Rising high-acuity emergency care services independently billed by advanced practice providers, 2013 to 2019.

BACKGROUND: Advanced practice providers (APPs) comprise an increasing proportion of the emergency medicine (EM) workforce, particularly in rural geographies. With little known regarding potential expanding practice patterns, we sought to evaluate trends in independent emergency care services billed by APPs from 2013 to 2019. METHODS: We performed a repeated cross-sectional analysis of emergency clinicians independently reimbursed for at least 50 evaluation and management (E/M) services (99281-99285, 99291) from Medicare Part B, with high-acuity services including Codes 99285 and 99291. We describe the outcome proportion of E/M services by acuity level and report at (1) the encounter level and (2) at the clinician level. We stratified analyses by clinician type and geography. RESULTS: A total of 47,323 EM physicians, 10,555 non-EM physicians, and 26,599 APPs were included in analyses. APPs billed emergency care services independently for 5.1% (rural 7.3%, urban 4.8%) of all high-acuity encounters in 2013, increasing to 9.7% (rural 16.4%, urban 8.8%) by 2019. At the clinician level, in 2013, the average rural-practicing APP independently billed 22.8% of services as high acuity, 72.6% as moderate acuity, and 4.5% as low acuity. By 2019, the average rural-practicing APP independently billed 36.2% of services as high acuity, representing a +58.8% relative increase from 2013. Relative increases in high-acuity visits independently billed by APPs were substantially greater when compared to EM physicians across both rural and urban geographies. CONCLUSIONS: In 2019, APPs billed independent services for approximately one in six high-acuity ED encounters in rural geographies and one in 11 high-acuity ED encounters in urban geographies, and well over one-third of the average APPs' encounters were for high-acuity E/M services. Given differences in training and reimbursement between clinician types, these estimates suggest further work is needed evaluating emergency care staffing decision making.

Trends in Urinary Catheter Use by Indication in US Emergency Departments, 2002-2019.

This retrospective study examines trends in urinary catheter use in US emergency departments between 2002 and 2019.

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.

Emergency clinician participation and performance in the Centers for Medicare & Medicaid Services Merit-based Incentive Payment System.

BACKGROUND: The Merit-based Incentive Payment System (MIPS) is the largest national pay-for-performance program and the first to afford emergency clinicians unique financial incentives for quality measurement and improvement. With little known regarding its impact on emergency clinicians, we sought to describe participation in the MIPS and examine differences in performance scores and payment adjustments based on reporting affiliation and reporting strategy. METHODS: We performed a cross-sectional analysis using the Centers for Medicare & Medicaid Services 2018 Quality Payment Program (QPP) Experience Report data set. We categorized emergency clinicians by their reporting affiliation (individual, group, MIPS alternative payment model [APM]), MIPS performance scores, and Medicare Part B payment adjustments. We calculated performance scores for common quality measures contributing to the quality category score if reported through qualified clinical data registries (QCDRs) or claims-based reporting strategies. RESULTS: In 2018, a total of 59,828 emergency clinicians participated in the MIPS-1,246 (2.1%) reported as individuals, 43,404 (72.5%) reported as groups, and 15,178 (25.4%) reported within MIPS APMs. Clinicians reporting as individuals earned lower overall MIPS scores (median [interquartile range {IQR}] = 30.8 [15.0-48.2] points) than those reporting within groups (median [IQR] = 88.4 [49.3-100.0]) and MIPS APMs (median [IQR] = 100.0 [100.0-100.0]; p < 0.001) and more frequently incurred penalties with a negative payment adjustment. Emergency clinicians had higher measure scores if reporting QCDR or QPP non-emergency medicine specialty set measures. CONCLUSIONS: Emergency clinician participation in national value-based programs is common, with one in four participating through MIPS APMs. Those employing specific strategies such as QCDR and group reporting received the highest MIPS scores and payment adjustments, emphasizing the role that reporting strategy and affiliation play in the quality of care.

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.

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.

Emergency Absentee Voting for Hospitalized Patients and Voting During COVID-19: A 50-State Study.

