The prehospital and hospital costs of emergency care for frequent ED patients.

INTRODUCTION: Frequent emergency department (ED) use has been identified as a cause of ED overcrowding and increasing health care costs. Studies have examined the expense of frequent patients (FPs) to hospitals but have not added the cost Emergency Medical Services (EMS) to estimate the total cost of this pattern of care. METHODS: Data on 2012 ED visits to a rural Level I Trauma Center and public safety net hospital were collected through a deidentified patient database. Transport data and 2012 Medicare Reimbursement Schedules were used to estimate the cost of EMS transport. Health information, outcomes, and costs were compared to find differences between the FP and non-FP group. RESULTS: This study identified 1242 FPs who visited the ED 5 or more times in 2012. Frequent patients comprised 3.25% of ED patients but accounted for 17% of ED visits and 13.7% of hospital costs. Frequent patients had higher rates of chronic disease, severity scores, and mortality. Frequent patients arrived more often via ambulance and accounted for 32% of total transports at an estimated cost of $2.5-$3.2 million. Hospital costs attributable to FPs were $29.1 million, bringing the total cost of emergency care to $31.6-$32.3 million, approximately $25,000 per patient. CONCLUSIONS: This study demonstrates that the inclusion of a prehospital cost estimate adds approximately 10% to the cost of care for the FP population. In addition to improving care for a sick population of patients, programs that reduce frequent EMS and ED use have the potential to produce a favorable cost benefit to communities and health systems.

Telephone-based reminder to improve safety after percutaneous coronary intervention.

Dual antiplatelet therapy (DAPT) is a class I guideline indication after percutaneous coronary intervention (PCI). Our population is high-risk for low medication adherence. With a multidisciplinary team we developed a telephone-based intervention to improve DAPT adherence post-PCI. Patients undergoing PCI at our center were contacted by nursing staff via telephone at 1 week, 30 days, and 60 days post-procedure. Calls included a reminder of the importance of DAPT and elicited any patient concerns. Concerns were relayed to the team who could take appropriate action. For patients filling their medications at any pharmacies within our closed system the proportion of days covered (PDC) was calculated. These were compared to data for patients undergoing PCI in the seven months prior to program initiation. Information on interventions performed as a result of calls was also collected. During the study period, 452 patients underwent PCI. Of these, 70% were contacted and 244 filled their prescription at our system pharmacies. Twelve-month median PDC was 74%, with 45% of patients having PDC > 80%. There was no significant difference when compared to the group prior to the intervention, median PDC 79% and 50% of patients having PDC > 80%. In 26 patients calls led to interventions, removing barriers that would have otherwise prevented continued adherence. A telephone-based reminder system led to directed interventions in nearly 1 in 10 patients contacted. It was not able to significantly improve PDC when compared to a contemporary sample. This highlights the difficulty in using PDC to detect barriers to adherence.

Internal Medicine Trainee Understanding and Reaction to Out of Pocket Costs.

BACKGROUND: Out-of-pocket costs are a serious barrier to care and drive suboptimal medical therapy. Understanding of these costs can lead to care oriented around the limits they generate. Despite this, there is minimal attention paid to these costs in post-graduate education. OBJECTIVE: To define a potential knowledge gap regarding costs experienced by patients by surveying Internal Medicine residents at our large academic institution. METHODS: We surveyed Internal Medicine residents in spring 2019 about knowledge and practices surrounding patient out-of-pocket costs. Participants answered questions considering their most recent inpatient panel and their clinic patient panel. Familiarity was ranked on a 5-point Likert scale, and for the purposes of presentation, was divided into "Poor" and "Moderate or Better." Non-parametric analysis was used to test differences between outpatients and inpatients and by year of training. RESULTS: Of 159 residents, 109 (67%) responded. Familiarity with patient insurance status was moderate or better in 85%. Reported understanding of costs associated with medications, testing, and clinic visits was less common. Respondents had higher familiarity with out-of-pocket costs for clinic patients compared with inpatients. Knowledge of cost of care was not an often-considered factor in decision making. There was no significant difference in response by year of training. CONCLUSION: Patient out-of-pocket costs are an important dimension of patient care which Internal Medicine Trainees at our institution do not confidently understand or utilize. Improvements in education around this topic may enable more patient-centered care.

Comparison of 1, 2, and 6-Month Readmission Rates in Patients With Acute Myocardial Infarction Directly Admitted to Hospital Versus Transferred From Another Hospital to an Academic Medical Center.

Patients with acute myocardial infarction (AMI) who are transferred are less likely than directly admitted patients to receive outpatient follow-up within 30 days and are more likely to be readmitted. In 2015, we launched a clinic where post-AMI patients (direct admits and transfers) are seen within 1 week of hospital discharge. We compared short- and long-term clinical outcomes of patients who were transferred to patients who were directly admitted to our institution to determine the impact of transfer status on early outpatient follow-up and clinical outcomes. A total of 280 post-AMI patients, 193 direct admissions (69%), and 87 transfers (31%) were referred to the clinic. Clinic attendance was similar between the transferred and the directly admitted patients (91% vs 92%, p = 0.688, respectively). Transferred patients had similar rates of confusion regarding their medical regimen as the directly admitted patients (11% vs 8%, p = 0.393). Compared with directly admitted patients, transferred patients lived farther from the hospital (median distance of 30 vs 48 miles, p <0.0001), were predominately white (77% vs 91%, p = 0.005), and had higher rates of chronic obstructive pulmonary disease (9% vs 17%, p = 0.014). There was no difference in 30- (16% vs 13%, p = 0.562) or 60-day readmission rates (6% vs 8%, p = 0.543) between transferred patients and directly admitted patients. At 6 months, mortality rates were similar (6% vs 4%, p = 0.556). In conclusion, transferred patients who were evaluated early after hospital discharge for acute MI had similar clinical outcomes (including rates of unplanned readmissions) to their directly admitted counterparts.