Hospital Occupancy and its Effect on Emergency Department Evaluation.

STUDY OBJECTIVE: To examine whether hospital occupancy was associated with increased testing and treatment during emergency department (ED) evaluations, resulting in reduced admissions. METHODS: We analyzed the electronic health records of an urban academic ED. We linked data from all ED visits from October 1, 2010, to May 29, 2015, with daily hospital occupancy (inpatients/total staffed beds). Outcome measures included the frequency of laboratory testing, advanced imaging, medication administration, and hospitalizations. We modeled each outcome using multivariable negative binomial or logistic regression, as appropriate, and examined their association with daily hospital occupancy quartiles, controlling for patient and visit characteristics. We calculated the adjusted outcome rates and relative changes at each daily hospital occupancy quartile using marginal estimating methods. RESULTS: We included 270,434 ED visits with a mean patient age of 48.1 (standard deviation 19.8) years; 40.1% were female, 22.8% were non-Hispanic Black, and 51.5% were commercially insured. Hospital occupancy was not associated with differences in laboratory testing, advanced imaging, or medication administration. Compared with the first quartile, the third and fourth quartiles of daily hospital occupancy were associated with decreases of 1.5% (95% confidence interval [CI] -2.9 to -0.2; absolute change -0.6 percentage points [95% CI -1.2 to -0.1]) and 4.6% (95% CI -6.0 to -3.2; absolute change -1.9 percentage points [95% CI -2.5 to -1.3]) in hospitalizations, respectively. CONCLUSION: The lack of association between hospital occupancy and laboratory testing, advanced imaging, and medication administration suggest that changes in ED testing or treatment did not facilitate the decrease in admissions during periods of high hospital occupancy.

Decline in U.S. Emergency Department admission rates driven by critical pathway conditions, 2006-2014.

OBJECTIVES: Despite increasing ED visits, evidence suggests overall hospitalization rates have decreased; however, it is unknown what clinical conditions account for these changes. We aim to describe condition-specific trends and hospital-level variation in hospitalization rates after ED visits from 2006 to 2014. METHODS: Retrospective observational study of adult ED visits to U.S. acute care hospitals using nationally weighted data from the 2006-2014 National Emergency Department Survey. Our primary outcome was ED admission rate, defined as the number of admissions originating in the ED divided by the number of ED visits. We report admission rates overall and for each condition, including changes over time. We used logistic regression to compare the odds of ED admission from 2006 to 2014, adjusting for patient and hospital characteristics. We also measured hospital-level variation by calculating hospital-level median ED admission rates and interquartile ranges. RESULTS: After adjusting for patient and hospital characteristics, the odds of ED admission for any condition were 0.49 (CI 0.45, 0.52) in 2014 compared to 2006. The conditions with the greatest relative change in ED admission rates were chest pain (21.7 to 7.5%) and syncope (28.9 to 13.8%). The decline in ED admission rates were accompanied by increased variation in hospital-level ED admission rates. CONCLUSIONS: Recent reductions in ED admissions are largely attributable to decreased admissions for conditions amenable to outpatient critical pathways. Focusing on hospitals with persistently above-average ED admission rates may be a promising approach to improve the value of acute care.

One year mortality of patients treated with naloxone for opioid overdose by emergency medical services.

Study objective: Prehospital use of naloxone for presumed opioid overdose has increased markedly in recent years because of the current opioid overdose epidemic. In this study, we determine the 1-year mortality of suspected opioid overdose patients who were treated with naloxone by EMS and initially survived. Methods: This was a retrospective observational study of patients using three linked statewide datasets in Massachusetts: emergency medical services (EMS), a master demographics file, and death records. We included all suspected opioid overdose patients who were treated with naloxone by EMS. The primary outcome measures were death within 3 days of treatment and between 4 days and 1 year of treatment. Results: Between July 1, 2013 and December 31, 2015, there were 9734 individuals who met inclusion criteria and were included for analysis. Of these, 807 (8.3% (95% confidence interval (CI) 7.7-8.8%)) died in the first 3 days, 668 (6.9% (95% CI 6.4-7.4%)) died between 4 days and 1 year, and 8259 (84.8% (95% CI 84.1-85.6%)) were still alive at 1 year. Excluding those who died within 3 days, 668 of the remaining 8927 individuals (7.5% (95% CI 6.9-8.0%)) died within 1 year. Conclusion: The 1-year mortality of those who are treated with naloxone for opioid overdose by EMS is high. Communities should focus both on primary prevention and interventions for this patient population, including strengthening regional treatment centers and expanding access to medication for opioid use disorder.

