Payment Innovation in Emergency Care: A Case for Global Clinician Budgets.

The fee-for-service funding model for US emergency department (ED) clinician groups is increasingly fragile. Traditional fee-for-service payment systems offer no financial incentives to improve quality, address population health, or make value-based clinical decisions. Fee-for-service also does not support maintaining ED capacity to handle peak demand periods. In fee-for-service, clinicians rely heavily on cross-subsidization, where high reimbursement from commercial payors offsets low reimbursement from government payors and the uninsured. Although fee-for-service survived decades of steady cuts in government reimbursement rates, it is increasingly strained because of visit volatility and the effects of the No Surprises Act, which is driving down commercial reimbursement. Financial pressures on ED clinician groups and higher hospital boarding and clinical workloads are increasing workforce attrition. Here, we propose an alternative model to address some of these fundamental issues: an all-payer-funded, voluntary global budget for ED clinician services. If designed and implemented effectively, the model could support robust clinician staffing over the long term, ensure stability in clinical workload, and potentially improve equity in payments. The model could also be combined with population health programs (eg, pre-ED and post-ED telehealth, frequent ED use programs, and other innovations), offering significant payer returns and addressing quality and value. A linked program could also change hospital incentives that contribute to boarding. Strategies exist to test and refine ED clinician global budgets through existing government programs in Maryland and potentially through state-level legislation as a precursor to broader adoption.

How artificial intelligence could transform emergency care.

Artificial intelligence (AI) in healthcare is the ability of a computer to perform tasks typically associated with clinical care (e.g. medical decision-making and documentation). AI will soon be integrated into an increasing number of healthcare applications, including elements of emergency department (ED) care. Here, we describe the basics of AI, various categories of its functions (including machine learning and natural language processing) and review emerging and potential future use-cases for emergency care. For example, AI-assisted symptom checkers could help direct patients to the appropriate setting, models could assist in assigning triage levels, and ambient AI systems could document clinical encounters. AI could also help provide focused summaries of charts, summarize encounters for hand-offs, and create discharge instructions with an appropriate language and reading level. Additional use cases include medical decision making for decision rules, real-time models that predict clinical deterioration or sepsis, and efficient extraction of unstructured data for coding, billing, research, and quality initiatives. We discuss the potential transformative benefits of AI, as well as the concerns regarding its use (e.g. privacy, data accuracy, and the potential for changing the doctor-patient relationship).

Defining Incidental Versus Non-incidental COVID-19 Hospitalizations.

Background Rates of COVID-19 hospitalization are an important measure of the health system burden of severe COVID-19 disease and have been closely followed throughout the pandemic. The highly transmittable, but often less severe, Omicron COVID-19 variant has led to an increase in hospitalizations with incidental COVID-19 diagnoses where COVID-19 is not the primary reason for admission. There is a strong public health need for a measure that is implementable at low cost with standard electronic health record (EHR) datasets that can separate these incidental hospitalizations from non-incidental hospitalizations where COVID-19 is the primary cause or an important contributor. Two crude metrics are in common use. The first uses in-hospital administration of dexamethasone as a marker of non-incidental COVID-19 hospitalizations. The second, used by the United States (US) CDC, relies on a limited set of COVID-19-related diagnoses (i.e., respiratory failure, pneumonia). Both measures likely undercount non-incidental COVID-19 hospitalizations. We therefore developed an improved EHR-based measure that is better able to capture the full range of COVID-19 hospitalizations. Methods We conducted a retrospective study of ED visit data from a national emergency medicine group from April 2020 to August 2023. We assessed the CDC approach, the dexamethasone-based measure, and alternative approaches that rely on co-diagnoses likely to be related to COVID-19, to determine the proportion of non-incidental COVID-19 hospitalizations. Results Of the 153,325 patients diagnosed with COVID-19 at 112 general EDs in 17 US states, and admitted or transferred, our preferred measure classified 108,243 (70.6%) as non-incidental, compared to 71,066 (46.3%) using the dexamethasone measure and 77,399 (50.5%) using the CDC measure. Conclusions Identifying non-incidental COVID-19 hospitalizations using ED administration of dexamethasone or the CDC measure provides substantially lower estimates than our preferred measure.

