Episodes of care: is emergency medicine ready?

Optimizing resource use, eliminating waste, aligning provider incentives, reducing overall costs, and coordinating the delivery of quality care while improving outcomes have been major themes of health care reform initiatives. Recent legislation contains several provisions designed to move away from the current fee-for-service payment mechanism toward a model that reimburses providers for caring for a population of patients over time while shifting more financial risk to providers. In this article, we review current approaches to episode of care development and reimbursement. We describe the challenges of incorporating emergency medicine into the episode of care approach and the uncertain influence this delivery model will have on emergency medicine care, including quality outcomes. We discuss the limitations of the episode of care payment model for emergency services and advocate retention of the current fee-for-service payment model, as well as identify research gaps that, if addressed, could be used to inform future policy decisions of emergency medicine health policy leaders. We then describe a meaningful role for emergency medicine in an episode of care setting.

Emergency department operational metrics, measures and definitions: results of the Second Performance Measures and Benchmarking Summit.

There is a growing mandate from the public, payers, hospitals, and Centers for Medicare & Medicaid Services (CMS) to measure and improve emergency department (ED) performance. This creates a compelling need for a standard set of definitions about the measurement of ED operational performance. This Concepts article reports the consensus of a summit of emergency medicine experts tasked with the review, expansion, and update of key definitions and metrics for ED operations. Thirty-two emergency medicine leaders convened for the Second Performance Measures and Benchmarking Summit on February 24, 2010. Before arrival, attendees were provided with the original definitions published in 2006 and were surveyed about gaps and limitations in the original work. According to survey responses, a work plan to revise and update the definitions was developed. Published definitions from key stakeholders in emergency medicine and health care were reviewed and circulated. At the summit, attendees discussed and debated key terminology and metrics and work groups were created to draft the revised document. Workgroups communicated online and by teleconference to reach consensus. When possible, definitions were aligned with performance measures and definitions put forth by the CMS, the Emergency Nurses Association Consistent Metrics Document, and the National Quality Forum. The results of this work are presented as a reference document.

Developing a standardized faculty evaluation in an emergency medicine residency.

BACKGROUND: Quality educators are a core component of successful residency training. A structured, consistent, validated evaluation of clinical educators is important to improve teaching aptitude, further faculty development, and improve patient care. STUDY OBJECTIVES: The authors sought to identify specific domains of instructional quality and to develop a composite instrument for assessing instructional quality. METHODS: The study setting is a 3-year residency program. Residents rated the quality of faculty member instruction using an 18-item survey twice over a 2-year period (2004-2005). Each survey item used a 9-point scale. Factor analysis employing a Varimax rotation identified domains of instructional performance. Cronbach's alpha was used to assess the internal consistency of the identified domains. RESULTS: There were 29 faculty members evaluated. Using 2004 data, five domains of instructional quality were identified that explained 92.5% of the variation in survey responses (χ(2) = 2.33, P = 0.11). These were: Competency and Professionalism (30% of variation), Commitment to Knowledge and Instruction (23%), Inclusion and Interaction (17%), Patient Focus (13%), and Openness to Ideas (9%). Competency and Professionalism included appropriate care, effective patient communication, use of new techniques, and ethical principles. Commitment to Knowledge and Instruction included research, mentoring, feedback, and availability. Inclusion and Interaction included procedural participation and bedside teaching. Patient Focus included compassion, effective care, and sensitivity to diverse populations. Openness to Ideas included enthusiasm and receptivity of new ideas. These five domains were consistent in the 2005 data (Cronbach's alpha 0.68-0.75). CONCLUSIONS: A five-domain instrument consistently accounted for variations in faculty teaching performance as rated by resident physicians. This instrument may be useful for standardized assessment of instructional quality.

Referral without access: for psychiatric services, wait for the beep.