Evaluation of sex disparities in opioid use among ED patients with sickle cell disease, 2006-2015.

BACKGROUND: Acute pain from a vaso-occlusive crisis (VOC) is a leading reason patients with sickle cell disease (SCD) visit the emergency department (ED). Prior studies suggest that women and men receive disparate ED treatment for acute pain in EDs. We aim to determine sex differences in analgesic use among patients with SCD presenting to the ED. METHODS: This cross-sectional study uses data from the National Hospital Ambulatory Medical Care Survey (NHAMCS), 2006-2015. We identified ED patients with a primary diagnosis of SCD. Among patients with SCD, we evaluated sex differences in the use of opioid analgesia using logistic regression (adjusting for patient and visit characteristics). Analyses accounted for survey design and weighting. RESULTS: When evaluating the effect of sex on any opioid medication use in this population, though not significant, the odds that male patients were prescribed opioids was 1.5 (95% CI 0.8-2.8) times that of female patients after adjusting for age, the reason for visit, region, insurance status, and pain score. There was no significant difference in pain scores between male patients, 8.1 (95% CI 7.55-8.68) compared to female patients, 7.4 (95% CI 6.7-8.12). CONCLUSIONS: In this nationally representative sample of ED visits among patients with SCD, there was no conclusive evidence of sex disparities in opioid prescribing. Though there is evidence of a trend signaling that male patients with SCD were more likely than female patients to be prescribed an opioid.

Choosing wisely in emergency medicine: Early results and insights from the ACEP emergency quality network (E-QUAL).

PURPOSE: To characterize performance among ED sites participating in the Emergency Quality Network (E-QUAL) Avoidable Imaging Initiative for clinical targets on the American College of Emergency Physicians Choosing Wisely list. METHODS: This was an observational study of quality improvement (QI) data collected from hospital-based ED sites in 2017-2018. Participating EDs reported imaging utilization rates (UR) and common QI practices for three Choosing Wisely targets: Atraumatic Low Back Pain, Syncope, or Minor Head Injury. RESULTS: 305 ED sites participated in the initiative. Among all ED sites, the mean imaging UR for Atraumatic Low Back Pain was 34.7% (IQR 26.3%-42.6%) for XR, 19.1% (IQR 11.4%-24.9%) for CT, and 0.09% (IQR 0%-0.9%) for MRI. The mean CT UR for Syncope was 50.0% (IQR 38.0%-61.4%). The mean CT UR for Minor Head Injury was 72.6% (IQR 65.6%-81.7%). ED sites with sustained participation showed significant decreases in CT UR in 2017 compared to 2018 for Syncope (56.4% vs 48.0%; 95% CI: -12.7%, -4.1%) and Minor Head Injury (76.3% vs 72.1%; 95% CI: -7.3%, -1.1%). There was no significant change in imaging UR for Atraumatic Back Pain for XR (36.0% vs 33.3%; 95% CI: -5.9%, -0;5%), CT (20.1% vs 17.7%; 95% CI: -5.1%, -0.4%) or MRI (0.8% vs 0.7%, 95% CI: -0.4%, -0.3%). CONCLUSIONS: Early data from the E-QUAL Avoidable Imaging Initiative suggests QI interventions could potentially improve imaging stewardship and reduce low-value care. Further efforts to translate the Choosing Wisely recommendations into practice should promote data-driven benchmarking and learning collaboratives to achieve sustained practice improvement.

Increases in Actual Health Care Costs and Claims After Firearm Injury.

