Total and Out-of-Pocket Costs Surrounding Emergency Department Care Among Older Adults Enrolled in Traditional Medicare and Medicare Advantage.

STUDY OBJECTIVE: We sought to quantify differences in total and out-of-pocket health care costs associated with treat-and-release emergency department (ED) visits among older adults with traditional Medicare and Medicare Advantage. METHODS: We conducted a repeated cross-sectional analysis of treat-and-release ED visits using 2015 to 2020 data from the Medicare Current Beneficiary Survey. We measured total and out-of-pocket health care spending during 3 time periods: the 30 days prior to the ED visit, the treat-and-release ED visit itself, and the 30 days after the ED visit. Stratified by traditional Medicare or Medicare Advantage status, we determined median total costs and the proportion of costs that were out-of-pocket. RESULTS: Among the 5,011 ED visits by those enrolled in traditional Medicare, the weighted median total (and % out-of-pocket) costs were $881.95 (13.3%) for the 30 days prior to the ED visit, $419.70 (10.1%) for the ED visit, and $809.00 (13.8%) for the 30 days after the ED visit. For the 2,595 ED visits by those enrolled in Medicare Advantage, the weighted median total (and % out-of-pocket) costs were $484.92 (24.0%) for the 30 days prior to the ED visit, $216.66 (21.9%) for the ED visit, and $439.13 (22.4%) for the 30 days after the ED visit. CONCLUSION: Older adults insured by Medicare Advantage incur lower total health care costs and face similar overall out-of-pocket expenses in the time period surrounding emergency care. However, a higher proportion of expenses are out-of-pocket compared with those insured by traditional Medicare, providing evidence of greater cost sharing for Medicare Advantage plan enrollees.

Compass for antibiotic stewardship: using a digital tool to improve guideline adherence and drive clinician behaviour for appendicitis treatment in the emergency department.

BACKGROUND: Antibiotic stewardship in the ED is important given the increasing prevalence of multidrug resistance associated with poorer patient outcomes. The use of broad-spectrum antibiotics in the ED for infections like appendicitis is common. At baseline, 75% of appendicitis cases at our institution received broad-spectrum ertapenem rather than the recommended narrower-spectrum ceftriaxone/metronidazole combination. We aimed to improve antibiotic stewardship by identifying barriers to guideline adherence and redesigning our appendicitis antibiotic guideline. METHODS: Using the 'Fit between Individuals, Task and Technology (FITT)' framework, we identified barriers that preventclinicians from adhering to guidelines. We reformatted a clinical guideline and disseminated it using our ED's clinical decision support system (CDSS), E*Drive. Next, we examined E*Drive's user data and clinician surveys to assess utilisation and satisfaction. Finally, we conducted a retrospective chart review to measure clinician behaviour change in antibiotic prescription for appendicitis treatment. RESULTS: Data demonstrated an upward trend in the number of monthly users of E*Drive from 1 April 2021 to 30 April 2022, with an average increase of 46 users per month. Our clinician survey results demonstrated that >95% of users strongly agree/agree that E*Drive improves access to clinical information, makes their job more efficient and that E*Drive is easy to access and navigate, with a Net Promoter Score increase from 26.0 to 78.3. 69.4% of patients treated for appendicitis in the post-intervention group received antibiotics concordant with our institutional guideline compared with 20.0% in the pre-intervention group (OR=9.07, 95% CI (3.84 to 21.41)). CONCLUSION: Antibiotic stewardship can be improved by ensuring clinicians have access to convenient and up-to-date guidelines through clinical decision support systems. The FITT model can help guide projects by identifying individual, task and technology barriers. Sustained adherence to clinical guidelines through simplification of guideline content is a potentially powerful tool to influence clinician behaviour in the ED.

Designing clinical guidelines that improve access and satisfaction in the emergency department.