INTRODUCTION: Voters facing illness or disability are disproportionately under-represented in terms of voter turnout. Earlier research has indicated that enfranchisement of these populations may reinforce the implementation of policies improving health outcomes and equity. Due to the confluence of the coronavirus 2019 (COVID-19) pandemic and the 2020 election, we aimed to assess emergency absentee voting processes, which allow voters hospitalized after regular absentee deadlines to still obtain an absentee ballot, and election changes due to COVID-19 in all 50 states. METHODS: We performed a cross-sectional study collecting 34 variables pertaining to emergency voting processes and COVID-19-related election changes, including deadlines, methods of submission for applications and ballots, and specialized services for patients. Data were obtained from, in order of priority, state boards of elections websites, poll worker manuals, application forms, and state legislation. We verified all data through direct correspondence with state boards of elections. RESULTS: Emergency absentee voting processes are in place in 39 states, with the remaining states having universal vote-by-mail (n = 5) or extended regular absentee voting deadlines (n = 6). The emergency absentee period most commonly began within 24 hours following the normal absentee application deadline, which was often seven days before an election (n = 11). Unique aspects of emergency voting processes included patients designating an "authorized agent" to deliver their applications and ballots (n = 38), electronic ballot delivery (n = 5), and in-person teams that deliver ballots directly to patients (n = 18). Documented barriers in these processes nationwide include unavailable online information (n = 11), restrictions mandating agents to be family members (n = 7), physician affidavits or signatures (n = 9), and notary or witness signature requirements (n = 15). For the November 2020 presidential election, 12 states expanded absentee eligibility to allow COVID-19 as a reason to request an absentee ballot, and 18 states mailed absentee ballot applications or absentee ballots to all registered voters. CONCLUSION: While 39 states operate emergency absentee voting processes for hospitalized voters, there are considerable areas for improvement and heterogeneity in guidelines for these protocols. For future election cycles, information on emergency voting and broader election reforms due to COVID-19 may be useful for emergency providers and patients alike to improve the democratic participation of voters experiencing illness.

Practice structure and quality improvement activities among emergency departments in the Emergency Quality (E-QUAL) Network.

OBJECTIVES: Little academic investigation has been done to describe emergency department (ED) practice structure and quality improvement activities. Our objective was to describe staffing, payment mechanisms, and quality improvement activities among EDs in a nationwide quality improvement network and also stratify results to descriptively compare (1) single- versus multi-site EDs and (2) small-group versus large-group EDs. METHODS: Observational study examining EDs that completed activities for the 2018 wave of the Emergency Quality Network (E-QUAL), a voluntary network of EDs nationwide that self-report quality improvement activities. EDs were defined as single-site or multi-site based on self-reported billing practices; additionally, EDs were defined as large-group if they and a majority of other sites with the same group name also identified as multi-site. All other sites were deemed small-group. RESULTS: Data from 377 EDs were included. For staffing, the median number of clinicians was 17 overall (16 single-site; 19 multi-site). For payment, 376 of 377 EDs (99.7%) participated in the Merit-Based Incentive Payment System. Thirty-five EDs (9.2%) participated in a federal alternative payment model, and 19 (5.0%) participated in a commercial alternative payment model. For quality improvement, single- and multi-site EDs reported similar progress on quality improvement strategies; however, small-group EDs reported more advanced quality improvement strategies compared to large-group EDs for 8/10 quality improvement strategies included in a survey (eg, "achieved a formal plan to eliminate waste"). CONCLUSION: Among EDs in E-QUAL, staffing, payment, and quality improvement activities are similar between single- and multi-site EDs. Group-level analysis suggests that practice structure may influence adoption of quality improvement strategies. Future work is needed to further evaluate practice structure and its influence on quality improvement activities and quality.

Association of Display of Patient Photographs in the Electronic Health Record With Wrong-Patient Order Entry Errors.