BACKGROUND: The incidence of firearm injury and death in the United States is increasing. Although the health care-related effect of firearm injury is estimated to be high, existing data are largely cross-sectional, do not include data on preinjury and postinjury health care visits and related costs, and use hospital charges rather than actual monetary payments. OBJECTIVE: To compare actual health care costs (that is, actual monetary payments) and utilizations within the 6 months before and after an incident (index) firearm injury. DESIGN: Before-after study. SETTING: Blue Cross Blue Shield plans of Illinois, Texas, Oklahoma, New Mexico, and Montana. PARTICIPANTS: Plan members continuously enrolled for at least 12 months before and after an index firearm injury sustained between 1 January 2015 and 31 December 2017. MEASUREMENTS: Eligible costs, out-of-pocket costs, and firearm injury-related International Classification of Diseases, Ninth or 10th Revision, codes. RESULTS: Total initial (emergency department [ED]) health care costs for persons with index firearm injuries who were discharged from the ED were $8 158 786 ($5686 per member). Total initial (hospital admission) costs for persons with index firearm injuries who required hospitalization were $41 255 916 ($70 644 per member). Compared with the 6 months before the index firearm injury, in the 6 months after, per-member costs increased by 347% (from $3984 to $17 806 per member) for those discharged from the ED and 2138% (from $4118 to $92 151 per member) for those who were hospitalized. The number of claims increased by 187% for patients discharged from the ED and 608% for those who were hospitalized. LIMITATION: Firearm injury intent was not specified because of misclassification concerns. CONCLUSION: In the 6 months after a firearm injury, patient-level health care visits and costs increased by 3 to 20 times compared with the 6 months prior. The burden of firearm injury on the health care system is large and quantifiable. PRIMARY FUNDING SOURCE: None.

Medicaid Expansion Reduced Emergency Department Visits by Low-income Adults Due to Barriers to Outpatient Care.

BACKGROUND: Prior studies have found conflicting effects of Medicaid expansion on emergency department (ED) utilization but have not studied the reasons patients go to EDs. OBJECTIVES: Examine the changes in reasons for ED use associated with Medicaid expansion. RESEARCH DESIGN: Difference-in-difference analysis. SUBJECTS: We included sample adults from the 2012 to 2017 National Health Interview Survey who were US citizens and reported a total family income below 138% federal poverty level (n=30,259). MEASURES: We examined changes in the proportion of study subjects reporting: (1) any ED visits; (2) ED visits due to perceived illness severity; (3) office not open; and (4) barriers to outpatient care, comparing expansion and nonexpansion states. RESULTS: Overall, 30.6% of low-income adults reported ED use in the past year, of which 74.1% reported illness acuity, 12.4% reported office not open, 9.5% reported access barriers, and 4.0% did not report any reason. Medicaid expansion was not associated with statistically significant changes in overall ED use [-2.2% (95% confidence interval-CI), -5.5% to 1.2%), P=0.21], ED visits due to perceived illness severity [0.5% (95% CI, -2.4% to 3.5%), P=0.73], or office not open [-0.9% (95% CI, -2.3% to 0.5%); P=0.22], but was associated with significant decrease in ED visits due to access barriers [-1.4% (95% CI, -2.6% to -0.2%), P=0.022]. CONCLUSIONS: Medicaid expansion was associated with a decrease in low-income adults who reported outpatient care barriers as reasons for ED visits. There were no significant changes in overall ED utilization, likely because the majority of respondent reported ED use due to concerns with illness severity or outpatient office was closed.

One-Year Mortality of Patients After Emergency Department Treatment for Nonfatal Opioid Overdose.

STUDY OBJECTIVE: Despite the increased availability of naloxone, death rates from opioid overdose continue to increase. The goal of this study is to determine the 1-year mortality of patients who were treated for a nonfatal opioid overdose in Massachusetts emergency departments (EDs). METHODS: This was a retrospective observational study of patients from 3 linked statewide Massachusetts data sets: a master demographics list, an acute care hospital case-mix database, and death records. Patients discharged from the ED with a final diagnosis of opioid overdose were included. The primary outcome measure was death from any cause within 1 year of overdose treatment. RESULTS: During the study period, 17,241 patients were treated for opioid overdose. Of the 11,557 patients who met study criteria, 635 (5.5%) died within 1 year, 130 (1.1%) died within 1 month, and 29 (0.25%) died within 2 days. Of the 635 deaths at 1 year, 130 (20.5%) occurred within 1 month and 29 (4.6%) occurred within 2 days. CONCLUSION: The short-term and 1-year mortality of patients treated in the ED for nonfatal opioid overdose is high. The first month, and particularly the first 2 days after overdose, is the highest-risk period. Patients who survive opioid overdose should be considered high risk and receive interventions such as being offered buprenorphine, counseling, and referral to treatment before ED discharge.

