Post-discharge Health Services Use for Patients with Serious Mental Illness Treated at an Emergency Department Versus a Dedicated Community Mental Health Center.

Emergency Medical Service (EMS) alternative destination programs may lead to improved care quality among those experiencing mental health crises but the association with cost and emergency department (ED) recidivism remains unexamined. We compare rates of post-discharge health services use and Medicaid spending among patients transported to an ED or community mental health center (CMHC) finding higher ED recidivism for patient treated in the ED, compared to those treated in a CMHC (68% vs 34%, p < 0.001). There were no differences in Medicaid spending or health services use post-discharge suggesting EMS-operated alternative destination programs may be cost-neutral for Medicaid programs.

Acute Crisis Care for Patients with Mental Health Crises: Initial Assessment of an Innovative Prehospital Alternative Destination Program in North Carolina.

OBJECTIVE: Emergency Departments (ED) are overburdened with patients experiencing acute mental health crises. Pre-hospital transport by Emergency Medical Services (EMS) to community mental health and substance abuse treatment facilities could reduce ED utilization and costs. Our objective was to describe characteristics, treatment, and outcomes of acute mental health crises patients who were transported by EMS to an acute crisis unit at WakeBrook, a North Carolina community mental health center. METHODS: We performed a retrospective cohort study of patients diverted to WakeBrook by EMS from August 2013-July 2014. We abstracted data from WakeBrook medical records and used descriptive statistics to quantify patient characteristics, diagnoses, length of stay (LOS), and 30-day recidivism. RESULTS: A total of 226 EMS patients were triaged at WakeBrook. The median age was 38 years, 55% were male, 58% were white, and 38% were uninsured. The most common chief complaints were suicidal ideation or self-harm (46%) and substance abuse (19%). The most common diagnoses were substance-related and addictive disorders (42%), depressive disorders (32%), and schizophrenia spectrum and other psychotic disorders (22%). Following initial evaluation, 28% of patients were admitted to facilities within WakeBrook, 40% were admitted to external psychiatric facilities, 18% were stabilized and discharged home, 5% were transferred to an ED within 4 hours for further medical evaluation, and 5% refused services. The median LOS at WakeBrook prior to disposition was 12.0 hours (IQR 5.4-21.6). Over a 30-day follow-up period, 60 patients (27%) had a return visit to the ED or WakeBrook for a mental health issue. CONCLUSIONS: A dedicated community mental health center is able to treat patients experiencing acute mental health crises. LOS times were significantly shorter compared to regional EDs. Successful broader programmatic implementation could improve care quality and significantly reduce the volume of patients treated in the ED for acute mental health disorders.

Potential Cost-effectiveness of Early Identification of Hospital-acquired Infection in Critically Ill Patients.

RATIONALE: Limitations in methods for the rapid diagnosis of hospital-acquired infections often delay initiation of effective antimicrobial therapy. New diagnostic approaches offer potential clinical and cost-related improvements in the management of these infections. OBJECTIVES: We developed a decision modeling framework to assess the potential cost-effectiveness of a rapid biomarker assay to identify hospital-acquired infection in high-risk patients earlier than standard diagnostic testing. METHODS: The framework includes parameters representing rates of infection, rates of delayed appropriate therapy, and impact of delayed therapy on mortality, along with assumptions about diagnostic test characteristics and their impact on delayed therapy and length of stay. Parameter estimates were based on contemporary, published studies and supplemented with data from a four-site, observational, clinical study. Extensive sensitivity analyses were performed. The base-case analysis assumed 17.6% of ventilated patients and 11.2% of nonventilated patients develop hospital-acquired infection and that 28.7% of patients with hospital-acquired infection experience delays in appropriate antibiotic therapy with standard care. We assumed this percentage decreased by 50% (to 14.4%) among patients with true-positive results and increased by 50% (to 43.1%) among patients with false-negative results using a hypothetical biomarker assay. Cost of testing was set at $110/d. MEASUREMENTS AND MAIN RESULTS: In the base-case analysis, among ventilated patients, daily diagnostic testing starting on admission reduced inpatient mortality from 12.3 to 11.9% and increased mean costs by $1,640 per patient, resulting in an incremental cost-effectiveness ratio of $21,389 per life-year saved. Among nonventilated patients, inpatient mortality decreased from 7.3 to 7.1% and costs increased by $1,381 with diagnostic testing. The resulting incremental cost-effectiveness ratio was $42,325 per life-year saved. Threshold analyses revealed the probabilities of developing hospital-acquired infection in ventilated and nonventilated patients could be as low as 8.4 and 9.8%, respectively, to maintain incremental cost-effectiveness ratios less than $50,000 per life-year saved. CONCLUSIONS: Development and use of serial diagnostic testing that reduces the proportion of patients with delays in appropriate antibiotic therapy for hospital-acquired infections could reduce inpatient mortality. The model presented here offers a cost-effectiveness framework for future test development.