Importance: Wrong-patient order entry (WPOE) errors have a high potential for harm; these errors are particularly frequent wherever workflows are complex and multitasking and interruptions are common, such as in the emergency department (ED). Previous research shows that interruptive solutions, such as electronic patient verification forms or alerts, can reduce these types of errors but may be time-consuming and cause alert fatigue. Objective: To evaluate whether the use of noninterruptive display of patient photographs in the banner of the electronic health record (EHR) is associated with a decreased rate of WPOE errors. Design, Setting, and Participants: In this cohort study, data collected as part of care for patients visiting the ED of a large tertiary academic urban hospital in Boston, Massachusetts, between July 1, 2017, and June 31, 2019, were analyzed. Exposures: In a quality improvement initiative, the ED staff encouraged patients to have their photographs taken by informing them of the intended safety impact. Main Outcomes and Measures: The rate of WPOE errors (measured using the retract-and-reorder method) for orders placed when the patient's photograph was displayed in the banner of the EHR vs the rate for patients without a photograph displayed. The primary analysis focused on orders placed in the ED; a secondary analysis included orders placed in any care setting. Results: A total of 2 558 746 orders were placed for 71 851 unique patients (mean [SD] age, 49.2 [19.1] years; 42 677 (59.4%) female; 55 109 (76.7%) non-Hispanic). The risk of WPOE errors was significantly lower when the patient's photograph was displayed in the EHR (odds ratio, 0.72; 95% CI, 0.57-0.89). After this risk was adjusted for potential confounders using multivariable logistic regression, the effect size remained essentially the same (odds ratio, 0.57; 95% CI, 0.52-0.61). Risk of error was significantly lower in patients with higher acuity levels and among patients whose race was documented as White. Conclusions and Relevance: This cohort study suggests that displaying patient photographs in the EHR provides decision support functionality for enhancing patient identification and reducing WPOE errors while being noninterruptive with minimal risk of alert fatigue. Successful implementation of such a program in an ED setting involves a modest financial investment and requires appropriate engagement of patients and staff.

Advanced imaging and trends in hospitalizations from the emergency department.

OBJECTIVE: The proportion of US emergency department (ED) visits that lead to hospitalization has declined over time. The degree to which advanced imaging use contributed to this trend is unknown. Our objective was to examine the association between advanced imaging use during ED visits and changes in ED hospitalization rates between 2007-2008 and 2015-2016. METHODS: We analyzed data from the National Hospital Ambulatory Medical Care Survey. The primary outcome was ED hospitalization, including admission to inpatient and observation units and outside transfers. The primary exposure was advanced imaging during the ED visit, including computed tomography, magnetic resonance imaging, and ultrasound. We constructed a survey-weighted multivariable logistic regression with binary outcome of ED hospitalization to examine changes in adjusted hospitalization rates from 2007-2008 to 2015-2016, comparing ED visits with and without advanced imaging. RESULTS: ED patients who received advanced imaging (versus those who did not) were more likely to be 65 years or older (25.3% vs 13.0%), non-Hispanic white (65.3% vs 58.5%), female (58.4% vs 54.1%), and have Medicare (26.5% vs 16.0%). Among ED visits with advanced imaging, adjusted annual hospitalization rate declined from 22.5% in 2007-2008 to 17.3% (adjusted risk ratio [aRR] 0.77; 95% CI 0.68, 0.86) in 2015-2016. In the same periods, among ED visits without advanced imaging, adjusted annual hospitalization rate declined from 14.3% to 11.6% (aRR 0.81; 95% CI 0.73, 0.90). The aRRs between ED visits with and without advanced imaging were not significantly different. CONCLUSION: From 2007-2016, ED visits with advanced imaging did not have a greater reduction in admission rate compared to those without advanced imaging. Our results suggest that increasing advanced imaging use likely had a limited role in the general decline in hospital admissions from EDs. Future research is needed to further validate this finding.

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.

Protocolized emergency department observation care improves quality of ischemic stroke care in Haiti.

INTRODUCTION: In many low-income countries, Emergency Medicine is underdeveloped and faces many operational challenges including emergency department (ED) overcrowding and prolonged patient length of stays (LOS). In high-resource settings, protocolized ED observation unit (EDOU) care reduces LOS while preserving care quality. EDOUs are untested in low-income countries. We evaluate the effect protocolized EDOU care for ischemic stroke on the quality and efficiency of care in Haiti. METHODS: We performed a prospective cohort study of protocolized observation care for ischemic stroke at a Haitian academic hospital between January 2014 and September 2015. We compared patients cared for in the EDOU using the ischemic stroke protocol (study group) to eligible patients cared for before protocol implementation (baseline group), as well as to eligible patients treated after protocol introduction but managed without the EDOU protocol (contemporary reference group). We analysed three quality of care measures: aspirin administration, physical therapy consultation, and swallow evaluation. We also analysed ED and hospital LOS as measures of efficiency. RESULTS: Patients receiving protocolized EDOU care achieved higher care quality compared to the baseline group, with higher rates of aspirin administration (91% v. 17%, p < 0.001), physical therapy consultation (50% v. 9.6%, p < 0.001), and swallow evaluation (36% v. 3.7%, p < 0.001). We observed similar improvements in the study group compared to the contemporary reference group. Most patients (92%) were managed entirely in the ED or EDOU. LOS for non-admitted patients was longer in the study group than the baseline group (28 v. 19 h, p = 0.023). CONCLUSION: Protocolized EDOU care for patients with ischemic stroke in Haiti improved performance on key quality measures but increased LOS, likely due to more interventions. Future studies should examine the aspects of EDOU care are most effective at promoting higher care quality, and if similar results are achievable in patients with other conditions.

Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey.

INTRODUCTION: Emergency departments (ED) in the United States (US) have increasingly taken the central role for the expedited diagnosis and treatment of acute episodic illnesses and exacerbations of chronic diseases, allowing outpatient management to be possible for many conditions that traditionally required hospitalization and inpatient care. The goal of this analysis was to examine the changes in ED care intensity in this context through the changes in ED patient population and ED care provided. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007-2016. Incorporating survey design and weight, we calculated the changes in ED patient characteristics and ED care provided between 2007 and 2016. We also calculated changes in the proportion of visits with low-severity illnesses that may be safely managed at alternative settings. Lastly, we compared ED care received and final ED dispositions by calculating adjusted relative risk (aRR) comparing ED visits in 2007 to 2016, using survey weighted multivariable logistic regression. RESULTS: NHAMCS included 35,490 visits in 2007 and 19,467 visits in 2016, representing 117 million and 146 million ED visits, respectively. Between 2007 and 2016, there was an increase in the proportion of ED patients aged 45-64 (21.0% to 23.6%) and 65-74 (5.9% to 7.5%), while visits with low-severity illnesses decreased from 37.3% to 30.4%. There was a substantial increase in the proportion of Medicaid patients (22.2% to 34.0%) with corresponding decline in the privately insured (36.2% to 28.3%) and the uninsured (15.4% to 8.6%) patients. After adjusting for patient and visit characteristics, there was an increase in the utilization of advanced imaging (aRR 1.29; 95% confidence interval [CI], 1.17-1.41), blood tests (aRR 1.16; 95% CI, 1.10-1.22), urinalysis (aRR 1.22; 95% CI, 1.13-1.31), and visits where the patient received four or more medications (aRR 2.17; 95% CI, 1.88-2.46). Lastly, adjusted hospitalization rates declined (aRR 0.74; 95% CI, 0.64-0.84) while adjusted discharge rates increased (aRR 1.06; 95%CI 1.03-1.08). CONCLUSION: From 2007 to 2016, ED care intensity appears to have increased modestly, including aging of patient population, increased illness severity, and increased resources utilization. The role of increased care intensity in the decline of ED hospitalization rate requires further study.

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.

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.

Can emergency department provider notes help to achieve more dynamic clinical decision support?

OBJECTIVE: Assess whether clinical data were present in emergency department (ED) provider notes at time of order entry for cervical spine (c-spine) imaging that could be used to augment or pre-populate clinical decision support (CDS) attributes. METHODS: This Institutional Review Board-approved retrospective study, performed in a quaternary hospital, included all encounters for adult ED patients seen April 1, 2013-September 30, 2014 for a chief complaint of trauma who received c-spine computed tomography (CT) or x-ray. We assessed proportion of ED encounters with at least 1 c-spine-specific CDS rule attribute in clinical notes available at the time of imaging order and agreement between attributes in clinical notes and data entered into CDS. RESULTS: A portion of the clinical note was submitted before imaging order in 42% (184/438) of encounters reviewed; 59.2% (109/184) of encounters with note portions submitted before imaging order had at least 1 positive CDS attribute identified supporting imaging study appropriateness; 34.8% (64/184) identified exclusion criteria where CDS appropriateness recommendations would not be applicable. 65.8% (121/184) of encounters had either a positive CDS attribute or an exclusion criterion. Concordance of c-spine CDS attributes when present in both notes and CDS was 68.4% (κ = 0.35 95% CI: 0.15-0.56; McNemar P = 0.23). CONCLUSIONS: Clinical notes are an underutilized source of clinical attributes needed for CDS, available in a substantial percentage of encounters at the time of imaging order. Automated pre-population of imaging order requisitions with relevant clinical information extracted from electronic health record provider notes may: (1) improve ordering efficiency by reducing redundant data entry, (2) help improve clinical relevance of CDS alerts, and (3) potentially reduce provider burnout from extraneous alerts.