Clinical guidelines are evidence-based clinician decision-support tools that improve health outcomes, reduce patient harm, and decrease healthcare costs, but are often underused in emergency departments (EDs). This article describes a replicable, evidence-based design-thinking approach to developing best practices for guideline design that improves clinical satisfaction and usage. We used a 5-step process to enhance guideline usability in our ED. First, we conducted end-user interviews to identify barriers to guideline usage. Second, we reviewed the literature to identify key principles in guideline design. Third, we applied our findings to create a standardized guideline format, incorporating rapid cycle learning and iterative improvements. Fourth, we ensured the clinical validity of our updated guidelines by using a rigorous process for peer review. Lastly, we evaluated the impact of our guideline conversion process by tracking clinical guidelines access per day from October 2020 to January 2022. Our end-user interviews and review of the design literature revealed several barriers to guideline use, including lack of readability, design inconsistencies, and guideline complexity. Although our previous clinical guideline system averaged 0.13 users per day, >43 users per day accessed the clinical guidelines on our new digital platform in January 2022, representing an increase in access and use exceeding 33,000%. Our replicable process using open-access resources increased clinician access to and satisfaction with clinical guidelines in our ED. Design-thinking and use of low-cost technology can significantly improve clinical guideline visibility and has the potential to increase guideline use.

Barriers to Colorectal Cancer Screening and Surveillance in Homeless Patients: A Case Report and Policy Recommendations.

Patients experiencing homelessness face significant barriers to screening and treatment for colorectal cancer, leading to worse outcomes. In this perspective, we use an exemplar patient case to highlight potential policy solutions for reducing this health care disparity by increasing access to early detection and treatment in this population.

The Association of Limited English Proficiency With Morbidity and Mortality After Trauma.

INTRODUCTION: Disparities following traumatic injury by race/ethnicity and insurance status are well-documented. However, the relationship between limited English proficiency (LEP) and outcomes after trauma is poorly understood. This study describes the association between LEP and morbidity and mortality after traumatic injury. METHODS: A retrospective cohort study was conducted of adult trauma patients admitted to a level 1 trauma center from 2012 to 2018. Morbidity (length of stay [LOS], intensive care unit admission, intensive care unit LOS, discharge destination) and in-hospital mortality for LEP and English proficient (EP) patients were compared using univariate and multivariable logistic and generalized linear models controlling for patient demographics (age, sex, race/ethnicity, insurance) and clinical characteristics (mechanism, activation level, Glasgow Coma Scale, Injury Severity Score, traumatic brain injury). RESULTS: Of the 13,104 patients, 16% were LEP patients. LEP languages included Chinese (44%) and Spanish (38%), and 18% categorized as "Other," including 33 languages. In multivariable models, LEP was statistically significantly associated with increased hospital LOS (P = 0.003) and increased discharge to home with home health services (P = 0.042) or to skilled nursing facility/rehabilitation (P = 0.006). Mortality rate was 7% for LEP versus 4% for EP patients (P < 0.0001). In multivariable analysis, speaking an LEP language other than Chinese or Spanish was statistically significantly associated with increased mortality compared to EP (P = 0.006). CONCLUSIONS: Following traumatic injury, LEP patients experience increased hospital LOS and are more frequently discharged to home with home health services or to skilled nursing facilities/rehabilitation. LEP patients speaking languages other than Chinese or Spanish experience increased mortality compared to EP patients.

Association of Race/Ethnicity With Substance Use Testing After Trauma: A Cross-Sectional Study.

INTRODUCTION: Race/ethnicity has been strongly associated with substance use testing but little is known about this association in injured patients. We sought to identify trends and associations between race/ethnicity and urine toxicology (UTox) or Blood Alcohol Concentration (BAC) testing in a diverse population after trauma. MATERIALS AND METHODS: We conducted a retrospective cross-sectional study of adult trauma patients admitted to a single Level-1 trauma center from 2012 to 2019. The prevalence of substance use testing was evaluated over time and analyzed using a multivariable logistic regression, with a subgroup analysis to evaluate the interaction of English language proficiency with race/ethnicity in the association of substance use testing. RESULTS: A total of 15,556 patients (40% White, 13% Black, 24% Latinx, 20% Asian, and 3% Native or Unknown) were included. BAC testing was done in 63.2% of all patients and UTox testing was done in 39.2%. The prevalence of substance use testing increased over time across all racial/ethnic groups. After adjustment, Latinx patients had higher odds of receiving a BAC test and Black patients had higher odds of receiving a UTox test (P < 0.001 and P < 0.001, respectively) compared to White patients. Asian patients had decreased odds of undergoing a UTox or BAC test compared to White patients (P < 0.001 and P < 0.001, respectively). Patients with English proficiency had higher odds of undergoing substance use testing compared to those with limited English proficiency (P < 0.001). CONCLUSIONS: Despite an increase in substance use testing over time, inequitable testing remained among racial/ethnic minorities. More work is needed to combat racial/ethnic disparities in substance use testing.