Reliability of a Measure of Admission Intensity for Emergency Physicians.

STUDY OBJECTIVE: We assess the stability of a measure of emergency department (ED) admission intensity for value-based care programs designed to reduce variation in ED admission rates. Measure stability is important to accurately assess admission rates across sites and among physicians. METHODS: We sampled data from 358 EDs in 41 states (January 2018 to December 2021), separate from sites where the measure was derived. The measure is the ED admission rate per 100 ED visits for 16 clinical conditions and 535 included International Classification of Disease 10 diagnosis codes. We used descriptive plots and multilevel linear probability models to assess stability over time across EDs and among physicians. RESULTS: Across included 3,571 ED-quarters, the average admission rate was 27.6% (95% confidence interval [CI] 26.0% to 28.2%). The between-facility standard deviation was 9.7% (95% CI 9.0% to 10.6%), and the within-facility standard deviation was 3.0% (95% CI 2.95% to 3.10%), with an intraclass correlation coefficient of 0.91. At the physician-quarter level, the average admission rate was 28.3% (95% CI 28.0% to 28.5%) among 7,002 physicians. Relative to their site's mean in each quarter, the between-physician standard deviation was 6.7% (95% CI 6.6% to 6.8%), and the within-physician standard deviation was 5.5% (95% CI 5.5% to 5.6%), with an intraclass correlation coefficient of 0.59. Moreover, 2.9% of physicians were high-admitting in 80%+ of their practice quarters relative to their peers in the same ED and in the same quarter, whereas 3.9% were low-admitting. CONCLUSION: The measure exhibits stability in characterizing ED-level admission rates and reliably identifies high- and low-admitting physicians.

Beyond the Four Walls: The American College of Emergency Physicians 2022 New Practice Models Task Force Report.

Emergency physicians are highly trained to deliver acute unscheduled care. The emergency physician core skillset gained during emergency medicine residency can be applied to many other roles that benefit patients and extend and diversify emergency physician careers. In 2022, the American College of Emergency Physicians (ACEP) convened the New Practice Models Task Force to describe new care models and emergency physician opportunities outside the 4 walls of the emergency department. The Task Force consisted of 21 emergency physicians with broad experience and 2 ACEP staff. Fifty-nine emergency physician roles were identified (21 established clinical roles, 16 emerging clinical roles, 9 established nonclinical roles, and 13 emerging nonclinical roles). A strength-weakness-opportunity-threat (SWOT) analysis was performed for each role. Using the analysis, the Task Force made recommendations for guiding ACEP internal actions, advocacy, education, and research opportunities. Emphasis was placed on urgent care, rural medicine, telehealth/virtual care, mobile integrated health care, home-based services, emergency psychiatry, pain medicine, addiction medicine, and palliative care as roles with high or rising demand that draw on the emergency physician skillset. Advocacy recommendations focused on removing state and federal regulatory and legislative barriers to the expansion of new and emerging roles. Educational recommendations focused on aggregating available resources, developing a centralized resource for career guidance, and new educational content for emerging roles. The Task Force also recommended promoting research on potential advantages (eg, improved outcomes, lower cost) of emergency physicians in certain roles and new care models (eg, emergency physician remote supervision in rural settings).

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic.

STUDY OBJECTIVE: We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022. METHODS: We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states. RESULTS: Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day. CONCLUSION: ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

Estimating the uncertain effect of the COVID pandemic on drug overdoses.

