Assessing risk of major adverse cardiac events among patients with chest pain and cocaine use using the HEART score.

INTRODUCTION: Chest pain (CP), a common presentation in the emergency department (ED) setting, is associated with significant morbidity and mortality if emergency clinicians miss the diagnosis of acute coronary syndrome (ACS). The HEART (History, Electrocardiogram, Age, Risk Factors, Troponin) score had been validated for risk-stratification patients who are at high risk for ACS and major adverse cardiac events (MACE). However, the use of cocaine as a risk factor of the HEART score was controversial. We hypothesized that patients with cocaine-positive (COP) would not be associated with higher risk of 30-day MACE than cocaine-negative (CON) patients. METHODS: This retrospective study included adult patients who presented to 13 EDs of a University's Medical System between August 7, 2017 to August 19, 2021. Patients who had CP and prospectively calculated HEART scores and urine toxicology tests as part of their clinical evaluation were eligible. Areas Under The Receiver Operating Curve (AUROC) were calculated for the performance of HEART score and 30-day MACE for each group. RESULTS: This study analyzed 46,210 patients' charts, 663 (1.4%) were COP patients. Mean age was statistically similar between groups but there were fewer females in the COP group (26.2% vs 53.2%, p < 0.001). Mean (+/- SD) HEART score was 3.7 (1.4) comparing to 3.1 (1.8, p < 0.001) between COP vs CON groups, respectively. Although more COP patients (54%) had moderate HEART scores (4-6) vs. CON group (35.2%, p < 0.001), rates of 30-day MACE were 1.1% for both groups. HEART score's AUROC was 0.72 for COP and 0.78 for CON groups. AUROC for the Risk Factor among COP patients, which includes cocaine, was poor (0.54). CONCLUSION: This study, which utilized prospective calculated HEART scores, demonstrated that overall performance of the HEART score was reasonable. Specifically, our analysis showed that the rate of 30-day MACE was not affected by cocaine use as a risk factor. We would recommend clinicians to consider the HEART score for this patient group.

Illicit Fentanyl Exposure Among Victims of Violence Treated at a Trauma Center.

INTRODUCTION: Opioid overdoses and violent injury are leading causes of death in the United States, yet testing for novel opioids like fentanyl remains uncommon. The purpose of this investigation is to characterize a population of victims of violence who test positive for illicit fentanyl. METHODS: Retrospective cohort study of patients treated at a level-one trauma center between January 31, 2019 and February 21, 2020. Data were extracted from the electronic medical record. Subjects were included if they had an encounter diagnosis for a violent or intentional injury, using the International Classification of Diseases, v10 (X92-Y09). We excluded patients who received licit fentanyl as a part of their care before testing. Those who tested positive for fentanyl exposure on our standard hospital urine drug screen were considered to have been exposed to illicit fentanyl. Those testing negative for fentanyl were considered controls. RESULTS: Of the 1132 patients treated for intentional injuries during the study period, 366 were included in the study (32.3%). Of these, 133 (36.3%) subjects were exposed to illicit fentanyl prehospital. There were no demographic differences between cases and controls. Cases had a lower GCS voice score on arrival (median = 4, interquartile range [IQR] = 4-5 versus median = 5, IQR = 4-5, P = 0.02), higher rates of ventilator usage (32.3% versus 21.5%, P = 0.02), and more intensive care unit admissions (27.1% versus 12.0%, P = 0.005). More than half of cases tested negative for opiates (78/133, 58.6%). Cases had more trauma center encounters (26.3% had ≥2 visits versus 15.5%). CONCLUSIONS: Exposure to illicit fentanyl was common among victims of violence in this single-center study. These patients are at increased risk of being admitted to intensive care units and repeated trauma center visits, suggesting fentanyl testing may help identify those who could benefit from violence prevention and substance abuse treatment.

Evaluating Social Determinants of Health in a Mobile Integrated Healthcare-Community Paramedicine Program.

