Environmentally sustainable emergency medicine.

Emergency clinicians worldwide are demonstrating increasing concern about the effect of climate change on the health of the populations they serve. The movement for sustainable healthcare is being driven by the need to address the climate emergency. Globally, healthcare contributes significantly to carbon emissions, and the healthcare sector has an important role to play in contributing to decarbonisation of the global economy. In this article, we consider the implications for emergency medicine of climate change, and suggest ways to improve environmental sustainability within emergency departments. We identify examples of sustainable clinical practice, as well as outlining research proposals to address the knowledge gap that currently exists in the area of provision of environmentally sustainable emergency care.

Medicare Reimbursement to Physicians Decreased for Common Emergency Medicine Services From 2000 to 2020.

STUDY OBJECTIVE: The change in reimbursement rates for emergency physician services has yet to be quantified. We attempted to fill this knowledge gap by evaluating the monetary trends in Medicare reimbursement rates over the last 20 years for the most common emergency medicine services. METHODS: We obtained commonly used Current Procedural Terminology (CPT) codes in emergency medicine from the American College of Emergency Physicians website. We queried the Physician Fee Schedule Look-Up Tool from the Centers for Medicare & Medicaid Services for each of the included CPT codes, and we extracted reimbursement data. We adjusted all monetary data for inflation to 2020 US dollars by using changes to the United States consumer price index. Both the average annual and the total percentage change in reimbursement were calculated on the basis of these adjusted trends for all included services. RESULTS: Reimbursement by Medicare for the services decreased by an average of 29.13% from 2000 to 2020 after adjusting for inflation. There was a stable decline in adjusted reimbursement rates throughout the study period, with an average decrease of 1.61% each year. The largest decrease was seen for laceration repairs up to 7.5 cm, with reimbursement rates for all 4 relevant CPT codes decreasing by more than 60%. CONCLUSION: When adjusted for inflation, Medicare reimbursement declined by an average of 29% over the last 20 years for the 20 most common emergency medicine services. Knowledge of these trends is essential to address current controversies in emergency medicine billing adequately and advocate for sustainable payment system reform.

Trends in Diagnostic Point-of-Care Ultrasonography Reimbursement for Medicare Beneficiaries Among the US Emergency Medicine Workforce, 2012 to 2016.

STUDY OBJECTIVE: Point-of-care ultrasonography allows rapid diagnosis in the emergency department. A previous study found that a low prevalence of emergency medicine clinicians received point-of-care ultrasonography reimbursement in 2012 (0.7%). We determine nationwide point-of-care ultrasonography reimbursement patterns for 4 subsequent years. METHODS: We performed a cross-sectional study using 2012 to 2016 data from the Centers for Medicare & Medicaid Fee-for-Service Provider Utilization and Payment Data Part B, defining point-of-care ultrasonographic examinations using Current Procedural Terminology codes. The emergency medicine workforce was defined by emergency medicine, family medicine, internal medicine, critical care, and advanced practice providers who received emergency medicine-specific reimbursements. We compared patterns of point-of-care ultrasonography reimbursement among emergency physicians in 2012 versus 2016 through a 2-sample test of proportions. RESULTS: In 2012, 342 (0.7% of total) emergency medicine workforce clinicians were reimbursed for diagnostic point-of-care ultrasonography versus 801 (1.3%) in 2016. Emergency physicians represented an increasing proportion of the total workforce, increasing from 86.0% (95% confidence interval 82.3% to 89.6%) in 2012 (N=294) to 94.6% (95% confidence interval 93.1% to 96.2%) in 2016 (N=758). From 2012 to 2016, total point-of-care ultrasonography reimbursements increased from 13,697 to 31,717, with significant growth from echocardiograms (4,127 to 14,978), abdominal examinations (3,682 to 7,140), and thoracic examinations (801 to 5,278). CONCLUSION: The proportion of emergency medicine workforce clinicians receiving diagnostic point-of-care ultrasonography reimbursements, as well as the number of point-of-care ultrasonographic studies, more than doubled from 2012 to 2016. Efforts are needed to understand barriers to adoption of point-of-care ultrasonography because only a small proportion of the emergency medicine clinician workforce was reimbursed in any year.

Review article: A primer for clinical researchers in the emergency department: Part X. Understanding economic evaluation alongside emergency medicine research.