Surgical Care of Patients Experiencing Homelessness: A Scoping Review Using a Phases of Care Conceptual Framework.

Homelessness is a growing concern across the world, particularly as individuals experiencing homelessness age and face an increasing burden of chronic health conditions. Although substantial research has focused on the medical and psychiatric care of patients experiencing homelessness, literature about the surgical care of these patients is sparse. Our objective was to review the literature to identify areas of concern unique to patients experiencing homelessness with surgical disease. A scoping review was conducted using a comprehensive database for studies from 1990 to September 1, 2020. Studies that included patients who were unhoused and discussed surgical care were included. The inclusion criteria were designed to identify evidence that directly affected surgical care, systems management, and policy making. Findings were organized within a Phases of Surgical Care framework: preoperative care, intraoperative care, postoperative care, and global use. Our search strategy yielded 553 unique studies, of which 23 met inclusion criteria. Most studies were performed at public and/or safety-net hospitals or via administrative datasets, and surgical specialties that were represented included orthopedic, cardiac, plastic surgery trauma, and vascular surgery. Using the Surgical Phases of Care framework, we identified studies that described the impact of housing status in pre- and postoperative phases as well as global use. There was limited identification of barriers to surgical and anesthetic best practices in the intraoperative phase. More than half of studies (52.2%) lacked a clear definition of homelessness. Thus, there is a marked gap in the surgical literature regarding the impact of housing status on optimal surgical care, with the largest area for improvement in the intraoperative phase of surgical and anesthetic decision making. Consistent use of clear definitions of homelessness is lacking. To promote improved care, a standardized approach to recording housing status is needed, and studies must explore vulnerabilities in surgical care unique to this population.

Limited English Proficiency Associated With Suboptimal Pain Assessment in Hospitalized Trauma Patients.

INTRODUCTION: Traumatic injury causes significant acute and chronic pain, and accurate pain assessment is foundational to optimal pain control. Prior literature has revealed disparities in the treatment of pain by race and ethnicity, but the effect of patient language on pain assessment remains unknown. We aimed to investigate the relationship between Limited English Proficiency (LEP) in pain assessment frequency and pain score magnitude for hospitalized trauma patients. METHODS: We conducted a cross-sectional, retrospective study including all hospitalized adult trauma patients from 2012 to 2018 at a single urban Level-1 trauma center. Patient language, 0-10 Numeric Rating Scale (NRS) pain scores, and demographic and clinical covariates were extracted from the electronic medical record. We used multivariable negative binomial regressions to compare NRS pain assessment frequency and multivariable linear regression to compare NRS pain score magnitude between LEP and English Proficient patients. RESULTS: Between 2012 and 2018, 9754 English proficient and 1878 LEP patients were hospitalized for traumatic injury. In multivariable models adjusted for demographic and injury characteristics, LEP patients had 2.4 fewer pain assessments per day compared to English proficient patients (7.21 versus 9.61, P = 0.001). Excluding days spent in the ICU, LEP patients had 2.6 fewer assessments per day (9.28 versus 11.88, P = 0.001). Median pain scores were lower in the LEP group (2.2 versus 3.61, P < 0.001), with a difference of 1.19 points in adjusted multivariable models. CONCLUSIONS: Compared to English Proficient patients, LEP patients had fewer pain assessments and lower NRS scores. Differences in pain assessment by patient language may be associated with disparities in pain management and morbidity.