OBJECTIVE: U.S. drug-related overdose deaths and Emergency Department (ED) visits rose in 2020 and again in 2021. Many academic studies and the news media attributed this rise primarily to increased drug use resulting from the societal disruptions related to the coronavirus (COVID-19) pandemic. A competing explanation is that higher overdose deaths and ED visits may have reflected a continuation of pre-pandemic trends in synthetic-opioid deaths, which began to rise in mid-2019. We assess the evidence on whether increases in overdose deaths and ED visits are likely to be related primarily to the COVID-19 pandemic, increased synthetic-opioid use, or some of both. METHODS: We use national data from the Centers for Disease Control and Prevention (CDC) on rolling 12-month drug-related deaths (2015-2021); CDC data on monthly ED visits (2019-September 2020) for EDs in 42 states; and ED visit data for 181 EDs in 24 states staffed by a national ED physician staffing group (January 2016-June 2022). We study drug overdose deaths per 100,000 persons during the pandemic period, and ED visits for drug overdoses, in both cases compared to predicted levels based on pre-pandemic trends. RESULTS: Mortality. National overdose mortality increased from 21/100,000 in 2019 to 26/100,000 in 2020 and 30/100,000 in 2021. The rise in mortality began in mid-to-late half of 2019, and the 2020 increase is well-predicted by models that extrapolate pre-pandemic trends for rolling 12-month mortality to the pandemic period. Placebo analyses (which assume the pandemic started earlier or later than March 2020) do not provide evidence for a change in trend in or soon after March 2020. State-level analyses of actual mortality, relative to mortality predicted based on pre-pandemic trends, show no consistent pattern. The state-level results support state heterogeneity in overdose mortality trends, and do not support the pandemic being a major driver of overdose mortality. ED visits. ED overdose visits rose during our sample period, reflecting a worsening opioid epidemic, but rose at similar rates during the pre-pandemic and pandemic periods. CONCLUSION: The reasons for rising overdose mortality in 2020 and 2021 cannot be definitely determined. We lack a control group and thus cannot assess causation. However, the observed increases can be largely explained by a continuation of pre-pandemic trends toward rising synthetic-opioid deaths, principally fentanyl, that began in mid-to-late 2019. We do not find evidence supporting the pandemic as a major driver of rising mortality. Policymakers need to directly address the synthetic opioid epidemic, and not expect a respite as the pandemic recedes.

The Cost Shifting Economics of United States Emergency Department Professional Services (2016-2019).

STUDY OBJECTIVE: We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care, and falling Medicare and commercial payments. METHODS: We used data from the Nationwide Emergency Department Sample (NEDS), Medicare, Medicaid, Health Care Cost Institute, and surveys to estimate national ED clinician revenue and costs from 2016 to 2019. We compare annual revenue and cost for each payor and calculate foregone revenue, the amount clinicians may have collected had uninsured patients had either Medicaid or commercial insurance. RESULTS: In 576.5 million ED visits (2016 to 2019), 12% were uninsured, 24% were Medicare-insured, 32% Medicaid-insured, 28% were commercially insured, and 4% had another insurance source. Annual ED clinician revenue averaged $23.5 billion versus costs of $22.5 billion. In 2019, ED visits covered by commercial insurance generated $14.3 billion in revenues and cost $6.5 billion. Medicare visits generated $5.3 billion and cost $5.7 billion; Medicaid visits generated $3.3 billion and cost $7 billion. Uninsured ED visits generated $0.5 billion and cost $2.9 billion. The average annual foregone revenue for ED clinicians to treat the uninsured was $2.7 billion. CONCLUSION: Large cost-shifting from commercial insurance cross-subsidizes ED professional services for other patients. This includes the Medicaid-insured, Medicare-insured, and uninsured, all of whom incur ED professional service costs that substantially exceed their revenue. Foregone revenue for treating the uninsured relative to what may have been collected if patients had health insurance is substantial.

Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess.