Organizational characteristics and patient experiences with hospital care: a survey study of hospital chief patient experience officers.

Beginning in fiscal year 2013, scores based on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) constitute 30% of incentive-based payments from Medicare's Value-Based Purchasing (VBP) initiative. Yet there is little empirical work to understand hospital approaches to improving the patient experience. In this study, chief patient experience officers at 416 VHA hospitals were surveyed to assess the relationship between organizational characteristics and publicly reported HCAHPS scores. Of 416 institutions, 143 (34.4%) participated. Respondents reported that boards (68%) and chief executive officers (81%) viewed the patient experience as extremely important. In contrast, they reported that in only 15% and 34% of hospitals, respectively, physicians and nurses were supportive of efforts to improve the patient experience. Hospitals with collaborative cultures and higher physician engagement had higher VBP total HCAHPS scores (6.9 points and 8.2 points higher, respectively; both P < .05). These areas should be addressed to improve the patient experience in provider organizations.

The mis-measure of physician performance.

The Affordable Care Act directs the Secretary of Health and Human Services to compare individual physicians using patient experience measures. This policy initiative will utilize the Clinician and Group Consumer Assessment of Healthcare Providers and Systems (CG-CAHPS) survey program. It will impact over 700,000 eligible physicians and will be tied to reimbursement and the Centers for Medicare and Medicaid Services' Physician Compare reporting feature starting in 2015. We believe that the relevance of this framework to today's clinical environment is a critical issue to address before implementing this regulatory mandate. In this article we discuss our concerns about tying individual physician performance to CG-CAHPS scores, including: 1) intrinsic versus extrinsic approaches to assessing the patient experience, 2) measurement issues, and 3) unintended consequences. We also suggest an alternative pathway and opt-out mechanism to facilitate more rapid translation of service excellence into clinical practice.

Assessment of temporal trends in mortality with implementation of a statewide ST-segment elevation myocardial infarction (STEMI) regionalization program.

STUDY OBJECTIVE: Although regionalized care for ST-segment elevation myocardial infarction (STEMI) has improved the use of timely reperfusion therapy, its effect on patient outcomes has been difficult to assess. Our objective is to explore temporal trends in STEMI mortality with the implementation of a statewide STEMI regionalization program (Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments [RACE]). METHODS: We compared trends in inpatient mortality among STEMI patients treated at North Carolina (NC) hospitals participating in the RACE program, relative to those not participating, using state inpatient claims data. Using Medicare claims data, we compared trends in 30-day mortality among Medicare beneficiaries in NC with those nationally. Logistic models with random effects were used to evaluate the association of the program with mortality. RESULTS: From 2005 to 2007, inpatient mortality for 6,565 STEMI patients treated at NC hospitals participating in RACE decreased from 11.6% to 10.1% (risk difference -1.5%; 95% confidence interval [CI] -3.0% to 0.04%), whereas inpatient mortality among 5,850 STEMI patients treated at NC nonparticipating hospitals decreased from 10.2% to 8.6% (risk difference -1.6%; 95% CI -3.1% to 0.10%); (adjusted odds ratio 1.28; 95% CI 0.88 to 1.85 for temporal differences between groups). During the same period, 30-day STEMI mortality among Medicare beneficiaries decreased from 22.7% to 21.4% in NC (risk difference -1.28%; 95% CI -3.60% to 1.03%) and from 22.3% to 21.6% nationally (risk difference -0.71%, 95% CI -1.13% to -0.29%; adjusted odds ratio 0.99, 95% CI 0.85 to 1.15 for temporal differences between regions). CONCLUSION: The initiation of a statewide STEMI collaborative care model was associated with a reduction in mortality rates according to claims data, yet these changes were similar to those seen nationally. Further study is needed to evaluate regionalized systems of STEMI care and to determine the role of claims data to evaluate population-based STEMI outcomes.

Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days.

OBJECTIVES: To determine whether hospitals where patients report higher overall satisfaction with their interactions among the hospital and staff and specifically their experience with the discharge process are more likely to have lower 30-day readmission rates after adjustment for hospital clinical performance. STUDY DESIGN: Among patients 18 years or older, an observational analysis was conducted using Hospital Compare data on clinical performance, patient satisfaction, and 30-day risk-standardized readmission rates for acute myocardial infarction, heart failure, and pneumonia for the period July 2005 through June 2008. METHODS: A hospital-level multivariable logistic regression analysis was performed for each of 3 clinical conditions to determine the relationship between patient-reported measures of their satisfaction with the hospital stay and staff and the discharge process and 30-day readmission rates, while controlling for clinical performance. RESULTS: In samples ranging from 1798 hospitals for acute myocardial infarction to 2562 hospitals for pneumonia, higher hospital-level patient satisfaction scores (overall and for discharge planning) were independently associated with lower 30-day readmission rates for acute myocardial infarction (odds ratio [OR] for readmission per interquartile improvement in hospital score, 0.97; 95% confidence interval [CI], 0.94-0.99), heart failure (OR, 0.96; 95% CI, 0.95-0.97), and pneumonia (OR, 0.97; 95% CI, 0.96-0.99). These improvements were between 1.6 and 4.9 times higher than those for the 3 clinical performance measures. CONCLUSIONS: Higher overall patient satisfaction and satisfaction with discharge planning are associated with lower 30-day risk-standardized hospital readmission rates after adjusting for clinical quality. This finding suggests that patient-centered information can have an important role in the evaluation and management of hospital performance.

Perspective: The case for research justice: inclusion of patients with limited English proficiency in clinical research.

Persons with limited English proficiency (LEP) constitute a growing portion of the U.S. population, yet they are underrepresented in clinical research. This inherently limits the societal benefits of the research and its generalizability to ethnic populations living in the United States. To illustrate the complexity associated with including LEP participants in clinical research, the authors critically evaluated LEP consent requirements posted on the Web sites of 134 academic health centers in March 2008. They found wide variability with regard to consent policies and striking interinstitutional differences in posted IRB policies and attitudes toward consent of LEP patients in research. The authors argue this variation highlights competing concerns between autonomy and justice. Outcomes-based justice requires inclusion of LEP patients in the research, yet the consent process is often resource-intensive and complex. The authors suggest that more uniform and specific guidance from federal agencies for enrollment of LEP patients in clinical research be established and that this guidance explicitly recalibrate the current balance between autonomy and justice. Investigators and institutional review boards should also develop streamlined best practices to reduce unnecessary effort and expense associated with recruitment of LEP individuals. LEP individuals should have fair access to clinical research in order to fully realize individual and societal benefits of their participation and to ensure the generalizability of scientific discovery.

Defining and measuring successful emergency care networks: a research agenda.

The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for "regionalized, coordinated, and accountable emergency care systems throughout the country." There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled "Beyond Regionalization: Integrated Networks of Emergency Care." This article is a product of the conference breakout session on "Defining and Measuring Successful Networks"; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non-time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM's vision of regionalized, coordinated, and accountable emergency care systems.

Impact of a statewide ST-segment-elevation myocardial infarction regionalization program on treatment times for women, minorities, and the elderly.