STUDY OBJECTIVE: We examine access to care for acute depression by insurance status compared to access for acute medical conditions in 9 metropolitan areas in the United States. METHODS: Using an audit study design, trained research assistants posing as patients referred from a local emergency department (ED) for treatment of depression called each clinic twice, with differing insurance status. The main outcome measure was the ability to schedule a mental health appointment within 2 weeks of the ED visit. RESULTS: In 45% of 322 calls to mental health clinics, the research assistant reached an answering machine compared with 8% of calls to medical clinics. As a result, only 31% of callers with depression vignettes were able to determine whether they could get an appointment versus 78% of callers with medical complaints. When they reached appointment personnel by telephone, 57% of depression callers successfully arranged an appointment (39% within 14 days). Among depression callers who reached appointment personnel, 67% of privately insured and 33% of Medicaid callers were able to make an appointment, for overall appointment rates of 22% and 12%, respectively. Appointment success for the uninsured was comparable to that of Medicaid patients. The high percentage of callers who encountered answering machines prevented us from completing the designed analysis of paired calls to individual clinics. CONCLUSION: Our findings indicate that the process for obtaining urgent follow-up appointments is systematically different for patients seeking behavioral health care than for those with physical complaints. The use of voicemail, in lieu of having a person answer the telephone, is much more prevalent in behavioral than physical health settings. More work is needed to determine the effect of this practice on depressed individuals and vulnerable populations.

Accuracy of staff-initiated emergency department tracking system timestamps in identifying actual event times.

STUDY OBJECTIVE: Managers use timestamps from computerized tracking systems to evaluate emergency department (ED) processes. This study was designed to determine how accurately these timestamps reflect the actual ED events they purport to represent. METHODS: An observer manually timestamped patient and provider movement events during all hours. The observed timestamps were then systematically matched to equivalent timestamps collected by an active tracking system (timestamps created by staff with keyboard/mouse) and a passive tracking system (timestamps created by sensor badge worn by staff members). The deviation intervals between the matched timestamps were analyzed. RESULTS: The observer noted a total of 901 events; 686 (76%) of these were successfully matched to active system timestamps and 60 (6.7%) were matched to passive system timestamps. For the active system, the median event was recorded 1.8 minutes before it was observed (interquartile range 30.7 minutes before to 2.9 minutes after). Protocol execution difficulties limited the study of the passive system (low number of successfully matched events). The median event was recorded by the passive system 1.1 minutes before it was observed (interquartile range 1.3 minutes before to 0.9 minutes before) (n=60). CONCLUSION: The timestamps recorded by both active and passive tracking systems contain systematic errors and nonnormal distributions. The active system had much lower precision than the passive system but similar accuracy when large numbers of active system observations were used. Medians should be used to represent timestamp and interval data for reporting purposes. Site-specific data validation should be performed before use of data in high-profile situations.

Emergency department crowding: old problem, new solutions.

Emergency department (ED) crowding is becoming an increasing problem in EDs throughout the United States for a multitude of reasons, including an increase in patient volume and a decrease in available EDs. Crowding has an adverse impact on the ability to deliver quality and timely care and may contribute to adverse patient outcomes. Conceptually, factors that contribute to ED crowding can be divided into three domains, which correspond to their "sites of action": input, throughput, and output. A number of measures have been developed to better quantify crowding and its effects. More research needs to be done to better understand the factors that contribute to crowding, the impact of this problem on patients and ED throughput, and how to alleviate this nationwide crisis.

Insurance status and access to urgent ambulatory care follow-up appointments.

CONTEXT: There is growing pressure to avoid hospitalizing emergency department patients who can be treated safely as outpatients, but this strategy depends on timely access to follow-up care. OBJECTIVE: To determine the association between reported insurance status and access to follow-up appointments for serious conditions that are commonly identified during an emergency department visit. DESIGN, SETTING, AND PARTICIPANTS: Eight research assistants called 499 randomly selected ambulatory clinics in 9 US cities (May 2002-February 2003) and identified themselves as new patients who had been seen in an emergency department and needed an urgent follow-up appointment (within 1 week) for 1 of 3 clinical vignettes (pneumonia, hypertension, or possible ectopic pregnancy). The same person called each clinic twice using the same clinical vignette but different insurance status. MAIN OUTCOME MEASURE: Proportion of callers who were offered an appointment within a week. RESULTS: Of 499 clinics contacted in the final sample, 430 completed the study protocol. Four hundred six (47.2%) of 860 total callers and 277 (64.4%) of 430 privately insured callers were offered appointments within a week. Callers who claimed to have private insurance were more likely to receive appointments than those who claimed to have Medicaid coverage (63.6% [147/231] vs 34.2% [79/231]; difference, 29.4 percentage points; 95% confidence interval, 21.2-37.6; P<.001). Callers reporting private insurance coverage had higher appointment rates than callers who reported that they were uninsured but offered to pay 20 dollars and arrange payment of the balance (65.3% [130/199] vs 25.1% [50/199]; difference, 40.2; 95% confidence interval, 31.4-49.1; P<.001). There were no differences in appointment rates between callers who claimed to have private insurance coverage and those who reportedly were uninsured but willing to pay cash for the entire visit fee (66.3% [132/199] vs 62.8% [125/199]; difference, 3.5; 95% confidence interval -3.7 to 10.8; P = .31). The median charge was 100 dollars (range, 25 dollars-600 dollars). Seventy-two percent of clinics did not attempt to determine the severity of the caller's condition. CONCLUSIONS: Reported insurance status is associated with access to timely follow-up ambulatory care for potentially serious conditions. Having private insurance and being willing to pay cash may not eliminate the difficulty in obtaining urgent follow-up appointments.

