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1.
Am J Emerg Med ; 2020 Jan 17.
Artículo en Inglés | MEDLINE | ID: mdl-32014376

RESUMEN

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.

2.
Med Care ; 2020 Jan 29.
Artículo en Inglés | MEDLINE | ID: mdl-32000172

RESUMEN

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.

3.
Ann Emerg Med ; 2020 Jan 20.
Artículo en Inglés | MEDLINE | ID: mdl-31973914

RESUMEN

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.

4.
Ann Emerg Med ; 75(1): 13-17, 2020 Jan.
Artículo en Inglés | MEDLINE | ID: mdl-31229387

RESUMEN

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.

5.
JAMA Netw Open ; 2(9): e1911139, 2019 Sep 04.
Artículo en Inglés | MEDLINE | ID: mdl-31517962

RESUMEN

Importance: The accuracy of mortality assessment by emergency clinicians is unknown and may affect subsequent medical decision-making. Objective: To determine the association of the question, "Would you be surprised if your patient died in the next one month?" (known as the surprise question) asked of emergency clinicians with actual 1-month mortality among undifferentiated older adults who visited the emergency department (ED). Design, Setting, and Participants: This prospective cohort study at a single academic medical center in Portland, Maine, included consecutive patients 65 years or older who received care in the ED and were subsequently admitted to the hospital from January 1, 2014, to December 31, 2015. Data analyses were conducted from January 2018 to March 2019. Exposures: Treating emergency clinicians were required to answer the surprise question, "Would you be surprised if your patient died in the next one month?" in the electronic medical record when placing a bed request for all patients who were being admitted to the hospital. Main Outcomes and Measures: The primary outcome was mortality at 1 month, assessed from the National Death Index. The secondary outcomes included accuracies of responses by both emergency clinicians and admitting internal medicine clinicians to the surprise question in identifying older patients with high 6-month and 12-month mortality. Results: The full cohort included 10 737 older adults (mean [SD] age, 75.9 [8.8] years; 5532 [52%] women; 10 157 [94.6%] white) in 16 223 visits treated in the ED and admitted to the hospital. There were 5132 patients (31.6%) with a Charlson Comorbidity Index score of 2 or more. Mortality rates were 8.3% at 1 month, 17.2% at 6 months, and 22.5% at 12 months. Emergency clinicians stated that they would not be surprised if the patient died in the next month for 2104 patients (19.6%). In multivariable analysis controlling for age, sex, race, admission diagnosis, and comorbid conditions, the odds of death at 1 month were higher in patients for whom clinicians answered that they would not be surprised if the patient died in the next 1 month compared with patients for whom clinicians answered that they would be surprised if the patient died in the next 1 month (odds ratio, 2.4 [95% CI, 2.2-2.7]; P < .001). However, the diagnostic test characteristics of the surprise question were poor (sensitivity, 20%; specificity, 93%; positive predictive value, 43%; negative predictive value, 82%; accuracy, 78%; area under the receiver operating curve of the multivariable model, 0.73 [95% CI, 0.72-0.74; P < .001]). Conclusions and Relevance: This study found that asking the surprise question of emergency clinicians may be a valuable tool to identify older patients in the ED with a high risk of 1-month mortality. The effect of implementing the surprise question to improve population-level health care for older adults in the ED who are seriously ill remains to be seen.

6.
Pain Med ; 2019 Sep 10.
Artículo en Inglés | MEDLINE | ID: mdl-31502638

RESUMEN

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.

7.
AJR Am J Roentgenol ; 213(3): 637-643, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-31063428

RESUMEN

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.


Asunto(s)
Diagnóstico por Imagen/estadística & datos numéricos , Servicio de Urgencia en Hospital/estadística & datos numéricos , Pautas de la Práctica en Medicina/estadística & datos numéricos , Femenino , Humanos , Masculino , Estudios Retrospectivos , Estados Unidos
8.
J Asthma ; : 1-9, 2019 Jun 12.
Artículo en Inglés | MEDLINE | ID: mdl-31112431

RESUMEN

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.