In this series we address research topics in emergency medicine. While traditionally there was an almost exclusive focus on the efficacy and effectiveness of interventions in emergency research, analysis of the costs and the societal impact of different approaches and pathways have become increasingly important. In this paper we will address what health economics means and discuss the different types and key features of economic evaluation relevant for clinical researchers.

A Qualitative Analysis of General Emergency Medicine Providers' Perceptions on Pediatric Emergency Telemedicine.

OBJECTIVE: Most children in the United States are evaluated in general emergency departments (ED), which are staffed by practitioners who care for both adults and children and may have limited pediatric resources. The application of telemedicine in pediatrics is growing and has been shown to be effective in outpatient as well as critical care settings. Telemedicine has the potential to address disparities in access to pediatric emergency care. The objective of this study was to explore experiences of general ED providers with telemedicine and their perception about a potential video telemedicine program with pediatric ED providers. METHODS: Using qualitative methods, a purposeful sample of general ED providers (attending physicians and physician assistants) in 3 Connecticut hospitals participated in audio-recorded semistructured interviews. In line with grounded theory, 3 researchers independently coded transcripts, collectively refined codes, and created themes. Data collection and analysis continued in an iterative manner, past the point of theoretical saturation. RESULTS: Eighteen general ED providers were interviewed. Three themes were identified: (a) familiarity with use in adult stroke patients but limited practical experience with telemedicine; (b) potential uses for pediatric telemedicine (guiding pediatric differential diagnosis and management, visual diagnosis, alleviating provider fears, low-frequency high-stakes events, determining disposition, assessing level of illness, and access to subspecialty consultation); and (c) limitations of telemedicine (infrequent need and implementation barriers). CONCLUSIONS: General ED providers identified 7 specific potential uses of pediatric emergency video telemedicine. However, they also identified several limitations of telemedicine in caring for pediatric emergency patients. Further studies after implementation of telemedicine program and comparing provider perceptions with actual practice may be helpful. Furthermore, studies on telemedicine's effect on patient-related outcomes and studies on cost-effectiveness might be necessary before the widespread implementation of a telemedicine program.

How can emergency physicians harness the power of new technologies in clinical practice and education?

As the Royal College of Emergency Medicine looks back on 50 years of progress towards the future it is clear that new and emerging technologies have the potential to substantially change the practice of emergency medicine. Education, diagnostics, therapeutics are all likely to change as algorithms, personalised medicine and insights into complexity become more readily available to the emergency clinician. This paper outlines areas of our practice that are already changing and speculates on how we might need to prepare our workforce for a technologically enhanced future.

Assessing the impact of the extended-release/long-acting opioid an-algesics risk evaluation and mitigation strategies on opioid prescrip-tion volume.

OBJECTIVE: The Food and Drug Administration approved the extended-release/long-acting (ER/LA) opioid analgesics risk evaluation and mitigation strategies (REMS) in July 2012 to educate healthcare providers and patients about safe and appropriate opioid analgesic use. The authors evaluated the impact of the REMS on ER/LA opioid analgesic utilization, overall and stratified by patient characteristics and prescriber type associated with greater expected need for analgesia. DESIGN: Retrospective repeated cross-sectional study. QuintilesIMS's National Prescription Audit™ and LifeLink™ patient-level longitudinal prescription databases measured prescription volumes, projected to national estimates. MAIN OUTCOME MEASURES: Changes were assessed in ER/LA opioid analgesic prescriptions dispensed from the 2-year pre-REMS implementation (July 2010 to June 2012) to the 18-month post-REMS implementation (July 2013 to December 2014) periods (with 12-month transitional implementation period in between). RESULTS: Average quarterly ER/LA opioid prescription volume significantly decreased by 4.3 percent from Preimple-mentation to the Active Period (5.58 vs 5.34 million, p < 0.001). Differences in prescription volume change were observed between age, gender, and payer types. Prescription volume either significantly decreased or remained stable from Preimplementation to the Active Period among most provider specialties evaluated. The largest volume decreases were observed for dentists (-48.5 percent) and emergency medicine specialists (-25.5 percent) (both p < 0.001). The largest increases were observed for nurse practitioners (+33.7 percent) and physician assistants (+31.2 percent; both p < 0.001), whose overall prescribing of nonopioid medications also increased. CONCLUSIONS: A significant decrease in dispensed ER/LA opioid prescriptions was observed following REMS implementation compared to Preimplementation. The impact on volume varied by patient characteristics and prescriber specialty. The REMS program, in conjunction with other healthcare policies and initiatives, likely influenced these observations.