In 2018, the University of Maryland Medical Center and the Baltimore City Fire Department implemented a community paramedicine program to help medically or socially complex patients transition from hospital to home and avoid hospital utilization. This study describes how patients' social determinants of health (SDoH) needs were identified, and measures the association between needs and hospital utilization. SDoH needs were categorized into ten domains. Multinomial logistic regression was used to measure association between identified SDoH domains and predicted risk of readmission. Poisson regression was used to measure association between SDoH domains and actual 30-day hospital utilization. The most frequently identified SDoH needs were in the Coordination of Healthcare (37.7%), Durable Medical Equipment (18.8%), and Medication (16.3%) domains. Compared with low-risk patients, patients with an intermediate risk of readmission were more likely to have needs within the Coordination of Healthcare (RRR [95% CI] 1.12 [1.01, 1.24], p = 0.032) and Durable Medical Equipment (RRR = 1.13 [1.00, 1.27], p = 0.046) domains. Patients with the highest risk for readmission were more likely to have needs in the Utilities domain (RRR = 1.76 [0.97, 3.19], p = 0.063). Miscellaneous domain needs, such as requiring a social security card, were associated with increased 30-day hospital utilization (IRR = 1.23 [0.96, 1.57], p = 0.095). SDoH needs within the Coordination of Healthcare, Durable Medical Equipment, and Utilities domains were associated with higher predicted 30-day readmission, while identification documentation and social services needs were associated with actual readmission. These results suggest where to allocate resources to effectively diminish hospital utilization.

Association Between Primary Care Availability and Emergency Medical Services Utilization.

BACKGROUND: Emergency medical services (EMS) contribute to the vital role of providing health care to an individual by delivering time-sensitive, episodic treatment to patients with acute illnesses. Understanding which factors impact EMS utilization can help guide policies and allocate resources more effectively. Increasing primary care access has often been touted to decrease unnecessary emergency care utilization. OBJECTIVES: This study seeks to determine whether a relationship exists between access to primary care and EMS utilization. METHODS: Using data from the National Emergency Medical Services Information System, Area Health Resources Files, and County Health Rankings and Roadmaps, U.S. county-level data were analyzed to determine whether increased access to primary care (and insurance coverage) was associated with decreased EMS utilization. RESULTS: Higher primary care availability is associated with less EMS utilization only when insurance coverage in the community surpassed 90%. CONCLUSIONS: Insurance coverage can play an important role in decreasing EMS utilization and may also impact the effect of increased primary care physician availability on EMS utilization in a region.

Analysis of an Alternative Model of Definitive Care For Low-Acuity Emergency Calls: A Natural Experiment.

BACKGROUND: Emergency medical services (EMS) diversion strategies attempt to limit the impact of low-acuity care on emergency department (ED) crowding, but evidence supporting these strategies is scarce. OBJECTIVE: This study aims to measure the effect of a treat-in-place and alternative destination program on ED transports and EMS utilization. METHODS: We used a natural experiment study design to measure effects of a pilot prehospital diversion program on ED transport, number of EMS vehicles dispatched, and EMS time on task for low-acuity emergency calls in a midsized urban setting characterized by a high prevalence of health disparities, concentrated poverty, and limited access to primary care between October 2018 and January 2020. We also used direct variable cost to estimate the return on investment attributable to avoided ED visits. RESULTS: Of 3725 calls that met eligibility criteria, the program responded to 1084 (29.1%), with 56.7% of those resulting in an ED visit, compared with 64.6% of the 492 control calls that were eligible but were dispatched when program services were unavailable. Of 1084 calls receiving response, 213 (19.6%) were enrolled in the program, and 8.5% of those were transported by EMS to the ED. Adjusted results show EMS time on task was 23.4 min less for enrolled calls vs. controls. The program can achieve a positive return on investment by enrolling 2.9 patients/day. CONCLUSIONS: A prehospital diversion program reduced ED visits and EMS transport times. Improved targeting of patients for enrollment would further increase the intervention's efficacy and cost savings.

Association of Timely Outpatient Follow-Up and Readmission Risk in a Mobile Integrated Health Program.

