom we solicited candidate triggers. We then conducted a modified Delphi process consisting of 4 stages as follows: (1) a systematic literature search and review, including an independent oversampling of review for inclusion, (2) solicitation of empiric triggers from participants, (3) a Web-based survey ranking triggers on specific performance constructs, and (4) a final in-person meeting to arrive at consensus triggers for testing. Results of each step were shared with participants between each stage. RESULTS: Among an initial 804 unique articles found using our search criteria, we identified 94 that were suitable for further review. Interrater reliability was high (κ = 0.80). Review of these articles yielded 56 candidate triggers. These were supplemented by 58 participant-submitted triggers yielding a total of 114 candidate triggers that were shared with team members electronically along with their definitions. Team members then voted on each measure via a Web-based survey, ranking triggers on their face validity, utility for quality improvement, and fidelity (sensitivity/specificity). Participants were also provided the ability to flag any trigger about which they had questions or they felt merited further discussion at the in-person meeting. Triggers were ranked by combining the first 2 categories (face validity and utility), and information on fidelity was reviewed for decision making at the in-person meeting. Seven redundant triggers were eliminated. At an in-person meeting including representatives from all facilities, we presented the 50 top-ranked triggers as well as those that were flagged on the survey by 2 or more participants. We reviewed each trigger individually, identifying 41 triggers about which there was a clear agreement for inclusion. Of the seven additional triggers that required subsequent voting via e-mail, 5 were adopted, arriving at a total of 46 consensus-derived triggers. CONCLUSIONS: Our modified Delphi process resulted in the identification of 46 final triggers for the detection of adverse events among ED patients. These triggers should be pilot field tested to quantify their individual and collective performance in detecting all-cause harm to ED patients.

Description and Yield of Current Quality and Safety Review in Selected US Academic Emergency Departments.

OBJECTIVES: Quality and safety review for performance improvement is important for systems of care and is required for US academic emergency departments (EDs). Assessment of the impact of patient safety initiatives in the context of increasing burdens of quality measurement compels standardized, meaningful, high-yield approaches for performance review. Limited data describe how quality and safety reviews are currently conducted and how well they perform in detecting patient harm and areas for improvement. We hypothesized that decades-old approaches used in many academic EDs are inefficient and low yield for identifying patient harm. METHODS: We conducted a prospective observational study to evaluate the efficiency and yield of current quality review processes at five academic EDs for a 12-month period. Sites provided descriptions of their current practice and collected summary data on the number and severity of events identified in their reviews and the referral sources that led to their capture. Categories of common referral sources were established at the beginning of the study. Sites used the Institute for Healthcare Improvement's definition in defining an adverse event and a modified National Coordinating Council for Medication Error Reporting and Prevention (MERP) Index for grading severity of events. RESULTS: Participating sites had similar processes for quality review, including a two-level review process, monthly reviews and conferences, similar screening criteria, and a grading system for evaluating cases. In 60 months of data collection, we reviewed a total of 4735 cases and identified 381 events. This included 287 near-misses, errors/events (MERP A-I) and 94 adverse events (AEs) (MERP E-I). The overall AE rate (event rate with harm) was 1.99 (95% confidence interval = 1.62%-2.43%), ranging from 1.24% to 3.47% across sites. The overall rate of quality concerns (events without harm) was 6.06% (5.42%-6.78%), ranging from 2.96% to 10.95% across sites. Seventy-two-hour returns were the most frequent referral source used, accounting for 47% of the cases reviewed but with a yield of only 0.81% in identifying harm. Other referral sources similarly had very low yields. External referrals were the highest yield referral source, with 14.34% (10.64%-19.03%) identifying AEs. As a percentage of the 94 AEs identified, external referrals also accounted for 41.49% of cases. CONCLUSIONS: With an overall adverse event rate of 1.99%, commonly used referral sources seem to be low yield and inefficient for detecting patient harm. Approximately 6% of the cases identified by these criteria yielded a near miss or quality concern. New approaches to quality and safety review in the ED are needed to optimize their yield and efficiency for identifying harm and areas for improvement.

Characteristics and Operational Performance of Hospital-affiliated Freestanding Emergency Departments.

