A Conceptual Model for Episodes of Acute, Unscheduled Care.

We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care. In accordance with this information, we then drafted a preliminary conceptual model and collected stakeholder feedback, using online focus groups and concept mapping. Two technical expert panels reviewed the draft model, examined the stakeholder feedback, and discussed ways the model could be improved. After integrating the experts' comments, we solicited public comment on the model and made final revisions. The final conceptual model includes social and individual determinants of health that influence the incidence of acute illness and injury, factors that affect care-seeking decisions, specific delivery settings where acute care is provided, and outcomes and costs associated with the acute care system. We end with recommendations for how researchers, policymakers, payers, patients, and providers can use the model to identify and prioritize ways to improve acute care delivery.

National Differences in Regional Emergency Department Boarding Times: Are US Emergency Departments Prepared for a Public Health Emergency?

OBJECTIVES: Boarding admitted patients decreases emergency department (ED) capacity to accommodate daily patient surge. Boarding in regional hospitals may decrease the ability to meet community needs during a public health emergency. This study examined differences in regional patient boarding times across the United States and in regions at risk for public health emergencies. METHODS: A retrospective cross-sectional analysis was performed by using 2012 ED visit data from the American Hospital Association (AHA) database and 2012 hospital ED boarding data from the Centers for Medicare and Medicaid Services Hospital Compare database. Hospitals were grouped into hospital referral regions (HRRs). The primary outcome was mean ED boarding time per HRR. Spatial hot spot analysis examined boarding time spatial clustering. RESULTS: A total of 3317 of 4671 (71%) hospitals were included in the study cohort. A total of 45 high-boarding-time HRRs clustered along the East/West coasts and 67 low-boarding-time HRRs clustered in the Midwest/Northern Plains regions. A total of 86% of HRRs at risk for a terrorist event had high boarding times and 36% of HRRs with frequent natural disasters had high boarding times. CONCLUSIONS: Urban, coastal areas have the longest boarding times and are clustered with other high-boarding-time HRRs. Longer boarding times suggest a heightened level of vulnerability and a need to enhance surge capacity because these regions have difficulty meeting daily emergency care demands and are at increased risk for disasters. (Disaster Med Public Health Preparedness. 2016;10:576-582).

Describing Total Population Health: A Review and Critique of Existing Units.

Total population health is a key tenet of health care reform efforts, evident in initiatives such as the National Quality Strategy, shifts toward population-based payments, and community benefit requirements for tax-exempt hospitals. Representing total population health in a way that guides best practices and establishes shared accountability for geographic communities, however, remains a challenge in part because of differences in how stakeholders define populations. To better understand the landscape of potential denominators for population health, this study examined a selection of relevant geographic units. The approach included a comprehensive review of health services and public health research literature as well as recent pertinent health policy documents. Units were characterized based on whether they: exhibit "breadth" of coverage across the whole US population; are "accurate" or grounded in health care utilization patterns; are "actionable" with mechanisms for implementing funding and regulation; and promote "synergism" or effective coordination of public health and health care activities. Although other key components of a total population health unit may exist and no single identified unit possesses all of the aforementioned features, several promising candidates were identified. Specifically, healthcare coalitions link health care and public health domains to care for a geographic community, but their connection to utilization is not empiric and limited funding exists at the coalition level. Although Accountable Care Organizations do not uniformly incorporate public health or facilitate coordination across all payers or providers, they represent an effective mechanism to increase collaboration within health care systems and represent a potential building block to influence total population health.

Early Dialysis and Adverse Outcomes After Hurricane Sandy.