The objective was to identify medical conditions associated with 30-day readmission, determine patient characteristics for which outpatient follow-up is most associated with reduced readmission, and evaluate how readmission risk changes with time to outpatient follow-up within a mobile integrated health-community paramedicine (MIH-CP) program. This retrospective observational study used data from 1,118 adult patient enrollments in a MIH-CP program operating in Baltimore, Maryland, from May 14, 2018, to December 21, 2021. Bivariate analysis identified chronic disease exacerbations associated with higher 30-day readmission risk. Kaplan-Meier curves and Cox proportional hazard regressions were used to measure how hazard of readmission changes with outpatient follow-up and how that association may vary with other factors. Receiver operating characteristic analysis was used to evaluate how well time to follow-up could predict 30-day readmission. Timely outpatient follow-up was associated with a significant reduction in hazard of readmission for patients aged 50 and younger and for patients with fewer than 5 social determinants of health needs identified. No significant association between readmission and specific chronic disease exacerbations was observed. An optimal follow-up time frame to reduce readmissions could not be identified. Timely outpatient follow-up may be effective for reducing readmissions in younger patients and patients who are less socially complex. Programs and policies aiming to reduce 30-day readmissions may have more success by expanding efforts to include these patients.

Assessing risk of major adverse cardiac event among COVID-19 patients using HEART score.

Coronavirus disease 2019 (COVID-19) is known to be associated with cardiovascular complications, but whether the current validated HEART score for chest pain is still applicable for these patients is unknown. This study aims to identify the impact and association of COVID-19 co-infection in patients presenting with chest pain and a calculated HEART score to the emergency departments (ED) with 30-day of major adverse cardiac event (MACE). This is a multicenter, retrospective observational study that included adult (age ≥ 18 years) patients visiting 13 different EDs with chest pain and evaluated using a HEART score. The primary outcome was the percentage of 30-day MACE, which included acute myocardial infarction, emergency percutaneous coronary intervention (PCI), coronary artery bypass graft (CABG), or death among patients who presented with chest pain and had COVID-19 co-infection. The sensitivity and specificity of the HEART score among COVID-19 co-infection for MACE were assessed by the receiver operating curve (ROC). We analyzed records of 46,210 eligible patients, in which 327 (0.7%) patients were identified as infected with COVID-19. Patients with COVID-19 had higher mean total HEART score of 3.3 (1.7), compared to patients who did not have COVID-19 (3.1, SD 1.8, P = 0.048). The rate of MACE was similar between both groups. There were only 2 (0.6%) COVID-19 patients who had MACE, compared to 504 (1.1%) patients in control group. Total HEART score was associated with an area under the ROC (AUROC) of 0.99, while the control group's was 0.78. History was associated with high AUROC in both COVID-19 (0.74) and control groups (0.76). Older age in COVID-19 had higher AUROC (0.89) than control patients (0.63). Among patients presenting to the ED with chest pain and having COVID-19 infection, HEART score had predictive capability for MACE, similar to patients without COVID-19 infection. Further studies with more COVID-19 patients are still necessary to confirm our observation.

Evaluating the Impact of a Mobile Integrated Health‒Community Paramedicine Program on Health-Related Social Needs and Hospital Readmissions.

OBJECTIVE: Evaluate a mobile integrated health-community paramedicine program's effect on addressing health-related social needs and their association with hospital readmissions. METHODS: This observational study enrolled 1,003 patients from 5/4/2018-7/23/21. Descriptive statistics summarize social needs. A Poisson regression model examined the association of interventions for social needs with 30-day readmissions. RESULTS: Patients who had their medication-related needs fully addressed had a 65% lower rate of total 30-day readmission compared with patients who had no such needs fully addressed (IRR=0.35, 95% CI 0.18-0.68, P=.002). No variables reached statistical significance related to unplanned 30-day readmissions, aside from the HOSPITAL Score. CONCLUSIONS: Assisting patients with medication-related needs is associated with reductions in overall 30-day readmissions. Interventions within most domains were not associated with reductions in overall or unplanned 30-day readmissions. This program had greater success addressing needs with one-step interventions, suggesting additional time and resources may be necessary to address complex social needs.