BACKGROUND: As there has been increasing pressure on acute care services to redefine how their care is delivered, hospital-affiliated freestanding emergency departments (FREDs) have rapidly expanded in some markets. Little is known about the populations served or the quality of care provided by these facilities. OBJECTIVE: The objective of this study was to compare patient visit characteristics, geographic catchment areas, and operational performance between hospital-affiliated FREDs and hospital-based emergency departments (HEDs). RESEARCH DESIGN: This was a population-based retrospective observational analysis of 19 FREDs and 5 HEDs in a single health system over a 1-year period. We abstracted patient visit data from the electronic health record and supplemented catchment area data with the 2016 American Community Survey. We analyzed lengths of stay using generalized linear models adjusted for age, severity, and insurance status. RESULTS: FREDs had lower proportions of visits from nonwhite patients and more visits from privately insured patients than HEDs, with similar proportions of uninsured patient visits. These trends were mirrored in catchment area analyses. FRED visits were lower acuity, with fewer imaging and laboratory tests performed. The adjusted mean length of stay for discharged patients was 109 minutes for FREDs compared with 169 minutes for HEDs. For admitted or transferred patients, adjusted lengths of stay were 213 minutes at FREDs and 287 minutes at HEDs. CONCLUSIONS: Hospital-affiliated FREDs serve more affluent and less diverse patient populations and geographic communities. Relative to HEDs, they have lower acuity patient visits with fewer tests, and they have shorter lengths of stay, even after adjustment for patient visit characteristics.

Emergency department front-end split-flow experience: 'physician in intake'.

Background: Emergency department (ED) crowding is a critical problem in the delivery of acute unscheduled care. Many causes are external to the ED, but antiquated operational traditions like triage also contribute. A physician intake model has been shown to be beneficial in a single-centre study, but whether this solution is generalisable is not clear. We aimed to characterise the current state of front-end intake models in a national sample of EDs and quantify their effects on throughput measures. Methods: We performed a descriptive mixed-method analysis of ED process changes implemented by a cross section of self-selecting institutions who reported 2 years of demographic/operational data and structured process descriptions of any 'new front-end processes to replace traditional nurse-based triage'. Results: Among 25 participating institutions, 19 (76%) provided data. While geographically diverse, most were urban, academic adult level 1 trauma centres. Thirteen (68%) reported implementing a new intake process. All were run by attending emergency physicians, and six (46%) also included advanced practice providers. Daily operating hours ranged from 8 to 16 (median 12, IQR 10.25-15.85), and the majority performed labs, imaging and medication administration and directly discharged patients. Considering each site's before-and-after data as matched pairs, physician-driven intake was associated with mean decreases in arrival-to-provider time of 25 min (95% CI 13 to 37), ED length of stay 36 min (95% CI 12 to 59), and left before being seen rate 1.2% (95% CI 0.6% to 1.8%). Conclusions: In this cross section of primarily academic EDs, implementing a physician-driven front-end intake process was feasible and associated with improvement in operational metrics.

Virtual Reality-Based Resilience Programs: Feasibility and Implementation for Inpatient Oncology Nurses.

The high prevalence of compassion fatigue contributes to burnout among oncology nurses. Interventions are needed to support individuals across diverse roles and practice settings in oncology. Virtual reality (VR) is an emerging technology that has been applied in healthcare education and training and is being explored as an intervention to reduce stress and support wellness for healthcare providers. This article reviews recommendations from an implementation project about a VR intervention for oncology nurses.

Designing efficient emergency departments: Discrete event simulation of internal-waiting areas and split flow sorting.

OBJECTIVE: Evaluate nine different models, the interaction of three flow models (ESI, intake attending physician, and no split flow) and three physical design typologies (zero, one, and two internal-waiting areas), on Emergency Department (ED) flow and patient-centered metrics. METHODS: Discrete Event Simulation (DES) was used to systematically manipulate flow and physical design. Three base models were developed and validated using ED and patient specific data. Subsequently, systematic manipulations of flow and internal-waiting areas were performed on other models. Five outcomes of interest were tracked - length of stay (LOS), bed utilization rate, door to provider time, left without being seen rate, and number of movements per patient. Models were compared for statistical significance and effect size using ANOVA, and linear and non-linear regression. RESULTS: The shortest LOS (mean 175.2 min) and highest bed utilization rate (5.02 patients/bed/day) were obtained with flow split by an intake attending physician with two internal-waiting areas. These represented improvements of 54 min and 1.48 patients/bed/day over the control model. Two-way ANOVA demonstrated that both physical design and flow type were statistically significant predictors of all outcomes of interest (p < .0001). Depending on flow type, adding one additional internal-waiting area resulted in decreased LOS (range 10.6-21.8 min), increased bed utilization (range 0.23-0.40 patients/bed/day), decreased D2P (range 1.3-4.8 min), and decreased LWBS (0.66%-2.0%). CONCLUSION: Based on a DES model with empirical data from a single institution, combining flow split by an intake attending physician and multiple internal-waiting areas resulted in improved ED operational and patient-centered metrics.