Areas of Potential Impact of the Patient Protection and Affordable Care Act on EMS: A Synthesis of the Literature.

INTRODUCTION: This comprehensive review synthesizes the existing literature on the Patient Protection and Affordable Care Act (ACA) as it relates to emergency medical services (EMS) in order to provide guidance for navigating current and future healthcare changes. METHODS: We conducted a comprehensive review to identify all existing literature related to the ACA and EMS and all sections within the federal law pertaining to EMS. RESULTS: Many changes enacted by the ACA directly affect emergency care with potential indirect effects on EMS systems. New Medicaid enrollees and changes to existing coverage plans may alter EMS transport volumes. Reimbursement changes such as adjustments to the ambulance inflation factor (AIF) alter the yearly increases in EMS reimbursement by incorporating the multifactor productivity value into yearly reimbursement adjustments. New initiatives, funded by the Center for Medicare & Medicaid Innovation are exploring novel and cost-effective prehospital care delivery opportunities while EMS agencies individually explore partnerships with healthcare systems. CONCLUSION: EMS systems should be aware of the direct and indirect impact of ACA on prehospital care due to the potential for changes in financial reimbursement, acuity and volume changes, and ongoing new care delivery initiatives.

What's the Evidence: Self-Assessment Implications for Life-Long Learning in Emergency Medicine.

BACKGROUND: The 2012 Academic Emergency Medicine Consensus Conference, "Education Research in Emergency Medicine: Opportunities, Challenges, and Strategies for Success" noted that emergency medicine (EM) educators often rely on theory and tradition when molding their approaches to teaching and learning, and called on the EM education community to advance the teaching of our specialty through the performance and application of research in teaching and assessment methods, cognitive function, and the effects of education interventions. OBJECTIVE: The purpose of this article was to review the research-based evidence for the effectiveness of self-assessment and to provide suggestions for its use in clinical teaching and practice in EM. DISCUSSION: This article reviews hypothesis-testing research related to self-assessment behaviors and learning. Evidence indicates that self-assessment is inherently flawed when used in isolation. We review a multi-dimensional approach to informed self-assessment that can serve as the basis for life-long learning and development. CONCLUSIONS: Advancing EM education will require that high-quality education research results be translated into actual curricular, pedagogical, assessment, and professional development changes. The informed self-assessment framework is a method that is applicable to teaching and practice in EM.

[Switch from emergency medicine to disaster medicine].

Disaster medical system in Japan has been changing after huge disaster attack. Disaster Medical Assistance Team (DMAT) was established on 1995 after the Hanshin-Awaji Great Earthquake and played important role in the Great Eastern Japan Earthquake on 2011. The action of DMAT is specialized within acute phase. Continual medical aid activity is required from acute phase to chronic phase. After DMAT evacuation, Japan Medical Association Team (JMAT), Japanese Red Cross Teams, Medical university teams and many other medical teams work sequentially in the disaster area. On the other hand, unbalance in the disaster area is occurred. Disaster medical coordinator accommodates that unbalance situation. Development of receive system for many medical assistance teams will be required.

Emergency Medicine Resident Rotations Abroad: Current Status and Next Steps.

INTRODUCTION: International rotations for residents are increasingly popular, but there is a dearth of evidence to demonstrate that these rotations are safe and that residents have appropriate training and support to conduct them. METHODS: A survey was sent to all U.S. emergency medicine (EM) residencies with publicly available e-mail addresses. The survey documents and examines the training and support that emergency medicine residents are offered for international rotations and the frequency of adverse safety events. RESULTS: 72.5% of program director responded that their residents are participating in rotations abroad. However, only 15.4% of programs reported offering training specific to working abroad. The results point to an increased need for specific training and insurance coverage. CONCLUSION: Oversight of international rotations should be improved to guarantee safety and education benefit.

Endowed Faculty Positions in Academic Emergency Medicine: One Decade Later.

