Identifying opportunities for community EMS fall prevention.

BACKGROUND: Falls are a leading cause of morbidity and mortality among older adults in the United States. Current fall prevention interventions rely on provider referral or enrollment during inpatient admissions and require engagement and independence of the patient. Community emergency medical services (CEMS) are a unique opportunity to rapidly identify older adults at risk for falls and provide proactive fall prevention interventions in the home. We describe the demographics and treatment characteristics of the older adult population most likely to benefit from these interventions. MATERIALS AND METHODS: We linked 2019 Healthcare Cost and Utilization Project Massachusetts State Emergency Department (ED) and State Inpatient Databases with American Hospital Association survey data to query ED encounters and inpatient admissions for adults age ≥55 with ED encounters for fall-related injury between July 1, 2019 and December 31, 2019. Univariable descriptive statistics assessed participant characteristics and bivariable tests of significance compared diagnoses, disposition, and hospital characteristics between older adults with and without an EMS encounter in the six months prior to the presenting fall. RESULTS: Of 66,027 older adults who presented with a fall to a Massachusetts ED in July-December 2019, 7,942 (11%) had a prior encounter with EMS in the preceding six months, most of which included an injury diagnosis (99%). Compared to older adults without previous EMS encounters, those with previous EMS encounters were more often in poorer health (17% vs. 10% with multiple or complex comorbidities, p < 0.001) and of lower socioeconomic status (12% vs. 8% in lowest neighborhood income quartile, p < 0.001; 10% vs. 6% enrolled in Medicaid, p < 0.001) compared to those without a prior EMS encounter. CONCLUSIONS: A significant proportion of older adults presenting to the ED with fall related injury have encounters with EMS in the preceding months. These participants are predisposed to poorer health and economic outcomes worsened by their fall and thus demonstrate a population that would benefit from CEMS fall prevention programs.

Community emergency medical services approaches to fall prevention: a systematic review.

BACKGROUND: Falls are a leading cause of morbidity and mortality among older adults in the USA. Current approaches to fall prevention often rely on referral by primary care providers or enrolment during inpatient admissions. Community emergency medical services (CEMS) present a unique opportunity to rapidly identify older adults at risk for falls and provide fall prevention interventions in the home. In this systematic review, we seek to assess the efficacy and qualitative factors determining success of these programs. METHODS: Studies reporting the outcomes of fall prevention interventions delivered by EMS were identified by searching the electronic databases PubMed, Embase, Web of Science Core Collection, CINAHL and the Cochrane Central Register of Controlled Trials through 11 July 2023. RESULTS: 35 studies including randomised and non-randomised experimental trials, systematic reviews and qualitative research primarily from Western Europe, the USA, Australia and Canada were included in our analysis. Current fall prevention efforts focus heavily on postfall referral of at-risk community members. CEMS fall prevention interventions reduced all-cause and fall-related emergency department encounters, subsequent falls and EMS calls for lift assist. These interventions also improved patient health-related quality of life, independence with activities of daily living, and secondary health outcomes. CONCLUSIONS: CEMS programmes provide an opportunity for direct, proactive fall prevention on the individual level. Addressing barriers to implementation in the context of current emergency medical systems in the USA is the next step toward widespread implementation of these novel fall prevention interventions.

Trends in performance of hospital outpatient procedures and associated 30-day costs among Medicare beneficiaries from 2011 to 2018.

BACKGROUND: United States healthcare has increasingly transitioned to outpatient care delivery. The degree to which Academic Medical Centers (AMCs) have been able to shift surgical procedures from inpatient to outpatient settings despite higher patient complexity is unknown. METHODS: This observational study used a 20% sample of fee-for-service Medicare beneficiaries age 65 and older undergoing eight elective procedures from 2011 to 2018 to model trends in procedure site (hospital outpatient vs. inpatient) and 30-day standardized Medicare costs, overall and by hospital teaching status. RESULTS: Of the 1,222,845 procedures, 15.9% occurred at AMCs. There was a 2.42% per-year adjusted increase (95% CI 2.39%-2.45%; p < .001) in proportion of outpatient hospital procedures, from 68.9% in 2011 to 85.4% in 2018. Adjusted 30-day standardized costs declined from $18,122 to $14,353, (-$560/year, 95% CI -$573 to -$547; p < .001). Patients at AMCs had more chronic conditions and higher predicted annual mortality. AMCs had a lower proportion of outpatient procedures in all years compared to non-AMCs, a difference that was statistically significant but small in magnitude. AMCs had higher costs compared to non-AMCs and a lesser decline over time (p < .001 for the interaction). AMCs and non-AMCs saw a similar decline in 30-day mortality. CONCLUSIONS: There has been a substantial shift toward outpatient procedures among Medicare beneficiaries with a decrease in total 30-day Medicare spending as well as 30-day mortality. Despite a higher complexity population, AMCs shifted procedures to the outpatient hospital setting at a similar rate as non-AMCs. IMPLICATIONS: The trend toward outpatient procedural care and lower spending has been observed broadly across AMCs and non-AMCs, suggesting that Medicare beneficiaries have benefited from more efficient delivery of procedural care across academic and community hospitals.