Building Back Better: Applying Lessons from the COVID-19 Pandemic to Expand Critical Information Access.

BACKGROUND: The Coronavirus disease 2019 (COVID-19) pandemic generated an unprecedented volume of evolving clinical guidelines that strained existing clinical information systems and necessitated rapid innovation in emergency departments (EDs). OBJECTIVES: Our team aimed to harness new COVID-19-related reliance on digital clinical support tools to re-envision how all clinical guidelines are stored and accessed in our ED. METHODS: We used a design-thinking approach including empathizing, defining the problem, ideating, prototyping, and testing to develop a low-cost, homegrown clinical information hub: E*Drive. To measure impact, we compared web traffic on E*Drive to our legacy cloud-based folder system and conducted a survey of end-users using a validated health technology utilization instrument. RESULTS: Our final product, E*Drive, is a centralized clinical information hub storing everything from clinical guidelines to discharge resources. Clinical guidelines are standardized and housed within the high-traffic E*Drive platform to increase accessibility. Since launch, E*Drive has averaged 84 unique weekly users, compared with less than one weekly user on the legacy system. We surveyed 52 clinicians for a total response rate of 47%. Prior to the E*Drive rollout, 12.5% of ED clinicians felt confident accessing clinical information on the legacy system, whereas 76.6% of ED clinicians felt they could more easily access clinical information using E*Drive. CONCLUSION: The COVID pandemic revealed vulnerabilities within our information dissemination system and presented an opportunity to improve clinical information delivery. Centralized web-based clinical information hubs designed around the clinician end-user experience can increase clinical guideline access in the ED.

Emergency general surgery utilization and disparities during COVID-19: an interrupted time-series analysis.

OBJECTIVE: We aimed to compare general surgery emergency (GSE) volume, demographics and disease severity before and during COVID-19. BACKGROUND: Presentations to the emergency department (ED) for GSEs fell during the early COVID-19 pandemic. Barriers to accessing care may be heightened, especially for vulnerable populations, and patients delaying care raises public health concerns. METHODS: We included adult patients with ED presentations for potential GSEs at a single quaternary-care hospital from January 2018 to August 2020. To compare GSE volumes in total and by subgroup, an interrupted time-series analysis was performed using the March shelter-in-place order as the start of the COVID-19 period. Bivariate analysis was used to compare demographics and disease severity. RESULTS: 3255 patients (28/week) presented with potential GSEs before COVID-19, while 546 (23/week) presented during COVID-19. When shelter-in-place started, presentations fell by 8.7/week (31%) from the previous week (p<0.001), driven by decreases in peritonitis (ß=-2.76, p=0.017) and gallbladder disease (ß=-2.91, p=0.016). During COVID-19, patients were younger (54 vs 57, p=0.001), more often privately insured (44% vs 38%, p=0.044), and fewer required interpreters (12% vs 15%, p<0.001). Fewer patients presented with sepsis during the pandemic (15% vs 20%, p=0.009) and the average severity of illness decreased (p<0.001). Length of stay was shorter during the COVID-19 period (3.91 vs 5.50 days, p<0.001). CONCLUSIONS: GSE volumes and severity fell during the pandemic. Patients presenting during the pandemic were less likely to be elderly, publicly insured and have limited English proficiency, potentially exacerbating underlying health disparities and highlighting the need to improve care access for these patients. LEVEL OF EVIDENCE: III.

Inequity in discharge pain management for trauma patients with limited English proficiency.