BACKGROUND: Spinal epidural abscess (SEA) is a rare, catastrophic condition for which diagnostic delays are common. Our national group develops evidence-based guidelines, known as clinical management tools (CMT), to reduce high-risk misdiagnoses. We study whether implementation of our back pain CMT improved SEA diagnostic timeliness and testing rates in the emergency department (ED). METHODS: We conducted a retrospective observational study before and after implementation of a nontraumatic back pain CMT for SEA in a national group. Outcomes included diagnostic timeliness and test utilization. We used regression analysis to compare differences before (January 2016-June 2017) and after (January 2018-December 2019) with 95% confidence intervals (CIs) clustered by facility. We graphed monthly testing rates. RESULTS: In 59 EDs, pre versus post periods included 141,273 (4.8%) versus 192,244 (4.5%) back pain visits and 188 versus 369 SEA visits, respectively. After implementation, SEA visits with prior related visits were unchanged (12.2% vs. 13.3%, difference +1.0%, 95% CI -4.5% to 6.5%). Mean number of days to diagnosis decreased but not significantly (15.2 days vs. 11.9 days, difference -3.3 days, 95% CI -7.1 to 0.6 days). Back pain visits receiving CT (13.7% vs. 21.1%, difference +7.3%, 95% CI 6.1% to 8.6%) and MRI (2.9% vs. 4.4%, difference +1.4%, 95% CI 1.0% to 1.9%) increased. Spine X-rays decreased (22.6% vs. 20.5%, difference 2.1%, 95% CI -4.3% to 0.1%). Back pain visits receiving erythrocyte sedimentation rate or C-reactive protein increased (1.9% vs. 3.5%, difference +1.6%, 95% CI 1.3% to 1.9%). CONCLUSIONS: Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related prior visit or time to SEA diagnosis.

Four- and three-year emergency medicine residency graduates perform similarly in their first year of practice compared to experienced physicians.

INTRODUCTION: United States emergency medicine (EM) post-graduate training programs vary in training length, either 4 or 3 years. However, it is unknown if clinical care by graduates from the two curricula differs in the early post-residency period. METHODS: We performed a retrospective observational study comparing measures of clinical care and practice patterns between new graduates from 4- and 3-year EM programs with experienced new physician hires as a reference group. We included emergency department (ED) encounters from a national EM group (2016-19) between newly hired physicians from 4- and 3- year programs and experienced new hires (>2 years' experience) during their first year of practice with the group. Primary outcomes were at the physician-shift level (patients per hour and relative value units [RVUs] per hour) and encounter-level (72-h return visits with admission/transfer and discharge length of stay [LOS]). Secondary outcomes included discharge opioid prescription rates, test ordering, computer tomography (CT) use, and admission/transfer rate. We compared outcomes using multivariable linear regression models that included patient, shift, and facility-day characteristics, and a facility fixed effect. We hypothesized that experienced new hires would be most efficient, followed by new 4-year graduates and then new 3-year graduates. RESULTS: We included 1,084,085 ED encounters by 4-year graduates (n = 39), 3-year graduates (n = 70), and experienced new hires (n = 476). There were no differences in physician-level and encounter-level primary outcomes except discharge LOS was 10.60 min (2.551, 18.554) longer for 4-year graduates compared to experienced new hires. Secondary outcomes were similar among the three groups except 4- and 3-year new graduates were less likely to prescribe opioids to discharged patients, -3.70% (-5.768, -1.624) and - 3.38% (-5.136, -1.617) compared to experienced new hires. CONCLUSIONS: In this sample, measures of clinical care and practice patterns related to efficiency, safety, and flow were largely similar between the physician groups; however, experienced new hires were more likely to prescribe opioids than new graduates. These results do not support recommending a specific length of residency training in EM.

Evaluation of the Emergency Severity Index in US Emergency Departments for the Rate of Mistriage.