Operative and Nonoperative Treatment of Humeral Shaft Fractures: A Cost-Effectiveness Analysis.

BACKGROUND: Decision-making with regard to the treatment of humeral shaft fractures remains under debate. The cost-effectiveness of these treatment options has yet to be established. This study aims to compare the cost-effectiveness of operative treatment with that of nonoperative treatment of humeral shaft fractures. METHODS: We developed a decision tree for treatment options. Surgical costs included the ambulatory surgical fee, physician fee, anesthesia fee, and, in the sensitivity analysis, lost wages during recovery. We used the Current Procedural Terminology codes from the American Board of Orthopaedic Surgery to determine physician fees via the U.S. Centers for Medicare & Medicaid Services database. The anesthesia fee was obtained from the national conversion factor and mean operative time for included procedures. We obtained data on mean wages from the U.S. Bureau of Labor and data on weeks missed from a similar study. We reported functional data via the Disabilities of the Arm, Shoulder and Hand (DASH) scores obtained from existing literature. We used rollback analysis and Monte Carlo simulation to determine the cost-effectiveness of each treatment option, presented in dollars per meaningful change in DASH score, utilizing a $50,000 willingness-to-pay (WTP) threshold. RESULTS: The cost per meaningful change in DASH score for operative treatment was $18,857.97 at the 6-month follow-up and $25,756.36 at the 1-year follow-up, by Monte Carlo simulation. Wage loss-inclusive models revealed values that fall even farther below the WTP threshold, making operative management the more cost-effective treatment option compared with nonoperative treatment in both settings. With an upward variation of the nonoperative union rate to 84.17% in the wage-exclusive model and 89.43% in the wage-inclusive model, nonoperative treatment instead became more cost-effective. CONCLUSIONS: Operative management was cost-effective at both 6 months and 1 year, compared with nonoperative treatment, in both models. Operative treatment was found to be even more cost-effective with loss of wages considered, suggesting that an earlier return to baseline function and, thus, return to work are important considerations in making operative treatment the more cost-effective option. LEVEL OF EVIDENCE: Economic and Decision Analysis Level III . See Instructions for Authors for a complete description of levels of evidence.

ACO Spending and Utilization Among Medicare Patients at the End of Life: an Observational Study.

BACKGROUND: End-of-life (EOL) costs constitute a substantial portion of healthcare spending in the USA and have been increasing. ACOs may offer an opportunity to improve quality and curtail EOL spending. OBJECTIVE: To examine whether practices that became ACOs altered spending and utilization at the EOL. DESIGN: Retrospective analysis of Medicare claims. PATIENTS: We assigned patients who died in 2012 and 2015 to an ACO or non-ACO practice. Practices that converted to ACOs in 2013 or 2014 were matched to non-ACOs in the same region. A total of 23,643 ACO patients were matched to 23,643 non-ACO patients. MAIN MEASURES: Using a difference-in-differences model, we examined changes in EOL spending and care utilization after ACO implementation. KEY RESULTS: The introduction of ACOs did not significantly impact overall spending for patients in the last 6 months of life (difference-in-difference (DID) = $192, 95%CI -$841 to $1125, P = 0.72). Changes in spending did not differ between ACO and non-ACO patients across spending categories (inpatient, outpatient, physician services, skilled nursing, home health, hospice). No differences were seen between ACO and non-ACO patients in rates of ED visits, inpatient admissions, ICU admission, mean healthy days at home, and mean hospice days at 180 and 30 days prior to death. However, non-ACO patients had a significantly greater increase in hospice utilization compared to ACO patients at 180 days (DID P-value = 0.02) and 30 days (DID P-value = 0.01) prior to death. CONCLUSIONS: With the exception of hospice care utilization, spending and utilization were not different between ACOs and non-ACO patients at the EOL. Longer follow-up may be necessary to evaluate the impact of ACOs on EOL spending and care.