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

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

Trends and predictors of hospitalization after emergency department asthma visits among U.S. Adults, 2006-2014.

Background: Asthma hospitalizations are an ambulatory care-sensitive condition; a majority originate in emergency departments (EDs).Objective: Describe trends and predictors of adult asthma hospitalizations originating in EDs.Methods: Observational study of ED visits resulting in hospitalization using a nationally representative sample. We tested trend in hospitalization rates from 2006 to 2014 using logistic regression, then assessed the association between hospitalization rates and patient and hospital characteristics using hierarchical multivariable regression accounting for hospital-level clustering.Results: Total ED asthma visits increased 15% from 2006 to 2014, from 1.06 to 1.22 million, while the likelihood of hospitalization decreased (20.9-18.2%, p < 0.01). Adjusting for increased asthma prevalence, ED visit rates and hospitalization rates decreased by 10 and 21%, respectively. Hospitalization was independently associated with older age, female gender (OR = 1.23, 95% CI 1.20-1.26), higher Charlson score (OR = 1.99, 95% CI 1.97-2.01), Medicaid (OR = 1.05, 95% CI 1.01-1.08) and Medicare (OR = 1.26, 95% CI 1.22-1.31) insurance, and trauma centers (OR = 1.34, 95% CI 1.12-1.60). Hospitalization was less likely for uninsured visits (OR = 0.7, 95% CI 0.67-0.73), lower income areas (OR = 0.89, 95% CI 0.85-0.93), non-metropolitan teaching hospitals (OR = 0.83, 95% CI 0.71-0.96), Midwestern (OR = 0.84, 95% CI 0.69-1.01) or Western regions (OR 0.69, 95% CI 0.56-0.83). Unmeasured hospital-specific effects account for 15.8% of variability in hospital admission rates after adjusting for patient and hospital factors.Conclusions: Total asthma ED visits increased, but prevalence-adjusted ED visits, and ED hospitalization rates have declined. Uninsured patients have disproportionately more ED visits but 30% lower odds of hospitalization. Substantial variation implies unmeasured clinical, social and environmental factors accounting for hospital-specific differences in hospitalization.

Effects of Rescheduling Hydrocodone on Opioid Prescribing in Ohio.

BACKGROUND: We quantified opioid prescribing after the 2014 rescheduling of hydrocodone from schedule III to II in the United States using a state-wide prescription database and studied trends three years before and after the policy change, focusing on certain specialties. METHODS: We used Ohio's state prescription drug monitoring program database, which includes all filled schedule II and III prescriptions regardless of payer or pharmacy, to conduct an interrupted time series analysis of the nine most prescribed opioids: hydrocodone, oxycodone, tramadol, codeine, and others. We analyzed hydrocodone prescribing trends for the physician specialties of internal medicine, anesthesiology, and emergency medicine. We evaluated trends 37 months before and after the rescheduling change. RESULTS: Rescheduling was associated with a hydrocodone level change of -26,358 (95% confidence interval [CI] = -36,700 to -16,016) prescriptions (-5.8%) and an additional decrease in prescriptions of -1,568 (95% CI = -2,296 to -839) per month (-0.8%). Codeine prescribing temporarily increased, at a level change of 6,304 (95% CI = 3,003 to 9,606) prescriptions (18.5%), indicating a substitution effect. Hydrocodone prescriptions by specialty were associated with a level change of -805 (95% CI = -1,280 to -330) prescriptions (-8.5%) for anesthesiologists and a level change of -14,619 (95% CI = -23,710 to -5,528) prescriptions (-10.2%) for internists. There was no effect on prescriptions by emergency physicians. CONCLUSIONS: The 2014 federal rescheduling of hydrocodone was associated with declines in hydrocodone prescriptions in Ohio beyond what had already been occurring, and hydrocodone may have been briefly substituted with codeine. These results indicate that rescheduling did have a lasting effect but affected prescribing specialties variably.

Use of Imaging in the Emergency Department: Do Individual Physicians Contribute to Variation?