The impact of automatic physician review of prescription drug monitoring program data on opioid prescribing in a Maryland statewide hospital system.

BACKGROUND AND AIMS: Prescription drug monitoring programs (PDMPs) were implemented to decrease dangerous opioid prescribing but have had variable results. This report details how automatic PDMP review changed opioid prescribing across a statewide medical system. DESIGN: An observational study. SETTING: Fourteen hospital networks in the United States. CASES: Healthcare encountered from July 1, 2016 to June 30, 2019. INTERVENTION: Starting from July 1, 2018, the patient's PDMP data would be displayed automatically to providers in the unified electronic medical record (EMR) whenever the provider began to write for an opioid prescription. MEASUREMENTS: Outcomes were prescriptions per encounter (PPE) and the morphine milligram equivalents (MME) per prescription. Outcomes were stratified by practice location, medication prescribed, and diagnosis. All data, including whether the prompt was triggered for a given encounter and whether a prescription was given, were extracted from the EMR. An interrupted timeseries analysis was used to determine how PPE and MME changed in response to the implementation of automatic PDMP review. FINDINGS: Of the 624,488 encounters examined, 18.37 percent (n = 114,710) were in emergency departments, 56.79 percent were admissions (n = 354,634), and 24.84 percent (n = 155,144) were outpatient visits. Opioid prescriptions were started and then canceled 24 percent of the time after the PDMP was shown. There was a decline in MME (ßOverall + Policy Trends = -3.17, p = <0.0001), which was driven by inpatient (ßOverall + Policy Trends = -2.10, p < 0.0001) and outpatient providers (ßOverall + Policy Trends = -3.24, p < 0.01). A decline in MME was seen in all medication categories (-1.72 < ßOverall + Policy Trends < -5.87, p < 0.01). There were no changes in these trends after excluding encounters for severe and acute pain. CONCLUSIONS: Automated PDMP review is associated with fewer prescriptions and smaller doses without decreasing appropriate use.

Impact of a mobile integrated healthcare and community paramedicine program on improving medication adherence in patients with heart failure and chronic obstructive pulmonary disease after hospital discharge: A pilot study.

Background: The mobile integrated health-community paramedicine (MIH-CP) program affiliated with the University of Maryland Medical Center focuses on improving patient transitions from hospital to home by addressing both medical and social determinants of health. Until recently, only self-contained health systems could integrate inpatient and outpatient medication data. Without some means to track patients in transition, there is a significant risk of medication-related problems and errors. Objective: To evaluate the impact of the MIH-CP program on medication adherence among patients with congestive heart failure (CHF) and/or chronic obstructive pulmonary disease (COPD). Methods: This is a pilot observational study designed to compare adherence to drug regimens prescribed at hospital discharge (measured by the proportion of days covered [PDC]) between patients enrolled in the MIH-CP program and a propensity-matched control group. Propensity scores were calculated using 11 demographic, diagnostic, third-party payer, and patient care-associated variables. Discharge medication details were obtained from electronic medical records. PDC for each of the medications were calculated from pharmacy claims data. Results: Eighty-three patients were included in the study; forty-three patients were placed in the intervention group and 40 were propensity-matched controls. After adjusting for age, sex, and third-party payer, findings indicated that medication adherence was higher among patients enrolled in the MIH-CP program compared with control during the first 30 days post-discharge, specifically among patients diagnosed with CHF (8% difference in PDC, 95% confidence interval [CI], -0.12-0.28%) and COPD (14% difference, 95% CI, -0.15-0.43%), although neither result achieved statistical significance. The differences in medication adherence between patients who were enrolled and those who were not enrolled in the MIH-CP program diminished after 30 days post-discharge. Conclusion: This pilot study demonstrated a trend toward improved medication adherence among patients enrolled in the MIH-CP program. Future research involving a larger patient cohort will be required to confirm these preliminary findings.