Adding A Climate Lens To Health Policy In The United States.

Climate change increasingly threatens the ability of the US health care system to deliver safe, effective, and efficient care to the American people. The existing health care system has key vulnerabilities that will grow more problematic as the effects of climate change on Americans' lives become stronger. Thus, health care policy makers must integrate a climate lens as they develop health system interventions. Applying a climate lens means assessing climate change-driven health risks and integrating them into policies and other actions to improve the nation's health. This lens can be applied to rethinking how to take a more population-based approach to health care delivery, prioritize health care system decarbonization and resilience, adapt data infrastructure, develop a climate-ready workforce, and pay for care. Our recommendations outline how to include climate-informed assessments into health care decision making and health policy, ultimately leading to a more resilient and equitable health care system that is better able to meet the needs of patients today and in the future.

Ambulatory Follow-up and Outcomes Among Medicare Beneficiaries After Emergency Department Discharge.

Importance: Ambulatory follow-up care is frequently recommended after an emergency department (ED) visit. However, the frequency with which follow-up actually occurs and the degree to which follow-up is associated with postdischarge outcomes is unknown. Objectives: To examine the frequency and variation in ambulatory follow-up among Medicare beneficiaries discharged from US EDs and the association between ambulatory follow-up and postdischarge outcomes. Design, Setting, and Participants: This cohort study of 9 470 626 ED visits to 4728 US EDs among Medicare beneficiaries aged 65 and older from 2011 to 2016 who survived the ED visit and were discharged to home used Kaplan-Meier curves and proportional hazards regression. Data analysis was conducted from December 2019 to July 2020. Exposures: Ambulatory follow-up after discharge from the ED. Main Outcomes and Measures: Postdischarge mortality, subsequent ED visit, or inpatient hospitalization within 30 days of an index ED visit. Results: The study sample consisted of 9 470 626 index outpatient ED visits to 4684 EDs; most visits (5 776 501 [61.0%]) were among women, and the mean (SD) age of patients was 77.3 (8.4) years. In this sample, the cumulative incidence of ambulatory follow-up was 40.5% (3 822 133 patients) at 7 days and 70.8% (6 662 525 patients) at 30 days, after accounting for censoring and for mortality as a competing risk. Characteristics associated with lower rates of ambulatory follow-up included beneficiary Medicaid eligibility (hazard ratio [HR], 0.77; 95% CI, 0.77-0.78; P < .001), Black race (HR, 0.82; 95% CI, 0.81-0.83; P < .001), and treatment at a rural ED (HR, 0.75; 95% CI, 0.73-0.77; P < .001) in the multivariable regression model. Ambulatory follow-up was associated with lower risk of postdischarge mortality (HR, 0.49; 95% CI, 0.49-0.50; P < .001) but higher risk of subsequent inpatient hospitalization (HR, 1.22; 95% CI, 1.21-1.23; P < .001) and ED visits (HR, 1.01; 95% CI, 1.00-1.01; P < .001), adjusting for visit diagnosis, patient demographic characteristics, and chronic conditions. Conclusions and Relevance: In this cohort study of Medicare beneficiaries discharged from the ED, nearly 30% lacked ambulatory follow-up at 30 days, with variation in follow-up rates by patient and hospital characteristics. Having an ambulatory follow-up visit was associated with higher risk of subsequent hospitalization but lower risk of mortality. Ambulatory care access may be an important driver of clinical outcomes after an ED visit.

Optimizing Endoscope Reprocessing Resources Via Process Flow Queuing Analysis.

The Massachusetts General Hospital (MGH) is merging its older endoscope processing facilities into a single new facility that will enable high-level disinfection of endoscopes for both the ORs and Endoscopy Suite, leveraging economies of scale for improved patient care and optimal use of resources. Finalized resource planning was necessary for the merging of facilities to optimize staffing and make final equipment selections to support the nearly 33,000 annual endoscopy cases. To accomplish this, we employed operations management methodologies, analyzing the physical process flow of scopes throughout the existing Endoscopy Suite and ORs and mapping the future state capacity of the new reprocessing facility. Further, our analysis required the incorporation of historical case and reprocessing volumes in a multi-server queuing model to identify any potential wait times as a result of the new reprocessing cycle. We also performed sensitivity analysis to understand the impact of future case volume growth. We found that our future-state reprocessing facility, given planned capital expenditures for automated endoscope reprocessors (AERs) and pre-processing sinks, could easily accommodate current scope volume well within the necessary pre-cleaning-to-sink reprocessing time limit recommended by manufacturers. Further, in its current planned state, our model suggested that the future endoscope reprocessing suite at MGH could support an increase in volume of at least 90% over the next several years. Our work suggests that with simple mathematical analysis of historic case data, significant changes to a complex perioperative environment can be made with ease while keeping patient safety as the top priority.