Access to emergency care: restricted by long waiting times and cost and coverage concerns.

STUDY OBJECTIVE: We monitor progress toward Healthy People 2010 objectives of reducing health disparities and decreasing delay and difficulty in access to emergency care. METHODS: This was a secondary analysis of 2001 National Health Interview Survey interviews of 33,326 adults to provide population-based estimates of self-reported delay, difficulty, or inability to get care from a hospital emergency department (ED) in the preceding 12 months. RESULTS: About 7.7% of the estimated 36.6 million adults who sought care in a hospital ED in the preceding 12 months reported a delay in receiving care, having difficulty receiving care, or being unable to receive care. Waiting times were the most frequently noted cause of problems. Concerns about service costs and insurance coverage were also commonly cited access barriers. Access problems were more likely to be reported by adults without health insurance, younger adults, adults in fair or poor health, and adults with annual incomes of less than 20,000 dollars. CONCLUSION: Self-reported access to ED care is impeded by prolonged waiting times and by cost and insurance coverage concerns. These access problems are occurring more frequently among groups that face multiple social and economic disadvantages. Hospital operational changes to reduce ED treatment delays and health care financing policies that reduce insurance coverage inequities may both be needed to meet these Healthy People 2010 objectives.

Using online analytical processing to manage emergency department operations.

The emergency department (ED) is a unique setting in which to explore and evaluate the utility of information technology to improve health care operations. A potentially useful software tool in managing this complex environment is online analytical processing (OLAP). An OLAP system has the ability to provide managers, providers, and researchers with the necessary information to make decisions quickly and effectively by allowing them to examine patterns and trends in operations and patient flow. OLAP software quickly summarizes and processes data acquired from a variety of data sources, including computerized ED tracking systems. It allows the user to form a comprehensive picture of the ED from both system-wide and patient-specific perspectives and to interactively view the data using an approach that meets his or her needs. This article describes OLAP software tools and provides examples of potential OLAP applications for care improvement projects, primarily from the perspective of the ED. While OLAP is clearly a helpful tool in the ED, it is far more useful when integrated into the larger continuum of health information systems across a hospital or health care delivery system.

Designing a research agenda to improve the quality of emergency care.

A systematic approach to develop a research agenda for improving the quality of emergency care is presented. This approach is based on the six domains of quality outlined by the Institute of Medicine (effective, timely, efficient, safe, patient-centered, and equitable care) and a sequence of four research steps (evidence, synthesis, assessment, and intervention). Examples related to the care of patients with acute myocardial infarction are used to illustrate the proposed approach. Examples of other emergency medicine research topics relevant to the Institute of Medicine quality domains are also presented. Research to improve the quality of emergency care can benefit from a more systematic consideration of the domains of quality and the research steps necessary to generate evidence and inform quality improvement efforts in practice.

Does improved access to care affect utilization and costs for patients with chronic conditions?

OBJECTIVE: To determine whether a major improvement in access (ie, implementing an open access system) in a large multispecialty medical group during 2000 was associated with changes in utilization or costs for patients with diabetes, coronary heart disease (CHD), or depression. STUDY DESIGN: Multilevel regression analysis of health plan administrative data. PATIENTS AND METHODS: Approximately 7000 patients with diabetes, 3800 with CHD, and 6000 with depression who received all of their care in this care system served as the subjects for this study. Utilization and costs between 1999 and 2001 (before and after implementation of open access) were compared for these patients. The main outcome measures were rates of inpatient admissions and various types of outpatient encounters as well as associated costs for these subjects. RESULTS: Between 1999 and 2001, total office visit changes were small and varied with condition, but the proportion of these visits made to primary care physicians increased significantly by an absolute 5% to 9% and primary care physician continuity increased for each condition. Urgent care visits also decreased significantly by an absolute 5% to 9%, but there was no change in emergency department visits or hospital admissions. Total costs of care for these patients were much larger than those for the overall population of the medical group, but increased at a similar rate. CONCLUSION: A major improvement in patient access to primary care clinics was associated with increased use and continuity of primary care for patients with 3 chronic conditions, but did not affect overall resource use.