The effect of a mobile integrated health program on health care cost and utilization.

OBJECTIVE: To measure the effect of a mobile integrated health community paramedicine (MIH-CP) transitional care program on hospital utilization, emergency department visits, and charges. DATA SOURCES: Retrospective secondary data from the electronic health record and regional health information exchange were used to analyze patients discharged from a large academic medical center and an affiliated community hospital in Baltimore, Maryland, May 2018-October 2019. STUDY DESIGN: We performed an observational study comparing patients enrolled in an MIH-CP program to propensity-matched controls. Propensity scores were calculated using measures of demographics, clinical characteristics, social determinants of health, and prior health care utilization. The primary outcome is inpatient readmission within 30 days of discharge. Secondary outcomes include excess days in acute care 30 days after discharge and emergency department visits, observation hospitalizations, and total health care charges within 30 and 60 days of discharge. DATA COLLECTION: Included patients were over 18 years old, discharged to home from internal/family medicine services, and live in eligible ZIP codes. The intervention group was enrolled in the MIH-CP program; controls met inclusion criteria but were not enrolled during the study period. PRINCIPAL FINDINGS: The adjusted model showed no difference in 30-day inpatient readmission between 464 enrolled patients and propensity-matched controls (adjusted incidence rate ratio = 1.19, 95% confidence interval [CI] [0.89, 1.60]). There was a higher rate of observation hospitalizations within 30 days of index discharge for MIH-CP patients (adjusted incidence rate ratio = 1.78, 95% CI = [1.01, 3.14]). This difference did not persist at 60 days, and there were no differences in other secondary outcomes. CONCLUSIONS: We found no significant difference in short-term health care utilization or charges between patients enrolled in an MIH-CP transitional care program and propensity-matched controls. This highlights the importance of well-controlled, robust evaluations of effectiveness in novel care-delivery systems.

Masking for COVID-19 Is Associated with Decreased Emergency Department Utilization for Non-COVID Viral Illnesses and Respiratory Conditions in Maryland.

BACKGROUND: Masking, which is known to decrease the transmission of respiratory viruses, was not widely practiced in the United States until the coronavirus disease 2019 (COVID-19) pandemic. This provides a natural experiment to determine whether the percentage of community masking was associated with decreases in emergency department (ED) visits due to non-COVID viral illnesses (NCVIs) and related respiratory conditions. METHODS: In this observational study of ED encounters in a 11-hospital system in Maryland during 2019-2020, year-on-year ratios for all complaints were calculated to account for "lockdowns" and the global drop in ED visits due to the pandemic. Encounters for specific complaints were identified using the International Classification of Diseases, version 10. Encounters with a positive COVID test were excluded. Linear regression was used to determine the association of publicly available masking data with ED visits for NCVI and exacerbations of asthma and chronic obstructive pulmonary disease (COPD), after adjusting for patient age, sex, and medical history. RESULTS: There were 285,967 and 252,598 ED visits across the hospital system in 2019 and 2020, respectively. There was a trend toward an association between the year-on-year ratio for all ED visits and the Maryland stay-at-home order (parameter estimate = -0.0804, P = .10). A 10% percent increase in the prevalence of community masking was associated with a 17.0%, 8.8%, and 9.4% decrease in ED visits for NCVI and exacerbations of asthma exacerbations and chronic obstructive pulmonary disease, respectively (P < .001 for all). CONCLUSIONS: Increasing the prevalence of masking is associated with a decrease in ED visits for viral illnesses and exacerbations of asthma and COPD. These findings may be valuable for future public health responses, particularly in future pandemics with respiratory transmission or in severe influenza seasons.

Balancing Efficiency and Access: Discouraging Emergency Department Boarding in a Global Budget System.

Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its "capitation" payment system (also known as "global budget"), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland's system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals' ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland's model that should also prove instructive for a variety of emerging alternative payment mechanisms.

Development of a Logic Model to Guide Implementation and Evaluation of a Mobile Integrated Health Transitional Care Program.