Importance: Accurate emergency department (ED) triage is essential to prioritize the most critically ill patients and distribute resources appropriately. The most used triage system in the US is the Emergency Severity Index (ESI). Objectives: To derive and validate an algorithm to assess the rate of mistriage and to identify characteristics associated with mistriage. Design, Setting, and Participants: This retrospective cohort study created operational definitions for each ESI level that use ED visit electronic health record data to classify encounters as undertriaged, overtriaged, or correctly triaged. These definitions were applied to a retrospective cohort to assess variation in triage accuracy by facility and patient characteristics in 21 EDs within the Kaiser Permanente Northern California (KPNC) health care system. All ED encounters by patients 18 years and older between January 1, 2016, and December 31, 2020, were assessed for eligibility. Encounters with missing ESI or incomplete ED time variables and patients who left against medical advice or without being seen were excluded. Data were analyzed between January 1, 2021, and November 30, 2022. Exposures: Assigned ESI level. Main Outcomes and Measures: Rate of undertriage and overtriage by assigned ESI level based on a mistriage algorithm and patient and visit characteristics associated with undertriage and overtriage. Results: A total of 5 315 176 ED encounters were included. The mean (SD) patient age was 52 (21) years; 44.3% of patients were men and 55.7% were women. In terms of race and ethnicity, 11.1% of participants were Asian, 15.1% were Black, 21.4% were Hispanic, 44.0% were non-Hispanic White, and 8.5% were of other (includes American Indian or Alaska Native, Native Hawaiian or other Pacific Islander, and multiple races or ethnicities), unknown, or missing race or ethnicity. Mistriage occurred in 1 713 260 encounters (32.2%), of which 176 131 (3.3%) were undertriaged and 1 537 129 (28.9%) were overtriaged. The sensitivity of ESI to identify a patient with high-acuity illness (correctly assigning ESI I or II among patients who had a life-stabilizing intervention) was 65.9%. In adjusted analyses, Black patients had a 4.6% (95% CI, 4.3%-4.9%) greater relative risk of overtriage and an 18.5% (95% CI, 16.9%-20.0%) greater relative risk of undertriage compared with White patients, while Black male patients had a 9.9% (95% CI, 9.8%-10.0%) greater relative risk of overtriage and a 41.0% (95% CI, 40.0%-41.9%) greater relative risk of undertriage compared with White female patients. High relative risk of undertriage was found among patients taking high-risk medications (30.3% [95% CI, 28.3%-32.4%]) and those with a greater comorbidity burden (22.4% [95% CI, 20.1%-24.4%]) and recent intensive care unit utilization (36.7% [95% CI, 30.5%-41.4%]). Conclusions and Relevance: In this retrospective cohort study of over 5 million ED encounters, mistriage with ESI was common. Quality improvement should focus on limiting critical undertriage, optimizing resource allocation by patient need, and promoting equity.

Estimated reimbursement impact of COVID-19 on emergency physicians.

BACKGROUND: The delivery and financing of health care services were altered in unprecedented ways by COVID-19 and subsequent policy responses. We estimated reimbursement losses to emergency physicians in 2020 compared to 2019 related to shifting acute care utilization during COVID-19. METHODS: This was an observational analysis of the Clinical Emergency Department Registry (CEDR) and the Nationwide Emergency Department Sample (NEDS). Study sample included all ED visits from a sample of 214 emergency department (ED) sites in the CEDR in 2019 and 2020 as well as all ED visits in the NEDS in 2019. We identified level of service billing code for evaluation and management (E&M) services, insurance payer, and geographic location of ED visits across sites in the CEDR and linked these to fee schedules to estimate total professional reimbursement across sites. Our primary analysis was to estimate reimbursement in 2020 compared to 2019 across the CEDR sites. In our secondary analysis, we linked sites in the CEDR to those in NEDS to estimate nationwide reimbursement. RESULTS: Total E&M reimbursement for emergency physicians in the CEDR was $1.6 billion in 2019 and $1.3 billion in 2020, reflecting a 19.7% decline year over year ($308 million loss). In our secondary analysis, we estimate nationwide losses of $6.6 billion, a -19.4% decline year over year. If emergency physicians had received maximum allowable federal relief funds via CARES Act Phases 1 to 3 (2% of 2019 revenue) this would sum to $680 million (2% of the $34 billion) or 10.3% of the estimated $6.6 billion pandemic-related losses. CONCLUSIONS: Our analyses provide an estimate of the scale of economic impacts of the COVID-19 pandemic. These findings warrant consideration for policymaker relief and future redesign of emergency care financing. Ultimately, the COVID-19 pandemic likely expanded known cracks in the financing of health care into steep fault lines.