9.
West J Emerg Med ; 20(3): 472-476, 2019 May.
Artículo en Inglés | MEDLINE | ID: mdl-31123548

RESUMEN

Introduction: Emergency departments (ED) are an important source of care for underserved populations and represent a significant part of the social safety net. In order to explore the effect of freestanding emergency departments (FSED) on access to care for urban underserved populations, we performed a geospatial analysis comparing the proximity of FSEDs and hospital EDs to public transit lines in three United States (U.S.) metropolitan areas: Houston, Denver, and Cleveland. Methods: We used publicly available U.S. Census data, public transportation maps obtained from regional transit authorities, and geocoded FSED and hospital ED locations. Euclidean distance from each FSED and hospital ED to the nearest public transit line was calculated in ArcGIS. We calculated the odds ratio (OR) of an FSED, relative to a hospital ED, being located within 0.5 miles (mi) of a public transit line using logistic regression, adjusting for population density and median household income and with error clustered at the metropolitan statistical area (MSA) level. Results: The median distance from FSEDs to public transit lines was significantly greater than from hospital EDs across all three markets. In Houston, Denver, and Cleveland, the median distance between FSEDs and public transit lines was greater than from hospital EDs by 1.0 mi, 0.2 mi, and 1.6 mi, respectively. The OR of a public transit line being located within 0.5 mi of an FSED, as compared with a hospital ED, across all three MSAs was 0.21 (95% confidence interval [CI], 0.13-0.34) unadjusted and 0.20 (95% CI, 0.11-0.40) adjusted for population density and median household income. Conclusion: In comparison with hospital EDs, FSEDs are located farther from public transit lines and are less likely to be within walking distance of public transportation. These findings suggest that FSEDs are unlikely to directly increase access to care for patients without private means of transportation. Further research is necessary to explore both the direct and indirect impact of FSEDs on access to care, potentially through effects on hospital ED crowding and overall healthcare expenditures, as well as the ultimate role and responsibility of FSEDs in improving access to care for underserved populations.


Asunto(s)
Servicio de Urgencia en Hospital/organización & administración , Accesibilidad a los Servicios de Salud/normas , Transportes , Adulto , Femenino , Geografía , Humanos , Masculino , Área sin Atención Médica , Mejoramiento de la Calidad , Análisis Espacial , Transportes/métodos , Transportes/normas , Estados Unidos
10.
Appl Clin Inform ; 10(2): 189-198, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30895573

RESUMEN

BACKGROUND: When a paucity of clinical information is communicated from ordering physicians to radiologists at the time of radiology order entry, suboptimal imaging interpretations and patient care may result. OBJECTIVES: Compare documentation of relevant clinical information in electronic health record (EHR) provider note to computed tomography (CT) order requisition, prior to ordering of head CT for emergency department (ED) patients presenting with headache. METHODS: In this institutional review board-approved retrospective observational study performed between April 1, 2013 and September 30, 2014 at an adult quaternary academic hospital, we reviewed data from 666 consecutive ED encounters for patients with headaches who received head CT. The primary outcome was the number of concept unique identifiers (CUIs) relating to headache extracted via ontology-based natural language processing from the history of present illness (HPI) section in ED notes compared with the number of concepts obtained from the imaging order requisition. RESULTS: Our analysis was conducted on cases where the HPI note section was completed prior to image order entry, which occurred in 23.1% (154/666) of encounters. For these 154 encounters, the number of CUIs specific to headache per note extracted from the HPI (median = 3, interquartile range [IQR]: 2-4) was significantly greater than the number of CUIs per encounter obtained from the imaging order requisition (median = 1, IQR: 1-2; Wilcoxon signed rank p < 0.0001). Extracted concepts from notes were distinct from order requisition indications in 92.9% (143/154) of cases. CONCLUSION: EHR provider notes are a valuable source of relevant clinical information at the time of imaging test ordering. Automated extraction of clinical information from notes to prepopulate imaging order requisitions may improve communication between ordering physicians and radiologists, enhance efficiency of ordering process by reducing redundant data entry, and may help improve clinical relevance of clinical decision support at the time of order entry, potentially reducing provider burnout from extraneous alerts.

