Do Hospitals Providing Telehealth in Emergency Departments Have Lower Emergency Department Costs?

Background: Since 2003, the University of Mississippi Medical Center has operated a robust telehealth emergency department (ED) network, TelEmergency, which enhances access to emergency medicine-trained physicians at participating rural hospitals. TelEmergency was developed as a cost-control measure for financially constrained rural hospitals to improve access to quality, emergency care. However, the literature remains unclear as to whether ED telehealth services can be provided at lower costs compared with traditional in-person ED services. Introduction: Our objective was to empirically determine whether TelEmergency was associated with lower ED costs at rural hospitals when compared with similar hospitals without TelEmergency between 2010 and 2017. Materials and Methods: A panel of data for 2010-2017 was constructed at the hospital level. Hospitals with TelEmergency (n = 14 hospitals; 112 hospital-years) were compared with similar hospitals that did not use TelEmergency from Arkansas, Georgia, Mississippi, and South Carolina (n = 102; 766 hospital-years), matched using Coarsened Exact Matching. The relationship between total ED costs and treatment (e.g., participation in TelEmergency) was predicted using generalized estimating equations with a Poisson distribution, a log link, an exchangeable error term, and robust standard errors. Results: After controlling for ownership type, critical access hospital status, year, and size, TelEmergency was associated with an estimated 31.4% lower total annual ED costs compared with similar matched hospitals that did not provide TelEmergency. Conclusions: TelEmergency utilization was associated with significantly lower total annual ED costs compared with similarly matched hospitals that did not utilize TelEmergency. These findings suggest that access to quality ED care in rural communities can occur at lower costs.

Sequential Organ Failure Assessment Component Score Prediction of In-hospital Mortality From Sepsis.

OBJECTIVES: Early organ dysfunction in sepsis confers a high risk of in-hospital mortality, but the relative contribution of specific types of organ failure to overall mortality is unclear. The objective of this study was to assess the predictive ability of individual types of organ failure to in-hospital mortality or prolonged intensive care. METHODS: Retrospective cohort study of adult emergency department patients with sepsis from October 1, 2013, to November 10, 2015. Multivariable regression was used to assess the odds ratios of individual organ failure types for the outcomes of in-hospital death (primary) and in-hospital death or ICU stay ≥ 3 days (secondary). RESULTS: Of 2796 patients, 283 (10%) experienced in-hospital mortality, and 748 (27%) experienced in-hospital mortality or an ICU stay ≥ 3 days. The following components of Sequential Organ Failure Assessment (SOFA) score were most predictive of in-hospital mortality (descending order): coagulation (odds ratio [OR]: 1.60, 95% confidence interval [CI]: 1.32-1.93), hepatic (1.58, 95% CI: 1.32-1.90), respiratory (OR: 1.33, 95% CI: 1.21-1.47), neurologic (OR: 1.20, 95% CI: 1.07-1.35), renal (OR: 1.14, 95% CI: 1.02-1.27), and cardiovascular (OR: 1.13, 95% CI: 1.01-1.25). For mortality or ICU stay ≥3 days, the most predictive SOFA components were respiratory (OR: 1.97, 95% CI: 1.79-2.16), neurologic (OR: 1.72, 95% CI: 1.54-1.92), cardiovascular (OR: 1.38, 95% CI: 1.23-1.54), coagulation (OR: 1.31, 95% CI: 1.10-1.55), and renal (OR: 1.19, 95% CI: 1.08-1.30) while hepatic SOFA (OR: 1.16, 95% CI: 0.98-1.37) did not reach statistical significance (P = .092). CONCLUSION: In this retrospective study, SOFA score components demonstrated varying predictive abilities for mortality in sepsis. Elevated coagulation or hepatic SOFA scores were most predictive of in-hospital death, while an elevated respiratory SOFA was most predictive of death or ICU stay >3 days.

Development of a Simple Sequential Organ Failure Assessment Score for Risk Assessment of Emergency Department Patients With Sepsis.

OBJECTIVES: Sepsis-3 recommends using the quick Sequential Organ Failure Assessment (qSOFA) score followed by SOFA score for sepsis evaluation. The SOFA is complex and unfamiliar to most emergency physicians, while qSOFA is insensitive for sepsis screening and may result in missed cases of sepsis. The objective of this study was to devise an easy-to-use simple SOFA score for use in the emergency department (ED). METHODS: Retrospective study of ED patients with sepsis with in-hospital mortality as the primary outcome. A simple SOFA score was derived and validated and compared with SOFA and qSOFA. RESULTS: A total of 3297 patients with sepsis were included, and in-hospital mortality was 10.1%. Simple SOFA had a sensitivity and specificity of 88% and 44% in the derivation set and 93% and 44% in the validation set for in-hospital mortality, respectively. The sensitivity and specificity of qSOFA was 38% and 86% and for SOFA was 90% and 50%, respectively. There were 2760 (84%) of 3297 qSOFA-negative (<2) patients. In this group, simple SOFA had a sensitivity and specificity of 86% and 48% in the derivation set and 91% and 48% in the validation set, respectively. Sequential Organ Failure Assessment was 86% sensitive and 57% specific in qSOFA-negative patients. For all encounters, the areas under the receiver-operator characteristic curves (AUROC) were 0.82 for SOFA, 0.78 (derivation) and 0.82 (validation) for simple SOFA, and 0.68 for qSOFA. In qSOFA-negative patients, the AUROCs were 0.80 for SOFA and 0.76 (derivation) and 0.82 (validation) for simple SOFA. CONCLUSIONS: Simple SOFA demonstrates similar predictive ability for in-hospital mortality from sepsis compared to SOFA. External validation of these findings is indicated.