BACKGROUND: Prior studies have demonstrated differences in time to reperfusion for ST-segment-elevation myocardial infarction (STEMI) in women, minorities, and the elderly, relative to their counterparts. Regionalization has been shown to improve overall STEMI treatment times, but its impact on care differences among these important patient subgroups is unknown. The objective of this analysis was to assess the impact of a statewide system of STEMI care (The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments) on treatment times according to patient sex, race, and age. METHODS AND RESULTS: STEMI treatment times were determined before (July 2005 to September 2005) and after (January 2007 to March 2007) a year-long implementation of coordinated regional treatment protocols. Times in the pre- and postintervention periods were compared by mixed-effects models. A total of 2063 STEMI patients were analyzed: 1140 at percutaneous coronary intervention hospitals and 923 at non-percutaneous coronary intervention hospitals. The Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments was associated with significant improvements in treatment times in women and the elderly, including door-to-ECG, door-to-device, door-in-door-out, and door-to-needle times (all P<0.05). Temporal improvements in treatment times at percutaneous coronary intervention hospitals were not significantly different in blacks than in whites. There was a reduction in baseline treatment disparities in door-to-ECG times in women versus men (4.4-minute reduction in difference; 95% CI, -8.1 to -0.4; P=0.03). After Reperfusion of Acute Myocardial Infarction in North Carolina Emergency Departments, an age-treatment time gap persisted in the elderly, relative to younger patients. CONCLUSIONS: A statewide STEMI regionalization program was associated with comparable improvement in treatment times for female, black, and elderly patients compared with middle-aged, white male patients. Nevertheless, there remain opportunities to further narrow treatment differences, particularly among the elderly.

Economic content in medical journal advertisements for medical devices and prescription drugs.

Previous studies of economic content in medical journal advertisements have not examined all types of economic content and have not included advertisements for medical devices. To examine trends in the economic content of medical device and pharmaceutical advertisements in medical journals. Three reviewers examined pharmaceutical and medical device advertisements in six leading medical journals from 1997 through 2006. Product characteristics, economic claims and evidence to support those claims were evaluated. Economic content appeared in 23.5% (561/2389) of pharmaceutical and device advertisements; 11.9% made market share claims and 12.7% made other economic claims. From 1997 through 2006, the percentage of medical device advertisements containing economic content declined from 26.7% to 6.7% (p = 0.02), whereas the percentage of pharmaceutical advertisements containing economic content remained stable (21.6-22.0%; p = 0.99). For pharmaceuticals, price claims declined significantly (15.7-4.2%; p < 0.01) and market share claims increased (2.8-11.5%; p = 0.09), and both consistently presented evidence (83% and 98%, respectively) while other types did not (e.g. 13.5% of formulary claims). Medical device economic claims differed from pharmaceutical economic claims; they made fewer market share claims (1.1% vs 12.8%) but more cost-effectiveness (6.5% vs 0.6%) and reimbursement (4.9% vs 0.8%) claims. Fewer than 2% of device advertisements with economic claims provided supporting evidence. The prevalence and type of economic content in pharmaceutical and device advertisements changed between 1997 and 2006, which may reflect evolving market dynamics, such as changes in reimbursement systems. Furthermore, the lack of supporting evidence in medical device advertisements and pharmaceutical formulary claims are potential areas of concern that require additional scrutiny by regulators and journal editors.

The North Carolina EMS Data System: a comprehensive integrated emergency medical services quality improvement program.

BACKGROUND: The EMS Agenda for the Future describes emergency medical services (EMS) as the intersection between public health, public safety, and health care. The most comprehensive method to describe, evaluate, and optimize these systems of care is using a state EMS data system. A centralized EMS data system can be a valuable tool to identify, evaluate, target, and improve EMS service delivery and patient care. Significant barriers, however, still exist to the standardization of EMS data systems and infrastructure nationally. Indeed, there is no comprehensive measurement of EMS service delivery or patient volume at the national level. OBJECTIVE: In this article, we describe the successful development of a fully integrated, statewide EMS data system for quality improvement of EMS service delivery and patient care in North Carolina. The article also provides a platform for linking EMS with emergency physicians, other health care providers, and public health agencies responsible for planning, disease surveillance, and disaster preparedness. RESULTS AND CONCLUSION: The North Carolina EMS Data System represents the successful development of a large, fully integrated, comprehensive statewide EMS database and quality improvement effort. The North Carolina EMS Data System applications include the Prehospital Medical Information System (PreMIS), the Credentialing Information System (CIS), the State Medical Asset Resource Tracking Tool (SMARTT), and the EMS Performance Improvement Toolkits. The system provides a quality and performance improvement program consistent with the idealized EMS design described in the EMS Agenda for the Future. The program has already achieved significant improvements in the quality of EMS service delivery, patient care, and integrated systems of care. Consistent with the goals of the 2007 Institute of Medicine's recommendations for EMS, the linkage of the North Carolina EMS Data System with other health care registries has created an environment that can evaluate larger systems of care and ultimate patient outcomes.