OBJECTIVE. The purpose of this study is to investigate the magnitude of physician variation in the use of imaging and the factors associated with variation in an urban emergency department (ED) in the United States. MATERIALS AND METHODS. This retrospective cohort study was conducted from April 1, 2013, to March 31, 2014, in the ED of a level I adult trauma center in the northeastern United States. The study cohort included all patient visits to the ED during the study period. We built hierarchic and logistic regression models to determine per-physician utilization of low- and high-cost imaging, and we identified factors correlated with variation in use. Global (i.e., intraclass correlation coefficient) and individual variability metrics were used to profile physician variation after controlling for patient-, visit-, and physician-related covariates. RESULTS. A total of 56,793 patients presented to the ED during the study; of these patients, 49.5% (28,135) underwent imaging, with 38.2% (21,686) undergoing low-cost imaging and 21.9% (12,430) undergoing high-cost imaging. Statistically significant predictors of imaging orders were patient age and sex, number of secondary diagnoses, certain primary diagnoses, time of arrival in the ED, and ED crowding. Unadjusted and adjusted intraclass correlation coefficients were 0.0072 and 0.0066, respectively, for low-cost imaging, and 0.0097 and 0.0090, respectively, for high-cost imaging. The coefficient of variation for adjusted imaging odds ratios was 10.9% and 14.0% for low- and high-cost imaging, respectively, indicating a moderate degree of variation. CONCLUSION. Unexplained and moderate variation in imaging utilization exists among ED physicians, even after controlling for patient, visit, and physician characteristics. Improvement initiatives using well-defined ED imaging quality measures may help improve quality and reduce waste.

A Quality Framework for Emergency Department Treatment of Opioid Use Disorder.

Emergency clinicians are on the front lines of responding to the opioid epidemic and are leading innovations to reduce opioid overdose deaths through safer prescribing, harm reduction, and improved linkage to outpatient treatment. Currently, there are no nationally recognized quality measures or best practices to guide emergency department quality improvement efforts, implementation science researchers, or policymakers seeking to reduce opioid-associated morbidity and mortality. To address this gap, in May 2017, the National Institute on Drug Abuse's Center for the Clinical Trials Network convened experts in quality measurement from the American College of Emergency Physicians' (ACEP's) Clinical Emergency Data Registry, researchers in emergency and addiction medicine, and representatives from federal agencies, including the National Institute on Drug Abuse and the Centers for Medicare & Medicaid Services. Drawing from discussions at this meeting and with experts in opioid use disorder treatment and quality measure development, we developed a multistakeholder quality improvement framework with specific structural, process, and outcome measures to guide an emergency medicine agenda for opioid use disorder policy, research, and clinical quality improvement.

Goals-of-Care Conversations for Older Adults With Serious Illness in the Emergency Department: Challenges and Opportunities.

During the last 6 months of life, 75% of older adults with preexisting serious illness, such as advanced heart failure, lung disease, and cancer, visit the emergency department (ED). ED visits often mark an inflection point in these patients' illness trajectories, signaling a more rapid rate of decline. Although most patients are there seeking care for acute issues, many of them have priorities other than to simply live as long as possible; yet without discussion of preferences for treatment, they are at risk of receiving care not aligned with their goals. An ED visit may offer a unique "teachable moment" to empower patients to consider their ability to influence future medical care decisions. However, the constraints of the ED setting pose specific challenges, and little research exists to guide clinicians treating patients in this setting. We describe the current state of goals-of-care conversations in the ED, outline the challenges to conducting these conversations, and recommend a research agenda to better equip emergency physicians to guide shared decisionmaking for end-of-life care. Applying best practices for serious illness communication may help emergency physicians empower such patients to align their future medical care with their values and goals.

The Impact of Conversion From an Urgent Care Center to a Freestanding Emergency Department on Patient Population, Conditions Managed, and Reimbursement.