BACKGROUND: Hemodialysis patients have historically experienced diminished access to care and increased adverse outcomes after natural disasters. Although "early dialysis" in advance of a storm is promoted as a best practice, evidence for its effectiveness as a protective measure is lacking. Building on prior work, we examined the relationship between the receipt of dialysis ahead of schedule before the storm (also known as early dialysis) and adverse outcomes of patients with end-stage renal disease in the areas most affected by Hurricane Sandy. STUDY DESIGN: Retrospective cohort analysis, using claims data from the Centers for Medicare & Medicaid Services Datalink Project. SETTING & PARTICIPANTS: Patients receiving long-term hemodialysis in New York City and the state of New Jersey, the areas most affected by Hurricane Sandy. FACTOR: Receipt of early dialysis compared to their usual treatment pattern in the week prior to the storm. OUTCOMES: Emergency department (ED) visits, hospitalizations, and 30-day mortality following the storm. RESULTS: Of 13,836 study patients, 8,256 (60%) received early dialysis. In unadjusted logistic regression models, patients who received early dialysis were found to have lower odds of ED visits (OR, 0.75; 95% CI, 0.63-0.89; P=0.001) and hospitalizations (OR, 0.77; 95% CI, 0.65-0.92; P=0.004) in the week of the storm and similar odds of 30-day mortality (OR, 0.80; 95% CI, 0.58-1.09; P=0.2). In adjusted multivariable logistic regression models, receipt of early dialysis was associated with lower odds of ED visits (OR, 0.80; 95% CI, 0.67-0.96; P=0.01) and hospitalizations (OR, 0.79; 95% CI, 0.66-0.94; P=0.01) in the week of the storm and 30-day mortality (OR, 0.72; 95% CI, 0.52-0.997; P=0.048). LIMITATIONS: Inability to determine which patients were offered early dialysis and declined and whether important unmeasured patient characteristics are associated with receipt of early dialysis. CONCLUSIONS: Patients who received early dialysis had significantly lower odds of having an ED visit and hospitalization in the week of the storm and of dying within 30 days.

State of emergency preparedness for US health insurance plans.

OBJECTIVES: Health insurance plans serve a critical role in public health emergencies, yet little has been published about their collective emergency preparedness practices and policies. We evaluated, on a national scale, the state of health insurance plans' emergency preparedness and policies. STUDY DESIGN: A survey of health insurance plans. METHODS: We queried members of America's Health Insurance Plans, the national trade association representing the health insurance industry, about issues related to emergency preparedness issues: infrastructure, adaptability, connectedness, and best practices. RESULTS: Of 137 health insurance plans queried, 63% responded, representing 190.6 million members and 81% of US plan enrollment. All respondents had emergency plans for business continuity, and most (85%) had infrastructure for emergency teams. Some health plans also have established benchmarks for preparedness (eg, response time). Regarding adaptability, 85% had protocols to extend claim filing time and 71% could temporarily suspend prior medical authorization rules. Regarding connectedness, many plans shared their contingency plans with health officials, but often cited challenges in identifying regulatory agency contacts. Some health insurance plans had specific policies for assisting individuals dependent on durable medical equipment or home healthcare. Many plans (60%) expressed interest in sharing best practices. CONCLUSIONS: Health insurance plans are prioritizing emergency preparedness. We identified 6 policy modifications that health insurance plans could undertake to potentially improve healthcare system preparedness: establishing metrics and benchmarks for emergency preparedness; identifying disaster-specific policy modifications, enhancing stakeholder connectedness, considering digital strategies to enhance communication, improving support and access for special-needs individuals, and developing regular forums for knowledge exchange about emergency preparedness.

Systems for rapidly detecting and treating persons with ebola virus disease--United States.

The U.S. Department of Health and Human Services (HHS), CDC, other U.S. government agencies, the World Health Organization (WHO), and international partners are taking multiple steps to respond to the current Ebola virus disease (Ebola) outbreak in West Africa to reduce its toll there and to reduce the chances of international spread. At the same time, CDC and HHS are working to ensure that persons who have a risk factor for exposure to Ebola and who develop symptoms while in the United States are rapidly identified and isolated, and safely receive treatment. HHS and CDC have actively worked with state and local public health authorities and other partners to accelerate health care preparedness to care for persons under investigation (PUI) for Ebola or with confirmed Ebola. This report describes some of these efforts and their impact.

Dialysis care and death following Hurricane Sandy.

BACKGROUND: Hurricane Sandy affected access to critical health care infrastructure. Patients with end-stage renal disease (ESRD) historically have experienced problems accessing care and adverse outcomes during disasters. STUDY DESIGN: Retrospective cohort study with 2 comparison groups. SETTING & PARTICIPANTS: Using Centers for Medicare & Medicaid Services claims data, we assessed the frequency of early dialysis, emergency department (ED) visits, hospitalizations, and 30-day mortality for patients with ESRD in Sandy-affected areas (study group) and 2 comparison groups: (1) patients with ESRD living in states unaffected by Sandy during the same period and (2) patients with ESRD living in the Sandy-affected region a year prior to the hurricane (October 1, 2011, through October 30, 2011). FACTOR: Regional variation in dialysis care patterns and mortality for patients with ESRD in New York City and the State of New Jersey. MEASUREMENTS: Frequency of early dialysis, ED visits, hospitalizations, and 30-day mortality. RESULTS: Of 13,264 study patients, 59% received early dialysis in 70% of the New York City and New Jersey dialysis facilities. The ED visit rate was 4.1% for the study group compared with 2.6% and 1.7%, respectively, for comparison groups 1 and 2 (both P<0.001). The hospitalization rate for the study group also was significantly higher than that in either comparison group (4.5% vs 3.2% and 3.8%, respectively; P<0.001 and P<0.003). 23% of study group patients who visited the ED received dialysis in the ED compared with 9.3% and 6.3% in comparison groups 1 and 2, respectively (both P<0.001). The 30-day mortality rate for the study group was slightly higher than that for either comparison group (1.83% vs 1.47% and 1.60%, respectively; P<0.001 and P=0.1). LIMITATIONS: Lack of facility level damage and disaster-induced power outage severity data. CONCLUSIONS: Nearly half the study group patients received early dialysis prior to Sandy's landfall. Poststorm increases in ED visits, hospitalizations, and 30-day mortality were found in the study group, but not in the comparison groups.