Development and Internal Validation of an Emergency Department Admission Intensity Measure Using Data From a National Group.

STUDY OBJECTIVE: We develop and assess variation in an emergency department (ED) admission intensity measure intended for value-based payment models. The measure includes ED diagnoses amenable to evidence-based protocols and where admission decisions vary based on physician discretion. METHODS: Measure International Classification of Diseases (ICD)-10 codes were selected by face validity by 3 emergency physicians using expertise and administrative data. Feedback was sought from a separate technical panel. Using data from a national group (2018 to 2019), we assessed measure stability at the physician and facility level by quarter using descriptive plots, multilevel linear probability models, and intraclass correlation coefficients (ICC). RESULTS: A total of 535 ICD-10 measure codes were selected from 23,590 codes. Across 127 EDs, facility-quarter admission rates averaged 26.1% (95% confidence interval [CI] 24.5 to 27.7). Between- and within-facility standard deviations were 9.2 (95% CI 8.2 to 10.5) and 2.9 (95% CI 2.7 to 3.0), respectively, with an ICC of 0.91. Most ED-quarters (749/961) fell within 2.5% of their facility's average. Among 2,398 physicians, quarterly rates averaged 29.1% (95% CI 28.6 to 29.6). The between- and within-physician standard deviation was 6.3 (95% CI 6.1 to 6.5) and 5.3 (95% CI 5.3 to 5.4), respectively, with an ICC of 0.58; 220 physicians (9.2%) had an admission rate consistently higher than average and 193 (8.0%) consistently lower. CONCLUSION: This set of ICD-10 diagnoses demonstrates face validity and stability for quarterly admission rates at the facility and physician levels. The measure may be useful to monitor facility admission rates in value-based models and reliably identify high and low admitters within facilities to manage admission variation.

Where to start? A two stage residual inclusion approach to estimating influence of the initial provider on health care utilization and costs for low back pain in the US.

BACKGROUND: Diagnostic testing and treatment recommendations can vary when medical care is sought by individuals for low back pain (LBP), leading to variation in quality and costs of care. We examine how the first provider seen by an individual at initial diagnosis of LBP influences downstream utilization and costs. METHODS: Using national private health insurance claims data, individuals age 18 or older were retrospectively assigned to cohorts based on the first provider seen at the index date of LBP diagnosis. Exclusion criteria included individuals with a diagnosis of LBP or any serious medical conditions or an opioid prescription recorded in the 6 months prior to the index date. Outcome measures included use of imaging, back surgery rates, hospitalization rates, emergency department visits, early- and long-term opioid use, and costs (out-of-pocket and total costs of care) twelve months post-index date. We used a two-stage residual inclusion (2SRI) estimation approach comparing copay for the initial provider visit and differential distance as the instrumental variable to reduce selection bias in the choice of first provider, controlling for demographics. RESULTS: Among 3,799,593 individuals, cost and utilization varied considerably based on the first provider seen by the patient. Copay and differential distance provided similar results, with copay preserving a greater sample size. The frequency of early opioid prescription was significantly lower when care began with an acupuncturist or chiropractor, and highest for those who began with an emergency medicine physician or advanced practice registered nurse (APRN). Long-term opioid prescriptions were low across most providers except physical medicine and rehabilitation physicians and APRNs. The frequency and time to serious illness varied little across providers. Total cost of care was lowest when starting with a chiropractor ($5093) or primary care physician ($5660), and highest when starting with an orthopedist ($9434) or acupuncturist ($9205). CONCLUSION: The first provider seen by individuals with LBP was associated with large differences in health care utilization, opioid prescriptions, and cost while there were no differences in delays in diagnosis of serious illness.