11.
JAMA Netw Open ; 2(2): e187831, 2019 02 01.
Artículo en Inglés | MEDLINE | ID: mdl-30794295

RESUMEN

Importance: Many physician professional organizations have endorsed public policies, such as expanded background checks, to reduce firearm-related injury. It is not known whether physician organizations' political giving aligns with these policy endorsements. Objectives: To compare physician organization-affiliated political action committee (PAC) campaign contributions with US House of Representatives and Senate candidates' stances on firearm safety policies and analyze whether physician organization endorsement of firearm safety policies is associated with contribution patterns. Design, Setting, and Participants: This cross-sectional study compared contributions from the 25 largest physician organization-affiliated PACs during the 2016 election cycle (January 1, 2014, to December 31, 2016) with US House of Representatives and Senate candidate support for firearm regulation. Physician organization endorsement of firearm safety policies was defined by endorsement of the 2015 Firearm-Related Injury and Death in the United States: A Call to Action From 8 Health Professional Organizations and the American Bar Association. Main Outcomes and Measures: Contributions to US House of Representatives and Senate candidates by stance on firearm safety legislation measured by (1) voting history on US Senate Amendment (SA) 4750, which proposed background check expansion; (2) cosponsorship of US House Resolution (HR) 1217, which sought to expand background checks and strengthen the national criminal background check system; and (3) an A rating (vs not A) by the National Rifle Association Political Victory Fund (NRA-PVF), a measure of overall candidate support for firearm regulation. Results: This study examined the 25 largest physician organization-affiliated PACs during the 2016 election cycle. Twenty of 25 PACs (80%) contributed more in total to incumbent Senate candidates who voted against SA 4750 (n = 21) than to those who voted for it (n = 8), and 24 of 25 PACs (96%) contributed more in total to incumbent US House of Representatives candidates who did not cosponsor HR 1217 (n = 227) than to those who cosponsored it (n = 166). A total of 21 of 25 PACs (84%) contributed more total dollars to US House of Representatives and Senate candidates rated A by the NRA-PVF (n = 386) than to those not rated A (n = 546). Twenty-four of 25 PACs (96%) contributed to a greater proportion of candidates rated A by the NRA-PVF than candidates not rated A. Among PACs whose affiliated organizations endorsed the Call to Action, 8 of 9 (89%) supported a greater proportion of candidates rated A by the NRA-PVF than candidates not rated A, whereas 16 of 16 PACs affiliated with nonendorsing organizations supported a greater proportion of candidates rated A by the NRA-PVF. After adjustment for other political factors, the 9 PACs that endorsed the Call to Action had a lower likelihood of donating to NRA-PVF A-rated candidates compared with PACs that did not endorse the Call to Action (odds ratio, 0.76; 95% CI, 0.58-0.99; P = .04). Conclusions and Relevance: Physician organization-affiliated PACs included in this study donated more funds to more US House of Representatives and Senate candidates who oppose firearm safety policies than to candidates in support of such policies. Although endorsement of the Call to Action was associated with a lower likelihood of donating to candidates who oppose firearm safety policies, the overall pattern was not consistent with professional societies' advocacy for firearm safety.


Asunto(s)
Armas de Fuego , Violencia con Armas/prevención & control , Médicos/organización & administración , Política , Sociedades Médicas/organización & administración , Armas de Fuego/economía , Armas de Fuego/legislación & jurisprudencia , Armas de Fuego/estadística & datos numéricos , Humanos , Estados Unidos
12.
Ann Emerg Med ; 74(2): 276-284, 2019 Aug.
Artículo en Inglés | MEDLINE | ID: mdl-30770207

RESUMEN

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.