Should payment policy be changed to allow a wider range of EMS transport options?

The Institute of Medicine and other national organizations have asserted that current payment policies strongly discourage emergency medical services (EMS) providers from transporting selected patients who call 911 to non-ED settings (eg, primary care clinics, mental health centers, dialysis centers) or from treating patients on scene. The limited literature available is consistent with the view that current payment policies incentivize transport of all 911 callers to a hospital ED, even those who might be better managed elsewhere. However, the potential benefits and risks of altering existing policy have not been adequately explored. There are theoretical benefits to encouraging EMS personnel to transport selected patients to alternate settings or even to provide definitive treatment on scene; however, existing evidence is insufficient to confirm the feasibility or safety of such a policy. In light of growing concerns about the high cost of emergency care and heavy use of EDs, assessing EMS transport options should be a high-priority topic for outcomes research.

The state of innovative emergency medical service programs in the United States.

BACKGROUND: The primary objective of this study was to determine how EMS organizations that are piloting patient-centered treatment and transport protocols are approaching the challenges of implementation, reimbursement, and quality assurance. We were particularly interested in determining if these pilot efforts have raised any patient safety concerns. METHODS: We conducted a set of discussions with a small group of key EMS stakeholders regarding the status of pioneering efforts to develop and evaluate innovative approaches to EMS in the United States. RESULTS: We had discussions with 9 EMS agencies to better understand their innovative programs, including: the history of their service policy and procedure for transports that do not require emergency department care; the impact of their innovative program on service costs and/or cost savings; any reimbursement issues or changes; patient safety; patient satisfaction; and overall impression as well as recommendations for other EMS systems considering adoption of this policy. CONCLUSIONS: In general, EMS systems are not reimbursed for service unless the patient is transported to an ED. Spokespersons for all nine sites covered by this project said that this policy creates a powerful disincentive to implementing pilot programs to safely reduce EMS use by directing patients to more appropriate sites of care or proactively treating them in their homes. Even though private and public hospitals and payers typically benefit from these programs, they have been generally reluctant to offer support. This raises serious questions about the long-term viability of these programs.

Giving EMS flexibility in transporting low-acuity patients could generate substantial Medicare savings.

Some Medicare beneficiaries who place 911 calls to request an ambulance might safely be cared for in settings other than the emergency department (ED) at lower cost. Using 2005-09 Medicare claims data and a validated algorithm, we estimated that 12.9-16.2 percent of Medicare-covered 911 emergency medical services (EMS) transports involved conditions that were probably nonemergent or primary care treatable. Among beneficiaries not admitted to the hospital, about 34.5 percent had a low-acuity diagnosis that might have been managed outside the ED. Annual Medicare EMS and ED payments for these patients were approximately $1 billion per year. If Medicare had the flexibility to reimburse EMS for managing selected 911 calls in ways other than transport to an ED, we estimate that the federal government could save $283-$560 million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.

The US emergency care system: meeting everyday acute care needs while being ready for disasters.

The emergency care system is an essential part of the US health care system. In addition to providing acute resuscitation and life- and limb-saving care, the emergency care system provides considerable support to physicians outside the emergency department and serves as an important safety-net provider. In times of disaster, the emergency care system must be able to surge rapidly to accommodate a massive influx of patients, sometimes with little or no notice. Extreme daily demands on the system can promote innovations and adaptations that are invaluable in responding to disasters. However, excessive and inappropriate utilization is wasteful and can diminish "surge capacity" when it is most needed. Certain features of the US health care system have imposed strains on the emergency care system. We explore policy issues related to moving toward an emergency care system that can more effectively meet both individuals' needs for acute care and the broader needs of the community in times of disaster. Strategies for the redesign of the emergency care system must include the active engagement of both patients and the community and a close look at how to align incentives to reward quality and efficiency throughout the health care system.