To provide medical and social services to underserved communities, many health care organizations across the United States have expanded the role of emergency medical services to include mobile integrated health and community paramedicine (MIH-CP). Although MIH-CP programs differ in structure and setting, many share the common goal of improving health through home-based, patient-centered care management models. Ideally, these innovative programs reduce use of health care services, including 911 (US emergency system) calls and emergency department visits. In 2018 a large, urban academic medical center partnered with the city's fire department to establish an MIH-CP program to support patients as they transition in their first 30 days at home after hospitalization. Prior to launch, a multidisciplinary team developed a logic model to guide development, implementation, and evaluation of this complex and innovative program. This paper describes the team's structured process for developing a logic model. It also describes key components of the initial logic model and the Transitional Health Support program structure, as well as subsequent revisions to both.

Integrating a safety smart list into the electronic health record decreases intensive care unit length of stay and cost.

PURPOSE: To measure how an integrated smartlist developed for critically ill patients would change intensive care units (ICUs) length of stay (LOS), mortality, and charges. MATERIALS AND METHODS: Propensity-score analysis of adult patients admitted to one of 14 surgical and medical ICUs between June 2017 and May 2018. The smart list aimed to certain preventative measures for all critical patients (e.g., removing unneeded catheters, starting thromboembolic prophylaxis, etc.) and was integrated into the electronic health record workflows at the hospitals under study. RESULTS: During the study period, 11,979 patients were treated in the 14 participating ICUs by 518 unique providers. Patients who had the smart list used during ≥60% of their ICU stay (N = 432 patients, 3.6%) were significantly more likely to have a shorter ICU LOS (HR = 1.20, 95% CI:1.0 to 1.4, p = 0.015) with an average decrease of -$1218 (95% CI: -$1830 to -$607, P < 0.001) in the amount charged per day. The intervention cohort had fewer average ventilator days (3.05 vent days, SD = 2.55) compared to propensity score matched controls (3.99, SD = 4.68, p = 0.015), but no changes in mortality (16.7% vs 16.0%, p = 0.78). CONCLUSIONS: An integrated smart list shortened LOS and lowered charges in a diverse cohort of critically ill patients.

Impact of Superstorm Sandy on Medicare Patients' Utilization of Hospitals and Emergency Departments.

INTRODUCTION: National health security requires that healthcare facilities be prepared to provide rapid, effective emergency and trauma care to all patients affected by a catastrophic event. We sought to quantify changes in healthcare utilization patterns for an at-risk Medicare population before, during, and after Superstorm Sandy's 2012 landfall in New Jersey (NJ). METHODS: This study is a retrospective cohort study of Medicare beneficiaries impacted by Superstorm Sandy. We compared hospital emergency department (ED) and healthcare facility inpatient utilization in the weeks before and after Superstorm Sandy landfall using a 20% random sample of Medicare fee-for-service beneficiaries continuously enrolled in 2011 and 2012 (N=224,116). Outcome measures were pre-storm discharges (or transfers), average length of stay, service intensity weight, and post-storm ED visits resulting in either discharge or hospital admission. RESULTS: In the pre-storm week, hospital transfers from skilled nursing facilities (SNF) increased by 39% and inpatient discharges had a 0.3 day decreased mean length of stay compared to the prior year. In the post-storm week, ED visits increased by 14% statewide; of these additional "surge" patients, 20% were admitted to the hospital. The increase in ED demand was more than double the statewide average in the most highly impacted coastal regions (35% versus 14%). CONCLUSION: Superstorm Sandy impacted both pre- and post-storm patient movement in New Jersey; post-landfall ED surge was associated with overall storm impact, which was greatest in coastal counties. A significant increase in the number and severity of pre-storm transfer patients, in particular from SNF, as well as in post-storm ED visits and inpatient admissions, draws attention to the importance of collaborative regional approaches to healthcare in large-scale events.

Identifying Indirect Benefits of Federal Health Care Emergency Preparedness Grant Funding to Coalitions: A Content Analysis.