Continuation of Gender Disparities in Pay Among Academic Emergency Medicine Physicians.

OBJECTIVES: The objective was to identify the effects of gender and other predictors of change in the salary of academic emergency physicians over a four sequential time period of survey administration, across a sample of physicians within different emergency departments (EDs) and within states representing the four main geographical regions of the United States. METHODS: This was a successive cross-sectional observational study of EDs in the United States using an annual salary survey distributed to all Association of Academic Chairs in Emergency Medicine (AACEM) and Academy of Administrators in Academic Emergency Medicine (AAAEM) members in 2013, 2015, 2016, and 2017 with a sample size of 7,102 respondents over all time periods. The primary variable of interest was the adjusted base salary, calculated to be the full-time effort of the physician without any enhancements (e.g., without stipend, release time, extra hours). Institutional predictive variables included U.S. region that ED was in and if the site was an academic or community academic hybrid ("community") ED. Individual level variables included gender, academic rank, years at academic rank, years at rank within the ED, and primary duty (clinical or other). A series of Wilcoxon tests were conducted to determine if the unadjusted difference in salaries by gender for each year of the survey were significantly different. The effects of relative change in adjusted base salary over time were assessed using a mixed-effects regression model, with institutional- and individual-level predictors included in the model. RESULTS: Data were provided by 81 departments across the four geographic regions of the United States (Northeast, South, West, and Midwest). Most of the survey respondents across the four time periods of administration were male (65%) and reported primary clinical appointments at an academic ED (94%). Overall salaries increased across the four time points of the data with an overall relative 10.8% (95% confidence interval [CI] = 9.6%-12%) change in median salary between 2013 and 2017; the relative percentage change for female respondents was 10.6% (95% CI = 9.4%-11.85%) and 11.1% (95% CI = 10.2%-12%) for males. Within survey years, not adjusting for academic rank, the median salary increase for males was higher ($226,746 in 2013 to $252,000 in 2017) than females ($217,000 in 2013 to $240,000 in 2017), with significance at all four time points (Z = 6.33, p < 0.001), with a median average salary gap of $12,000 in 2017. In the predictive model that adjusted for covariates, gender significantly predicted median adjusted salary, with males earning significantly more than females (F(1) = 22.5, p < 0.001). CONCLUSIONS: Despite previously published data showing an inappropriate gender salary gap in emergency medicine, this gap has remained essentially unchanged over the past 4 years.

Coordination Program Reduced Acute Care Use And Increased Primary Care Visits Among Frequent Emergency Care Users.

Many high utilizers of the emergency department (ED) have public insurance, especially through Medicaid. We evaluated how participation in Bridges to Care (B2C)-an ED-initiated, multidisciplinary, community-based program-affected subsequent ED use, hospital admissions, and primary care use among publicly insured or Medicaid-eligible high ED utilizers. During the six months after the B2C intervention was completed, participants had significantly fewer ED visits (a reduction of 27.9 percent) and significantly more primary care visits (an increase of 114.0 percent), compared to patients in the control group. In a subanalysis of patients with mental health comorbidities, we found that recipients of B2C services had significantly fewer ED visits (a reduction of 29.7 percent) and hospitalizations (30.0 percent), and significantly more primary care visits (an increase of 123.2 percent), again compared to patients in the control group. The B2C program reduced acute care use and increased the number of primary care visits among high ED utilizers, including those with mental health comorbidities.

How alternative payment models in emergency medicine can benefit physicians, payers, and patients.

While there has been considerable effort devoted to developing alternative payment models (APMs) for primary care physicians and for episodes of care beginning with inpatient admissions, there has been relatively little attention by payers to developing APMs for specialty ambulatory care, and no efforts to develop APMs that explicitly focus on emergency care. In order to ensure that emergency care is appropriately integrated and valued in future payment models, emergency physicians (EPs) must engage with the stakeholders within the broader health care system. In this article, we describe a framework for the development of APMs for emergency medicine and present four examples of APMs that may be applicable in emergency medicine. A better understanding of how APMs can work in emergency medicine will help EPs develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system.