Tramadol Use in United States Emergency Departments 2007-2018.

BACKGROUND: Amidst the opioid epidemic, there has been an increasing focus on opioid utilization in U.S. emergency departments (EDs). Compared with other opioids, little is known about the use of tramadol over the past decade. Tramadol has uncertain efficacy and a concerning adverse effect profile compared with traditional opioids. OBJECTIVE: Our aim was to describe trends in tramadol use in U.S. EDs between 2007 and 2018. METHODS: We analyzed the National Hospital Ambulatory Medical Care Survey from 2007 to 2018 to examine ED visits by patients 18 years or older in which tramadol was administered or prescribed. We examined trends in demographics and resource utilization and compared these trends with those of traditional opioids. Survey-weighted analyses were conducted to provide national-level estimates. RESULTS: Between 2007 and 2018, ED visits in which tramadol was used increased 70.6%, from 1.7% of all ED visits in 2007 to 2.9% in 2018. The largest increases were noted among patients aged 55 through 64 years and 65 years and older. Diagnostic resource utilization increased across the study period. Overall opioid utilization during the study period decreased from 28.4% in 2007 to 17.9% in 2018 (p < 0.001). The use of other specific opioids declined or remained stable between 2007 and 2018. CONCLUSIONS: Although the use of traditional opioids decreased from 2007 to 2018, the use of tramadol increased. Increases were largest among older patients, who may be more susceptible to the adverse effects associated with this medication. Further research in the appropriate use of tramadol in the ED setting is warranted.

Healthcare utilization and clinical outcomes after ablation of atrial fibrillation in patients with and without insertable cardiac monitoring.

BACKGROUND: Compared with short-term electrocardiogram (ECG) monitors, insertable cardiac monitors (ICMs) have been shown to increase atrial fibrillation (AF) detection rates and the opportunity to treat recurrent AF in patients postablation. OBJECTIVE: To examine healthcare utilization and clinical outcomes following AF ablation, in patients with vs without ICM. METHODS: Retrospective analysis pooling Optum Clinformatics and Medicare Fee-for-service 5% Sample claims databases. Patients with an AF ablation between January 1, 2011, and March 31, 2018 who received an ICM implant within 1 year pre-/postablation were propensity score matched 1:3 to patients without ICM. Outcomes included AF-related healthcare utilization, medication use, and occurrence of composite severe cardiovascular events (stroke / transient ischemic attack, major bleeds, systemic embolism, AF- or heart failure-related hospitalization, or death). RESULTS: A total of 1000 ICM patients and 2998 non-ICM patients were included. During mean follow-up of 33 ± 16 months postablation, ICM patients experienced significantly fewer severe cardiovascular events (1.09 ± 2.22 vs 1.37 ± 4.19, P = .008) and associated costs ($20,757 vs $29,106, P = .0005). ICM patients had a greater number of AF-related clinic visits (16.8 vs 11.6 visits, P < .0001) and were more likely to receive a repeat ablation (38.7% vs 32.4%, P = .0003). Total all-cause costs during follow-up were not statistically different. Discontinuation of oral anticoagulation was higher in ICM patients at 1 year (44% vs 31%, P < .0001) and 2 years (73% vs 64%, P = .0012). CONCLUSION: A shift from acute, reactive care to routine outpatient management was observed in patients with long-term ECG monitoring. Results suggest closer patient management in patients with long-term monitoring after an AF ablation and an improvement in outcomes, at similar overall cost.