Simulating changes to emergency care resources to compare system effectiveness.

OBJECTIVE: To apply systems optimization methods to simulate and compare the most effective locations for emergency care resources as measured by access to care. STUDY DESIGN AND SETTING: This study was an optimization analysis of the locations of trauma centers (TCs), helicopter depots (HDs), and severely injured patients in need of time-critical care in select US states. Access was defined as the percentage of injured patients who could reach a level I/II TC within 45 or 60 minutes. Optimal locations were determined by a search algorithm that considered all candidate sites within a set of existing hospitals and airports in finding the best solutions that maximized access. RESULTS: Across a dozen states, existing access to TCs within 60 minutes ranged from 31.1% to 95.6%, with a mean of 71.5%. Access increased from 0.8% to 35.0% after optimal addition of one or two TCs. Access increased from 1.0% to 15.3% after optimal addition of one or two HDs. Relocation of TCs and HDs (optimal removal followed by optimal addition) produced similar results. CONCLUSIONS: Optimal changes to TCs produced greater increases in access to care than optimal changes to HDs although these results varied across states. Systems optimization methods can be used to compare the impacts of different resource configurations and their possible effects on access to care. These methods to determine optimal resource allocation can be applied to many domains, including comparative effectiveness and patient-centered outcomes research.

Disaster preparedness of nationally certified emergency medical services professionals.

OBJECTIVES: During disasters, the public expects that emergency care will be available at a moment's notice. As such, an emergency medical services (EMS) workforce that is trained and prepared for disasters is imperative. The primary objectives of this study were to quantify the amount of individual-level training EMS professionals receive in terrorism and disaster-preparedness, as well as to assess EMS professionals' participation in multiagency disaster drills across the United States. Characteristics of those most likely to have received individual-level training or participated in multiagency disaster drills were explored. The secondary objectives were to assess EMS professional's perception of preparedness and to determine whether the amount of training individuals received was correlated with their perceptions of preparedness. METHODS: A structured survey was administered to nationally certified EMT-Basics and paramedics as part of their 2008 recertification paperwork. Outcome variables included individual-level preparedness training, participation in multiagency disaster drills, and perception of preparedness. Descriptive statistics and logistic regression modeling were used to quantify the amount of training received. Spearman rank correlation coefficients were used to analyze whether training was correlated with an individual's perception of preparedness. RESULTS: There were 46,127 EMS professionals who had the opportunity to complete the recertification questionnaire; 30,570 (66.3%) responded. A complete case analysis was performed on 21,438 respondents. Overall, 19,551 respondents (91.2%) reported receiving at least 1 hour of individual-level preparedness training, and 12,828 respondents (59.8%) reported participating in multiagency disaster drills, in the prior 24 months. Spearman rank correlation coefficients revealed that hours of individual-level preparedness training were significantly correlated with the perception of preparedness. CONCLUSIONS: While areas where EMS should focus attention for improvement were identified, a majority of nationally certified EMT-Basics and paramedics reported participating in both individual and multiagency disaster-preparedness training. A large majority of respondents reported feeling adequately prepared to respond to man-made and natural disasters and the perception of preparedness correlated with hours of training.

Strategies of high-performing paramedic educational programs.

OBJECTIVE: To identify the specific educational strategies used by paramedic educational programs that have attained consistently high success rates on the National Registry of Emergency Medical Technicians (NREMT) examination. METHODS: NREMT data from 2003-2007 were analyzed to identify consistently high-performing paramedic educational programs. Representatives from 12 programs that have maintained a 75% first-attempt pass rate for at least four of five years and had more than 20 graduates per year were invited to participate in a focus group. Using the nominal group technique (NGT), participants were asked to answer the following question: "What are specific strategies that lead to a successful paramedic educational program?" RESULTS: All 12 emergency medical services (EMS) educational programs meeting the eligibility requirements participated. After completing the seven-step NGT process, 12 strategies were identified as leading to a successful paramedic educational program: 1) achieve and maintain national accreditation; 2) maintain high-level entry requirements and prerequisites; 3) provide students with a clear idea of expectations for student success; 4) establish a philosophy and foster a culture that values continuous review and improvement; 5) create your own examinations, lesson plans, presentations, and course materials using multiple current references; 6) emphasize emergency medical technician (EMT)-Basic concepts throughout the class; 7) use frequent case-based classroom scenarios; 8) expose students to as many prehospital advanced life support (ALS) patient contacts as possible, preferably where they are in charge; 9) create and administer valid examinations that have been through a review process (such as qualitative analysis); 10) provide students with frequent detailed feedback regarding their performance (such as formal examination reviews); 11) incorporate critical thinking and problem solving into all testing; and 12) deploy predictive testing with analysis prior to certification. CONCLUSION: Twelve specific strategies were identified by representatives from high-performing paramedic education programs. Further study should be conducted to determine whether implementation of these recommendations would improve program pass rates on the NREMT credentialing examination and improve entry-level paramedic field performance.