OBJECTIVE: This study aimed to identify the indirect benefits of health care preparedness funding as perceived by current and former recipients of the US Department of Health and Human Services Office of the Assistant Secretary for Preparedness and Response's Hospital Preparedness Program. METHODS: This was a qualitative inductive content analysis of telephone interviews conducted with regional stakeholders from several health care coalitions to identify their perceptions of the indirect benefits of preparedness funding. RESULTS: Content analysis of interviewee responses resulted in 2 main categories of indirect benefits of federal health care preparedness funding: (1) dual-use technology and programs and (2) impact of relationships on day-to-day operations. Within the dual-use technology and programs category, 3 subcategories were identified: (1) information systems, (2) clinical technology, and (3) health care operations. Similarly, 3 subcategories relating to the indirect benefits in the impact of relationships on day-to-day operations category were identified: (1) cooperation, (2) information sharing, and (3) sense of community. CONCLUSION: This study identified indirect benefits of federal investment in hospital and health care preparedness in day-to-day operations. Major categories of these benefits included dual-use technology and programs and impact of relationships on day-to-day operations. Coalition members placed a high value on these benefits, even though they were not direct outcomes of grant programs. Further research is needed to quantify the economic value of these indirect benefits to more accurately measure the total return on investment from federal grant funding.

An Economic Analysis and Approach for Health Care Preparedness in a Substate Region.

OBJECTIVE: To demonstrate the application of economics to health care preparedness by estimating the financial return on investment in a substate regional emergency response team and to develop a financial model aimed at sustaining community-level disaster readiness. METHODS: Economic evaluation methods were applied to the experience of a regional Pennsylvania response capability. A cost-benefit analysis was performed by using information on funding of the response team and 17 real-world events the team responded to between 2008 and 2013. By use of the results of the cost-benefit analysis as well as information on the response team's catchment area, a risk-based insurance-like membership model was built. RESULTS: The cost-benefit analysis showed a positive return after 6 years of investment in the regional emergency response team. Financial modeling allowed for the calculation of premiums for 2 types of providers within the emergency response team's catchment area: hospitals and long-term care facilities. CONCLUSION: The analysis indicated that preparedness activities have a positive return on their investment in this substate region. By applying economic principles, communities can estimate their return on investment to make better business decisions in an effort to increase the sustainability of emergency preparedness programs at the regional level.

Impact of oral nutritional supplementation on hospital outcomes.

OBJECTIVES: To assess the effect of inpatient oral nutritional supplement (ONS) use on length of stay, episode cost, and 30-day readmission probability. STUDY DESIGN: Eleven-year retrospective study (2000 to 2010). METHODS: Analyses were conducted using the Premier Perspectives Database, which contained information on 44.0 million adult inpatient episodes. Using a matched sample of ONS and non-ONS episodes for any inpatient diagnosis, instrumental variables regression analysis was performed to quantify the effect of ONS use on length of stay, episode cost, and probability of approximate 30-day readmission. For the readmission outcome, the matched sample was restricted to episodes where the patient was known to be at risk of readmission. The fraction of a hospital's episodes in a given quarter involving ONS was used as an instrumental variable. RESULTS: Within the database, 1.6% of 44.0 million adult inpatient episodes involved ONS use. Based on a matched sample of 1.2 million episodes, ONS patients had a shorter length of stay by 2.3 days (95% confidence interval [CI] - 2.42 to -2.16), from 10.9 to 8.6 days (21.0% decline), and decreased episode cost of $4734 (95% CI - $4754 to - $4714), from $21,950 to $17,216 (21.6% decline). Restricting the matched sample to the 862,960 episodes where patients were readmitted at some point, ONS patients had a reduced probability of early readmission (within 30 days) of 2.3 percentage points (95% CI - 0.027 to - 0.019), from 34.3% to 32.0% (6.7% decline). CONCLUSIONS: Use of ONS decreases length of stay, episode cost, and 30-day readmission risk in the inpatient population.