BACKGROUND: Freestanding emergency departments (FSEDs), EDs not attached to acute care hospitals, are expanding. One key question is whether FSEDs are more similar to higher-cost hospital-based EDs or to lower-cost urgent care centers (UCCs). OBJECTIVE: Our aim was to determine whether there was a change in patient population, conditions managed, and reimbursement among three facilities that converted from a UCC to an FSED. METHODS: Using insurance claims from Blue Cross Blue Shield of Texas, we compared outcomes of interest for three facilities that converted from a UCC to an FSED for 1 year before and after conversion. RESULTS: There was no significant change in age, sex, and comorbidities among patients treated after conversion. Conditions were similar after conversion, though there was a small increase in visits for potentially more severe conditions. For example, the most common diagnoses before and after conversion were upper respiratory infections (42.8% of UCC visits, 26.0% of FSED visits), while chest pain increased from rank 30 to 10 (0.5% of UCC visits, 2.3% of FSED visits). Yearly number of visits decreased after conversion, while median reimbursement per visit increased (facility A: $148 to $2,153; facility B: $137 to $1,466; and facility C: $131 to $1,925) and total revenue increased (facility A: $1,389,590 to $1,486,203; facility B: $896,591 to $4,294,636; and facility C: $637,585 to $8,429,828). CONCLUSIONS: After three UCCs converted to FSEDs, patient volume decreased and reimbursement per visit increased, despite no change in patient characteristics and little change in conditions managed. These case studies suggest that some FSEDs are similar to UCCs in patient mix and conditions treated.

Preliminary Performance on the New CMS Sepsis-1 National Quality Measure: Early Insights From the Emergency Quality Network (E-QUAL).

STUDY OBJECTIVE: We describe current hospital-level performance for the Centers for Medicare & Medicaid Services' Severe Sepsis/Septic Shock Early Management Bundle (SEP-1) quality measure and qualitatively assess emergency department (ED) sepsis quality improvement best practice implementation. METHODS: Using a standardized Web-based submission portal, we surveyed quality improvement data from volunteer hospital-based EDs participating in the Emergency Quality Network Sepsis Initiative. Each hospital submitted preliminary SEP-1 local chart review data, using existing Centers for Medicare & Medicaid Services definitions. We report descriptive statistics of SEP-1 data availability and performance. The primary outcome for this study was SEP-1 bundle compliance, defined as the proportion of all severe sepsis and septic shock cases receiving all required bundle elements, and secondary outcomes included conditional compliance on reported SEP-1 numerator components and ED implementation of sepsis quality improvement best practices. RESULTS: A total of 50 EDs participated in the survey; 74% were nonteaching sites and 26% were affiliated with academic centers. Of all participating EDs, 80% were in regions with relatively high population density. The mean hospital SEP-1 bundle compliance was 54% (interquartile range 30% to 75%). Bundle compliance improved during fiscal year 2016 from 39% to 57%. Broad variation existed for each bundle component, with intravenous fluid resuscitation and repeated lactate bundle elements having the widest variation and largest gaps in quality. At least one consensus sepsis quality improvement best practice implementation occurred in 92% of participating sites. CONCLUSION: Preliminary data on SEP-1 performance suggest wide hospital-level variation in performance, with modest improvement during the first year of data collection.

Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study.

STUDY OBJECTIVE: Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding. METHODS: In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). RESULTS: We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability. CONCLUSION: There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.

Opioid Prescriptions by Specialty in Ohio, 2010-2014.

Background: The current US opioid epidemic is attributed to the large volume of prescribed opioids. This study analyzed the contribution of different medical specialties to overall opioids by evaluating the pill counts and morphine milligram equivalents (MMEs) of opioid prescriptions, stratified by provider specialty, and determined temporal trends. Methods: This was an analysis of the Ohio prescription drug monitoring program database, which captures scheduled medication prescriptions filled in the state as well as prescriber specialty. We extracted prescriptions for pill versions of opioids written in the calendar years 2010 to 2014. The main outcomes were the number of filled prescriptions, pill counts, MMEs, and extended-released opioids written by physicians in each specialty, and annual prescribing trends. Results: There were 56,873,719 prescriptions for the studied opioids dispensed, for which 41,959,581 (73.8%) had prescriber specialty type available. Mean number of pills per prescription and MMEs were highest for physical medicine/rehabilitation (PM&R; 91.2 pills, 1,532 mg, N = 1,680,579), anesthesiology/pain (89.3 pills, 1,484 mg, N = 3,261,449), hematology/oncology (88.2 pills, 1,534 mg, N = 516,596), and neurology (84.4 pills, 1,230 mg, N = 573,389). Family medicine (21.8%) and internal medicine (17.6%) wrote the most opioid prescriptions overall. Time trends in the average number of pills and MMEs per prescription also varied depending on specialty. Conclusions: The numbers of pills and MMEs per opioid prescription vary markedly by prescriber specialty, as do trends in prescribing characteristics. Pill count and MME values define each specialty's contribution to overall opioid prescribing more accurately than the number of prescriptions alone.