Teaching and clinical efficiency: competing demands.

INTRODUCTION: Teaching ability and efficiency of clinical operations are important aspects of physician performance. In order to promote excellence in education and clinical efficiency, it would be important to determine physician qualities that contribute to both. We sought to evaluate the relationship between teaching performance and patient throughput times. METHODS: The setting is an urban, academic emergency department with an annual census of 65,000 patient visits. Previous analysis of an 18-question emergency medicine faculty survey at this institution identified 5 prevailing domains of faculty instructional performance. The 5 statistically significant domains identified were: Competency and Professionalism, Commitment to Knowledge and Instruction, Inclusion and Interaction, Patient Focus, and Openness and Enthusiasm. We fit a multivariate, random effects model using each of the 5 instructional domains for emergency medicine faculty as independent predictors and throughput time (in minutes) as the continuous outcome. Faculty that were absent for any portion of the research period were excluded as were patient encounters without direct resident involvement. RESULTS: Two of the 5 instructional domains were found to significantly correlate with a change in patient treatment times within both datasets. The greater a physician's Commitment to Knowledge and Instruction, the longer their throughput time, with each interval increase on the domain scale associated with a 7.38-minute increase in throughput time (90% confidence interval [CI]: 1.89 to 12.88 minutes). Conversely, increased Openness and Enthusiasm was associated with a 4.45-minute decrease in throughput (90% CI: -8.83 to -0.07 minutes). CONCLUSION: Some aspects of teaching aptitude are associated with increased throughput times (Openness and Enthusiasm), while others are associated with decreased throughput times (Commitment to Knowledge and Instruction). Our findings suggest that a tradeoff may exist between operational and instructional performance.

The chest pain choice decision aid: a randomized trial.

BACKGROUND: Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results, unnecessary downstream procedures, and increased cost. We judged it unlikely that patient preferences were driving the decision to obtain stress testing. METHODS AND RESULTS: The Chest Pain Choice trial was a prospective randomized evaluation involving 204 patients who were randomized to a decision aid or usual care and were followed for 30 days. The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options (observation unit admission and stress testing or 24-72 hours outpatient follow-up). The primary outcome was patient knowledge measured by an immediate postvisit survey. Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Compared with usual care patients (n=103), decision aid patients (n=101) had significantly greater knowledge (3.6 versus 3.0 questions correct; mean difference, 0.67; 95% CI, 0.34-1.0), were more engaged in decision making as indicated by higher OPTION (observing patient involvement) scores (26.6 versus 7.0; mean difference, 19.6; 95% CI, 1.6-21.6), and decided less frequently to be admitted to the observation unit for stress testing (58% versus 77%; absolute difference, 19%; 95% CI, 6%-31%). There were no major adverse cardiac events after discharge in either group. CONCLUSIONS: Use of a decision aid in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing.

Conference proceedings-improving the quality and efficiency of emergency care across the continuum: a systems approach.

In October 2009, the American College of Emergency Physicians (ACEP) convened a conference held in Boston, Massachusetts, to outline critical issues in emergency care quality and efficiency and to develop a series of research agendas and projects aimed at addressing important questions about how to improve acute, episodic care. The aim of the conference was to describe how hospital-based emergency department (ED) systems could provide solutions for broader delivery problems in the U.S. health care system. The conference featured keynote speakers Drs. Carolyn Clancy (Director, Agency for Healthcare Research and Quality) and Elliott Fisher (Director, Center for Health Policy Research at Dartmouth Medical School). Panels focused on: 1) systems and workflow redesign to improve health care and 2) improving coordination of care for high-cost patients. Additional sessions were conducted to develop five research agendas on the following topics: 1) health information technology; 2) demand for acute care services; 3) frequent, high-cost users of emergency care; 4) critical pathways for post-emergency care diagnosis and treatment; and 5) end-of-life and palliative care in the ED.