13.
J Emerg Med ; 56(3): 352-358, 2019 Mar.
Artículo en Inglés | MEDLINE | ID: mdl-30638646

RESUMEN

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.


Asunto(s)
Atención Ambulatoria/organización & administración , Servicio de Urgencia en Hospital/organización & administración , Reembolso de Seguro de Salud/estadística & datos numéricos , Innovación Organizacional , Vigilancia de la Población/métodos , Atención Ambulatoria/economía , Atención Ambulatoria/estadística & datos numéricos , Servicio de Urgencia en Hospital/economía , Servicio de Urgencia en Hospital/estadística & datos numéricos , Humanos , Reembolso de Seguro de Salud/economía , Texas
14.
Ann Emerg Med ; 73(3): 237-247, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30318376

RESUMEN

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.


Asunto(s)
Sobredosis de Droga/prevención & control , Servicio de Urgencia en Hospital/organización & administración , Trastornos Relacionados con Opioides/prevención & control , Atención al Paciente/normas , Pautas de la Práctica en Medicina/normas , Analgésicos Opioides/envenenamiento , Consenso , Humanos , Trastornos Relacionados con Opioides/diagnóstico , Mejoramiento de la Calidad , Estados Unidos
15.
J Rural Health ; 35(4): 490-497, 2019 09.
Artículo en Inglés | MEDLINE | ID: mdl-30488590

RESUMEN

PURPOSE: The Centers for Medicare and Medicaid Services (CMS) and the American College of Emergency Physicians (ACEP) developed national quality measures for emergency department (ED) sepsis care. Like care for many conditions, meeting sepsis quality metrics can vary between settings. We sought to examine and compare sepsis care quality in rural vs urban hospital-based EDs. METHODS: We analyzed data from EDs participating in the national Emergency Quality Network (E-QUAL). We collected preliminary performance data on both the CMS measure (SEP-1) and the ACEP measures via manual chart review. We analyzed SEP-1 data at the hospital level based on existing CMS definitions and analyzed ACEP measure data at the patient level. We report descriptive statistics of performance variation in rural and urban EDs. FINDINGS: Rural EDs comprised 58 of the EDs reporting SEP-1 results and 405 rural patient charts in the manual review. Of sites reporting SEP-1 results, 44% were rural and demonstrated better aggregate SEP-1 bundle adherence than urban EDs (79% vs 71%; P = .049). Both urban and rural hospitals reported high levels of compliance with the ACEP recommended initial actions of obtaining lactate and blood cultures, with urban EDs outperforming rural EDs on metrics of IV fluid administration and antibiotics (74% urban vs 60% rural; P ≤  .001; 91% urban vs 84% rural; P ≤  .001, respectively). CONCLUSIONS: Sepsis care at both rural and urban EDs often achieves success with national metrics. However, performance on individual components of ED sepsis care demonstrates opportunities for improved processes of care at rural EDs.

16.
J Palliat Med ; 22(3): 267-273, 2019 03.
Artículo en Inglés | MEDLINE | ID: mdl-30418094

RESUMEN

BACKGROUND: Most seriously ill older adults visit the emergency department (ED) near the end of life, yet no feasible method exists to empower them to formulate their care goals in this setting. OBJECTIVE: To develop an intervention to empower seriously ill older adults to formulate their future care goals in the ED. DESIGN: Prospective intervention development study. SETTING: In a single, urban, academic ED, we refined the prototype intervention with ED clinicians and patient advisors. We tested the intervention for its acceptability in English-speaking patients ≥65 years old with serious illness or patients whose treating ED clinician answered "No" to the "surprise question" ("would not be surprised if died in the next 12 months"). We excluded patients with advance directives or whose treating ED clinician determined the patient to be inappropriate. MEASUREMENTS: Our primary outcome was perceived acceptability of our intervention. Secondary outcomes included perceived main intent and stated attitude toward future care planning. RESULTS: We refined the intervention with 16 mock clinical encounters of ED clinicians and patient advisors. Then, we administered the refined intervention to 23 patients and conducted semistructured interviews afterward. Mean age of patients was 76 years, 65% were women, and 43% of patients had metastatic cancer. Most participants (n = 17) positively assessed our intervention, identified questions for their doctors, and reflected on how they feel about their future care. CONCLUSION: An intervention to empower seriously ill older adults to understand the importance of future care planning in the ED was developed, and they found it acceptable.