Improving Operating Room Efficiency via Reduction and Standardization of Video-Assisted Thoracoscopic Surgery Instrumentation.

Being the economic powerhouses of most large medical centers, operating rooms (ORs) require the highest levels of teamwork, communication, and efficiency in order to optimize patient safety and reduce hospital waste. A major component of OR waste comes from unused surgical instrumentation; instruments that are frequently prepared for procedures but are never touched by the surgical team still require a full reprocessing cycle at the conclusion of the case. Based on our own previous successes in the perioperative domain, in this work we detail an initiative that reduces surgical instrumentation waste of video-assisted thoracoscopic surgery (VATS) procedures by placing thoracotomy conversion instrumentation in a standby location and designing a specific instrument kit to be used solely for VATS cases. Our estimates suggest that this initiative will reduce at least 91,800 pounds of unnecessary surgical instrumentation from cycling through our ORs and reprocessing department annually, resulting in increased OR team communication without sacrificing the highest standard of patient safety.

Communication Patterns in the Perioperative Environment During Epic Electronic Health Record System Implementation.

In April 2016, Massachusetts General Hospital (MGH) went live with the Epic electronic health records (EHR) system, replacing a variety of EHRs that previously existed in different departments throughout the hospital. At the time of implementation, the Vocera® Badge Communication System, a wireless hands-free communication device distributed to perioperative team members, had increased perioperative communication flow and efficiency. As a quality improvement effort to better understand communication patterns during an EHR go-live, we monitored our Vocera call volume and user volume before, during and after our go-live. We noticed that call volume and user volume significantly increased during our immediate go-live period and quickly returned to baseline levels. We also noticed that call volume increased during periods of unplanned EHR downtime long after our immediate go-live period. When planning the implementation of a new EHR, leadership must plan for and support this critical communication need at the time of the go-live and must also be aware of these needs during unplanned downtime.

Implementation of the Vocera Communication System in a Quaternary Perioperative Environment.

In the hospital, fast and efficient communication among clinicians and other employees is paramount to ensure optimal patient care, workflow efficiency, patient safety and patient comfort. The implementation of the wireless Vocera® Badge, a hands-free wearable device distributed to perioperative team members, has increased communication efficiency across the perioperative environment at Massachusetts General Hospital (MGH). This quality improvement project, based upon identical pre- and post-implementation surveys, used qualitative and quantitative analysis to determine if and how the Vocera system affected the timeliness of information flow, ease of communication, and operating room noise levels throughout the perioperative environment. Overall, the system increased the speed of information flow and eased communication between coworkers yet was perceived to have raised the overall noise level in and around the operating rooms (ORs). The perceived increase in noise was outweighed by the closed-loop communication between clinicians. Further education of the system's features in regard to speech recognition and privacy along with expected conversation protocol are necessary to ensure hassle-free communication for all staff.

Antimicrobials, drug discovery, and genome mining.

Over the years, antibiotics have provided an effective treatment for a number of microbial diseases. However recently, there has been an increase in resistant microorganisms that have adapted to our current antibiotics. One of the most dangerous pathogens is methicillin-resistant Staphylococcus aureus (MRSA). With the rise in the cases of MRSA and other resistant pathogens such as vancomycin-resistant Staphylococcus aureus, the need for new antibiotics increases every day. Many challenges face the discovery and development of new antibiotics, making it difficult for these new drugs to reach the market, especially since many of the pharmaceutical companies have stopped searching for antibiotics. With the advent of genome sequencing, new antibiotics are being found by the techniques of genome mining, offering hope for the future.

Responding to aggressive behavior: impact of training on staff members' knowledge and confidence.

The impact of a training program designed to help staff members prevent and effectively manage aggressive behavior was assessed with 109 staff members who worked in services for persons with developmental disabilities. Instruction in distraction and defusion strategies was provided as was nonaggressive physical intervention. We employed both a between- and within-participant design. Results indicated that the training significantly improved participants' knowledge of reactive behavior management and their confidence to work with aggressive individuals.