Where Do Freestanding Emergency Departments Choose to Locate? A National Inventory and Geographic Analysis in Three States.

STUDY OBJECTIVE: We determine the number and location of freestanding emergency departments (EDs) across the United States and determine the population characteristics of areas where freestanding EDs are located. METHODS: We conducted a systematic inventory of US freestanding EDs. For the 3 states with the highest number of freestanding EDs, we linked demographic, insurance, and health services data, using the 5-digit ZIP code corresponding to the freestanding ED's location. To create a comparison nonfreestanding ED group, we matched 187 freestanding EDs to 1,048 nonfreestanding ED ZIP codes on land and population within state. We compared differences in demographic, insurance, and health services factors between matched ZIP codes with and without freestanding EDs, using univariate regressions with weights. RESULTS: We identified 360 freestanding EDs located in 30 states; 54.2% of freestanding EDs were hospital satellites, 36.6% were independent, and 9.2% were not classifiable. The 3 states with the highest number of freestanding EDs accounted for 66% of all freestanding EDs: Texas (181), Ohio (34), and Colorado (24). Across all 3 states, freestanding EDs were located in ZIP codes that had higher incomes and a lower proportion of the population with Medicaid. In Texas and Ohio, freestanding EDs were located in ZIP codes with a higher proportion of the population with private insurance. In Texas, freestanding EDs were located in ZIP codes that had fewer Hispanics, had a greater number of hospital-based EDs and physician offices, and had more physician visits and medical spending per year than ZIP codes without a freestanding ED. In Ohio, freestanding EDs were located in ZIP codes with fewer hospital-based EDs. CONCLUSION: In Texas, Ohio, and Colorado, freestanding EDs were located in areas with a better payer mix. The location of freestanding EDs in relation to other health care facilities and use and spending on health care varied between states.

The Effect of Opioid Prescribing Guidelines on Prescriptions by Emergency Physicians in Ohio.

STUDY OBJECTIVE: The objective of our study is to evaluate the association between Ohio's April 2012 emergency physician guidelines aimed at reducing inappropriate opioid prescribing and the number and type of opioid prescriptions dispensed by emergency physicians. METHODS: We used Ohio's prescription drug monitoring program data from January 1, 2010, to December 31, 2014, and included the 5 most commonly prescribed opioids (hydrocodone, oxycodone, tramadol, codeine, and hydromorphone). The primary outcome was the monthly statewide prescription total of opioids written by emergency physicians in Ohio. We used an interrupted time series analysis to compare pre- and postguideline level and trend in number of opioid prescriptions dispensed by emergency physicians per month, number of prescriptions stratified by 5 commonly prescribed opioids, and number of prescriptions for greater than 3 days' supply of opioids. RESULTS: Beginning in January 2010, the number of prescriptions dispensed by all emergency physicians in Ohio decreased by 0.3% per month (95% confidence interval [CI] -0.49% to -0.15%). The implementation of the guidelines in April 2012 was associated with a 12% reduction (95% CI -17.7% to -6.3%) in the level of statewide total prescriptions per month and an additional decline of 0.9% (95% CI -1.1% to -0.7%) in trend relative to the preguideline trend. The estimated effect of the guidelines on total monthly prescriptions greater than a 3-day supply was an 11.2% reduction in level (95% CI -18.8% to -3.6%) and an additional 0.9% (95% CI -1.3% to -0.5%) decline in trend per month after the guidelines. Guidelines were also associated with a reduction in prescribing for each of the 5 individual opioids, with various effect. CONCLUSION: In Ohio, emergency physician opioid prescribing guidelines were associated with a decrease in the quantity of opioid prescriptions written by emergency physicians. Although introduction of the guidelines occurred in parallel with other opioid-related interventions, our findings suggest an additional effect of the guidelines on prescribing behavior. Similar guidelines may have the potential to reduce opioid prescribing in other geographic areas and for other specialties as well.