INTRODUCTION: Pain management is critical for optimal recovery after trauma. Previous work at our institution revealed differences in pain assessment by patient language, which may impact management. This study aimed to understand differences in discharge opioid prescribing for trauma patients with limited English proficiency (LEP). METHODS: We conducted a cross-sectional study of adult trauma patients discharged to the community from a diverse, urban level 1 trauma center in 2018. Opioid prescriptions were obtained from discharge pharmacy records and converted to standard oral morphine equivalents (OMEs). Multivariable logistic and quantile regression was used to examine the relationship between LEP, opioid prescriptions, and OMEs at discharge, controlling for demographic and clinical characteristics. RESULTS: Of 1,419 patients included in this study, 83% were English proficient (EP) and 17% were LEP. At discharge, 56% of EP patients received an opioid prescription, compared with 41% of LEP patients. In multivariable models, EP patients were 1.63 times more likely to receive any opioid prescription (95% CI, 1.17-2.25; p = 0.003). Mean OME was 147 for EP and 94 for LEP patients. In multivariable models, the difference between EP and LEP patients was 40 OMEs (95% CI, 21.10-84.22; p = 0.004). In adjusted quantile regression models, differences in total OMEs increased with the amount of OMEs prescribed. There was no difference in OMEs at the 20th and 40th percentile of total OMEs, but LEP patients received 26 fewer OMEs on average at the 60th percentile (95% CI, -3.23 to 54.90; p = 0.081) and 45 fewer OMEs at the 80th percentile (95% CI, 5.48-84.48; p = 0.026). CONCLUSION: Limited English proficiency patients with traumatic injuries were less likely to receive any opioid prescription and were prescribed lower quantities of opiates, which could contribute to suboptimal pain management and recovery. Addressing these disparities is an important focus for future quality improvement efforts. LEVEL OF EVIDENCE: Care Management, level IV.

Patient Perceptions on Barriers and Facilitators to Accessing Low-acuity Surgery During COVID-19 Pandemic.

BACKGROUND: The onset of the COVID-19 pandemic led to the postponement of low-acuity surgical procedures in an effort to conserve resources and ensure patient safety. This study aimed to characterize patient-reported concerns about undergoing surgical procedures during the pandemic. METHODS: We administered a cross-sectional survey to patients who had their general and plastic surgical procedures postponed at the onset of the pandemic, asking about barriers to accessing surgical care. Questions addressed dependent care, transportation, employment and insurance status, as well as perceptions of and concerns about COVID-19. Mixed methods and inductive thematic analyses were conducted. RESULTS: One hundred thirty-five patients were interviewed. We identified the following patient concerns: contracting COVID-19 in the hospital (46%), being alone during hospitalization (40%), facing financial stressors (29%), organizing transportation (28%), experiencing changes to health insurance coverage (25%), and arranging care for dependents (18%). Nonwhite participants were 5 and 2.5 times more likely to have concerns about childcare and transportation, respectively. Perceptions of decreased hospital safety and the consequences of possible COVID-19 infection led to delay in rescheduling. Education about safety measures and communication about scheduling partially mitigated concerns about COVID-19. However, uncertainty about timeline for rescheduling and resolution of the pandemic contributed to ongoing concerns. CONCLUSIONS: Providing effective surgical care during this unprecedented time requires both awareness of societal shifts impacting surgical patients and system-level change to address new barriers to care. Eliciting patients' perspectives, adapting processes to address potential barriers, and effectively educating patients about institutional measures to minimize in-hospital transmission of COVID-19 should be integrated into surgical care.

The Brain Health Champion study: Health coaching changes behaviors in patients with cognitive impairment.

INTRODUCTION: Converging evidence suggests that increasing healthy behaviors may slow or prevent cognitive decline. METHODS: We piloted a six-month, randomized, controlled investigation of 40 patients with mild dementia, mild cognitive impairment, or subjective cognitive decline. The intervention consisted of weekly motivational interviewing phone calls and three visits with a "Brain Health Champion" health coach, who guided participants to achieve personalized goals. Changes in behavior were measured using validated questionnaires. RESULTS: Compared with the standard-of-care control group, Brain Health Champion participants had statistically significant and clinically meaningful increases in physical activity (Cohen's d = 1.37, P < .001), adherence to the Mediterranean diet (Cohen's d = 0.87, P = .016), cognitive/social activity (Cohen's d = 1.09, P = .003), and quality of life (Cohen's d = 1.23, P < .001). The magnitude of behavior change strongly predicted improvement in quality of life. DISCUSSION: Our results demonstrate the feasibility and potential efficacy of a health coaching approach in changing health behaviors in cognitively impaired and at-risk patients.