BACKGROUND: In 2004 and 2009, we examined the number of endowed faculty positions in academic departments of Emergency Medicine (ADEMs). OBJECTIVE: We sought to survey ADEMs regarding the number of endowed faculty positions and compare the results to the 2004 and 2009 studies. METHODS: A survey was e-mailed to the chairs of all ADEMs belonging to the Association of Academic Chairs of Emergency Medicine. We requested information on the following: the number of endowed chair and professorship positions; the amount required to fund; the amount allowed to be spent annually; the date established; and the source of funding. RESULTS: Eighty-nine chairs responded (100% response rate). Nineteen chairs reported 1 endowed chair position. One chair reported 2 such positions, and 2 chairs reported 3 positions. One chair reported 4 positions. In total, 23 ADEMs (25.8%) reported 31 endowed chair positions. For endowed professorships, 8 chairs reported 1 professorship each. Four chairs replied that they had 2 positions each and 2 chairs reported 3 positions each. A total of 14 ADEMS (15.7%) reported having 22 endowed professorships. The most common amount required to fund an endowed chair position was $2 million, and $1 million for an endowed professorship. The majority of ADEMs were allowed to spend 4% to 5% of the value of the endowment annually. CONCLUSION: Thirty ADEMs (33.7%) currently have an endowed position, compared to only 19 (26%) 5 years ago. Emergency Medicine now has a total of 53 endowed positions, compared to only 25 such positions in 2009 and just 9 endowed positions in 2004.

[Assistance medicine, a novel discipline of emergency medicine]. / A sürgosségi ellátás új területe: az assistance orvostan.

The number of international travels has been continuously increasing since World War II. Though the travelers' demand for safer ways of travelling appeared, only a handful of them sought pretravel advices. This is the reason why 50% of the travelers have to face some kind of medical problem during their journey. If they have travel insurance, the company's assistance team organizes, monitors and covers their abroad treatment. A doctor of the assistance team has to find her/his ways in various fields: not only a multidisciplinary medical knowledge is a must for a professional like this, but she/he needs to have a good grasp of the basic idea behind the insurance policy, too. Also, she/he should be familiar with the public health care systems of different countries and some legal knowledge is also needed. If the patients are unable to continue their trip, they must be repatriated. Making a decision about the repatriation's timing and modality requires interdisciplinary medical experience and the approach of a critical care/emergency doctor. Among further tasks for the assistance team's doctor one can find medical escort and on-spot medical visit for foreign patients. Both of these two aforementioned medical activities are highly different from - for example - a general practitioner's routine. That is the reason why an assistance doctor has to be familiar with the critical and emergency care. Organizing and monitoring medical treatment for a traveler abroad, providing medical escort, making decisions about repatriation and providing medical help for a foreign patient all fall within the competence of a new medical discipline, the assistance medicine. Creating a body of knowledge, collecting appropriate protocols and establishing postgraduate courses for assistance medicine diplomas are the tasks of the critical care and emergency medicine professionals.

The Patient Protection and Affordable Care Act's Effect on Emergency Medicine: A Synthesis of the Data.

This review synthesizes the existing literature to provide evidence-based predictions for the future of emergency care in the United States as a result of the Patient Protection and Affordable Care Act, with a focus on emergency department (ED) visit volume, acuity, and reimbursement. Patient behavior will likely be quite different for patients gaining Medicaid than for those gaining private insurance through the Marketplaces. Despite the threat of the individual mandate, not all uninsured patients will enroll, and those who choose to enroll will likely be a different population from those who remain uninsured. New Medicaid enrollees will be a sicker population and will likely increase their number of ED visits substantially. Their acuity will be higher at first but will then revert to the traditionally high number of low-acuity visits made by Medicaid patients. Most patients enrolling through the Marketplace are choosing high-deductible health plans, and they will initially avoid the ED because of high out-of-pocket costs but may present later and sicker after self-rationing their care. Most patients gaining health coverage through the Affordable Care Act will be shifting from uninsured to either Medicaid or private insurance, both of which reimburse more than self-pay, so ED collections should increase. Because of the differences between Medicaid and Marketplace plans, there will be a difference in ED volume, acuity, and financial outcomes, depending on states' current demographics, whether states expand Medicaid, and how aggressively states advertise new options for coverage in Medicaid or state health insurance Marketplaces.

Executive summary: global health and emergency care-what do we need to know to address the burden of illness and injury?

Emergency physicians are uniquely poised to address challenges in health services, health care systems development and management, and emerging global disease burdens (both communicable and noncommunicable). This special issue of Academic Emergency Medicine reports the results of the 2013 consensus conference, which included eight focus areas that are intended to advance emergency care research. Advancing our understanding of cardiac and injury resuscitation, ethics of research, health systems development, and the education of our future leaders in global health will ultimately affect the populations of all nations across the globe.