Resource use and costs of treatment with anticoagulation and antiplatelet agents: results of the WATCH trial economic evaluation.

BACKGROUND: The Warfarin and Antiplatelet Therapy in Chronic Heart Failure (WATCH) trial revealed no significant differences among 1587 symptomatic heart failure patients randomized to warfarin, clopidogrel, or aspirin in time to all-cause death, nonfatal myocardial infarction, or nonfatal stroke. We compared within-trial medical resource use and costs between treatments. METHODS AND RESULTS: We assigned country-specific costs to medical resources incurred during follow-up. Annualized rates of hospitalizations, inpatient and outpatient procedures, and emergency department visits did not differ significantly between groups. Annualized total costs averaged $5901 (95% confidence interval [CI], $4776-$7520) for the aspirin group, $5646 (95% CI, $4903-$6584) for the clopidogrel group, and $5830 (95% CI, $4838-$7400) for the warfarin group. CONCLUSIONS: Consistent with clinical findings, our analyses did not identify significant cost differences between treatments.

Alternative pay-for-performance scoring methods: implications for quality improvement and patient outcomes.

BACKGROUND: Pay-for-performance programs typically rate hospitals using a composite summary score in which process measures are weighted by the total number of treatment opportunities. Alternative methods that weight process measures according to how hospitals organize care and the range for possible improvement may be more closely related to patient outcomes. OBJECTIVES: To develop a hospital-level summary process measure adherence score that reflects how hospitals organize cardiac care and the range for possible improvement; and to compare associations of hospital adherence to this score and adherence to a composite score based on the Centers for Medicare and Medicaid Services scoring system with inpatient mortality. RESEARCH DESIGN AND SUBJECTS: Hospital-level analysis of 7 process measures for acute myocardial infarction (AMI) and 4 process measures for heart failure at 4226 hospitals, and inpatient mortality after AMI at 1351 hospitals in the United States. Data are from the Hospital Compare and Joint Commission Core Measures databases for October 2004 through September 2006. MEASURES: Associations between composite scores based on Centers for Medicare and Medicaid Services methodology and alternative adherence scores with inpatient survival after AMI. RESULTS: In principal components analysis, hospital cardiac care varied between hospitals largely along the lines of "clinical" (ie, pharmacologic interventions) and "administrative" (ie, patient instructions or counseling) activities. A scoring system reflecting this organization was strongly associated with inpatient survival and fit the mortality data better than the composite score. Higher administrative activities scores, holding the clinical activities score fixed, were associated with lower survival. CONCLUSIONS: In-hospital cardiac care is organized by clinical and administrative processes of care. Pay-for-performance schemes that incentivize hospitals to focus on administrative process measures may be associated with decreased adherence to clinical processes. A pay-for-performance scheme that acknowledges these factors may be associated with improved inpatient mortality.

Innovative health reform models: pay-for-performance initiatives.

Pay-for-performance (P4P) programs have the potential to improve overall quality of care by narrowing gaps between what national care guidelines recommend and those treatments actually delivered in routine community practice. P4P is also viewed as a tool to promote more efficient use of healthcare resources while improving patient outcomes. P4P provides financial incentives for quality of service instead of quantity of service. Despite the promise of healthcare quality, concerns have been raised that P4P may have potential unintended consequences for patients, physicians, and hospitals. The shortcomings of many traditional P4P programs have fueled the emergence of new and innovative models of payment reform. P4P and newer models that link reimbursement with quality and efficiency show promise to improve patient outcomes and lower costs, but multiple approaches are needed to ensure that future initiatives provide value for key stakeholders, including patients, providers, and payers.