Assessing continued cognitive competence among rural emergency medical technicians.

INTRODUCTION: In emergency medical services (EMS), it has been accepted that continued cognitive competency can be impacted through continuing education (CE). OBJECTIVE: The objective of this study was to assess the continued cognitive competence of emergency medical technicians-basic (EMT-Basics) practicing in low-frequency environments. It was hypothesized that an individual's continued cognitive competence would be associated with hours of continuing education and frequency of patient encounters. METHODS: Data collection occurred at two state EMS conferences. These states were selected because they were closely matched on many demographic characteristics. Selection criteria required that participants be currently state-licensed/certified EMT-Basics and in attendance at their respective state conference. Individuals were asked to complete a demographic survey and the National Registry of Emergency Medical Technicians' (NREMT's) computer-adaptive EMT-Basic cognitive examination. The outcome variable for this study was an individual's pass or fail of the cognitive portion of the NREMT-Basic certification examination. Independent variables assessed included number of continuing education hours in the preceding 12 months, call volume in a typical week, gender, and level of education. Multivariable logistic regression was used to identify variables significantly associated with the outcome. RESULTS: There were 127 (53.1%) participants from state A and 112 (46.9%) participants from state B. Overall, 151 (63.2%) individuals met or exceeded the passing standard of the NREMT-Basic cognitive examination, with 90 (70.9%) passing in state A and 61 (54.5%) passing in state B. Individuals reported an average of 48.6 continuing education hours. A clear majority of individuals reported responding to 0 or 1 call in a typical week. A logistic regression model was constructed in which level of education and volunteer status were significantly associated with passing the examination. After adjustment, amount of continuing education and call volume were not significantly associated with passing the NREMT-Basic certification examination. CONCLUSION: This study assessed the cognitive competency of currently state-certified EMT-Basics in a low-frequency practice environment using the current NREMT-Basic cognitive examination. Variables commonly assumed to be associated with continued cognitive competence, hours of CE and practice frequency, were not significantly associated with success on the cognitive examination.

Physician medical oversight in emergency medical services: where are we?

OBJECTIVE: The objective of this study was to quantify the amount of direct contact with medical direction that nationally registered emergency medical services (EMS) professionals receive. The secondary objective was to determine whether differences in medical director contact were associated with work-related characteristics. METHODS: As part of biennial reregistration paperwork, nationally registered EMS professionals reregistering in 2004 were asked to complete a survey regarding medical direction. There were three survey questions asking participants to indicate, on a five-point scale, how often they interacted with their medical director in specific situations (whether the medical director participated in continuing education, met personally to discuss an EMS issue, and was seen at the scene of an EMS call). Individuals were categorized as having limited contact if they had not observed their medical director in any of the above situations for more than six months. All others where categorized as having recent contact. Demographic characteristics were collected and statistical analysis was performed using chi-square. RESULTS: In 2004, 45,173 individuals reregistered, with 28,647 (63%) returning surveys. A complete case analysis was performed, leaving 22,026 (49%) individuals. There were 13,756 (62.5%) individuals who reported having recent medical director contact. A stepwise increase in the percentage of those reporting recent contact was present when comparing the providers' certification levels (emergency medical technician EMT-Basic 47.6%, EMT-Intermediate 62.3%, and EMT-Paramedic 78.5%, p < 0.001). The highest percentage of recent contact was reported by those who worked for a hospital-based service, whereas the lowest percentage was reported by volunteer services (hospital-based 78.8%, county/municipal 70.8%, private 67.6%, military 62.4%, government 61.1%, fire-based 57.0%, and volunteer 50.8% chi(2) = 712.4, p < 0.001). EMS professionals working in urban areas were more likely to report recent contact than those in rural areas (64.9% vs. 59.2%, p < 0.001). CONCLUSION: It has been suggested that EMS professionals benefit from direct contact with a physician medical director. Nearly one-third of participants in this study reported having limited medical director contact. Certification level, service type, and community size were significantly associated with the amount of contact with medical direction.