18.
J Patient Saf ; 15(4): e86-e89, 2019 Dec.
Artículo en Inglés | MEDLINE | ID: mdl-30444742

RESUMEN

OBJECTIVES: We sought to analyze the effect of an anonymous morbidity and mortality (M&M) conference on participants' attitudes toward the educational and punitive nature of the conference. We theorized that an anonymous conference might be more educational, less punitive, and would shift analysis of cases toward systems-based analysis and away from individual cognitive errors. METHODS: We implemented an anonymous M&M conference at an academic emergency medicine program. Using a pre-post design, we assessed attitudes toward the educational and punitive nature of the conference as well as the perceived focus on systems versus individual errors analyzed during the conference. Means and standard deviations were compared using a paired t test. RESULTS: Fifteen conferences were held during the study period and 53 cases were presented. Sixty percent of eligible participants (n = 38) completed both the pretest and posttest assessments. There was no difference in the perceived educational value of the conference (4.42 versus 4.37, P = 0.661), but the conference was perceived to be less punitive (2.08 versus 1.76, P = 0.017). There was no difference between the perceived focus of the conference on systems (2.76 versus 2.76, P = 1.00) versus individual (4.21 versus 4.16, P = 0.644) errors. Most participants (59.5%) preferred that the conference remain anonymous. CONCLUSIONS: We assessed the effect of anonymity in our departmental M&M conference for a 7-month period and found no difference in the perceived effect of M&M on the educational nature of the conference but found a small improvement in the punitive nature of the conference.

19.
Crit Pathw Cardiol ; 17(4): 201-207, 2018 12.
Artículo en Inglés | MEDLINE | ID: mdl-30418250

RESUMEN

BACKGROUND: Chest pain of possible cardiac etiology is a leading reason for emergency department (ED) visits and hospitalizations nationwide. Evidence suggests outpatient management is safe and effective for low-risk patients; however, ED admission rates for chest pain vary widely. To identify barriers and facilitators to outpatient management after ED visits, we performed a multicenter qualitative study of key stakeholders. METHODS AND RESULTS: We identified Massachusetts hospitals with below-average admission rates for adult ED chest pain visits from 2010 to 2011. We performed a qualitative case study of 27 stakeholders across 4 hospitals to identify barriers and facilitators to outpatient management. Clinicians cited ability to coordinate follow-up care, including stress testing and cardiology consultation, as key facilitators of ED discharge. When these services are unavailable, or inconsistently available, they present a barrier to outpatient management. Clinicians identified pressure to maintain throughput and the lack of observation units as barriers to ED discharge. At 3 of 4 hospitals without observation units, clinicians did not use clinical protocols to guide the admission decision. At the site with a dedicated ED observation unit, low ED admission rates were attributed to clinician adherence to clinical protocols. CONCLUSIONS: In conclusion, most participants have not adopted protocols focused on reducing variation in ED chest pain admissions. Robust systems to ensure follow-up care after ED visits may reduce admission rates by mitigating the perceived risk of discharging ED patients with chest pain. Greater use of observation protocols may promote adoption of clinical guidelines and reduce admission rates.


Asunto(s)
Dolor en el Pecho/diagnóstico , Servicio de Urgencia en Hospital/estadística & datos numéricos , Admisión del Paciente/tendencias , Investigación Cualitativa , Medición de Riesgo/métodos , Triaje/métodos , Adulto , Dolor en el Pecho/epidemiología , Estudios Transversales , Femenino , Humanos , Incidencia , Masculino , Massachusetts/epidemiología , Persona de Mediana Edad , Estudios Retrospectivos
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