Evidence-based perspectives on pay for performance and quality of patient care and outcomes in emergency medicine.

Pay for performance is gaining momentum as a means to improve the quality of clinical care. Recently, the Centers for Medicare & Medicaid Services has expanded pay for performance initiatives to incorporate 9 emergency care metrics, including indicators for cardiac, pneumonia, and stroke care. The American College of Cardiology and American Heart Association (ACC/AHA) have published methodology for the selection and creation of performance measures for quantifying the quality of cardiovascular care. The purpose of this study is to grade each of the 9 Physician Quality Reporting Initiative emergency medicine process measures according to the ACC/AHA criteria related to clinical evidence (yes, no, indeterminate). Five of the 9 recently selected metrics in emergency medicine do not appear to meet all of the ACC/AHA criteria for measurement selection. Several of the metrics, including aspirin for acute myocardial infarction (mean hospital adherence 94.7%; SD 6.7%) and pulse oximetry for community-acquired pneumonia (mean 99.4%; SD 2.0%), already have high levels of performance nationally, which raises uncertainty about the overall cost-effectiveness of quality improvement interventions for these measures. Formal methodology needs to be established for future selection of performance measures for quality improvement programs in emergency care. These performance measures should focus on unique aspects of emergency and acute care, including recognition and treatment of time-sensitive life-threatening conditions, assessment of patients with undifferentiated signs and symptoms, and care of all-inclusive geographically based patient populations. In key emergency therapeutic areas, the evidence linking treatment and improved patient outcomes will require additional study before inclusion in pay for performance programs. New research initiatives are needed to assess the effect of timely administration of emergency department interventions on patient outcomes.

Challenges in enrollment of minority, pediatric, and geriatric patients in emergency and acute care clinical research.

STUDY OBJECTIVE: Emergency department (ED) -based clinical research has the potential to include patient populations that are typically underrepresented in clinical research. The objective of this study is to assess how emergency clinical care and research processes, informed consent, and patient demographic factors (age, sex, and ethnicity/race) affect enrollment and consent in clinical research in the ED. METHODS: This was an analysis of prospectively collected data of all patients (aged 2 to 101 years) eligible for one of 7 clinical research studies from February 2005 to April 2007 in an academic ED. We measured rates of enrollment and consent in the clinical studies. RESULTS: One thousand two hundred two of the 4418 patients screened for participation in 7 clinical studies were clinically eligible for enrollment. Of the 868 patients who were able to provide a voluntary decision regarding consent, 639 (73.6%) agreed to participate; an overall enrollment rate of 53.2%. The mean age of patients enrolled was 51.8 years (range 3 to 98 years). Black patients (49.2% enrollment) and Latino patients (18.4% enrollment) were less likely to be enrolled in comparison with white patients (58.3% enrollment) (adjusted odds ratio [OR] of enrollment for blacks=0.64; 95% confidence interval [CI] 0.50 to 0.82; adjusted OR of enrollment for Latinos=0.16; 95% CI 0.08 to 0.33). Enrollment rates were lower among pediatric (40.0%) and geriatric patients (49.1%) in comparison with adult patients ages 18 to 64 years (55.5%) (adjusted OR of enrollment for pediatric patients=0.70, 95% CI 0.34 to 1.43; adjusted OR of enrollment for geriatric patients=0.69, 95% CI 0.53 to 0.90). Unique issues contributing to underenrollment included challenges in consent among pediatric and elderly patients, language issues in Latino patients, reduced voluntary consent rates among black patients, and perhaps underuse of minimal risk waivers. CONCLUSION: In a large academic ED, minority, pediatric, and geriatric patients were less likely to be enrolled in acute care clinical research studies than middle-aged whites. Enrollment and consent strategies designed to enhance research participation in these important patient populations may be necessary to address disparities in the development and application of evidence-based emergency and acute care.