Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care.

BACKGROUND: Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear. METHODS: Using a commercial and Medicare Advantage claims database, we identified members 19 to 63 years old whose employers exclusively offered low-deductible (≤$500) plans in 1 year, then, at an index date, mandated enrollment in HDHPs (≥$1000) for a subsequent year. We matched them with contemporaneous members whose employers only offered low-deductible plans. Primary outcomes included population rates of index ED visits with a principal diagnosis of nonspecific chest pain, admission during index ED visits, and index ED visits followed by noninvasive cardiac testing within 3 and 30 days, coronary revascularization, and acute myocardial infarction hospitalization within 30 days. We performed a cumulative interrupted time-series analysis, comparing changes in annual outcomes between the HDHP and control groups before and after the index date using aggregate-level segmented regression. Members from higher-poverty neighborhoods were a subgroup of interest. RESULTS: After matching, we included 557 501 members in the HDHP group and 5 861 990 in the control group, with mean ages of 42.0 years, 48% to 49% female, and 67% to 68% non-Hispanic White individuals. Employer-mandated HDHP switches were associated with a relative decrease of 4.3% (95% CI, -5.9 to -2.7; absolute change, -4.5 [95% CI, -6.3 to -2.8] per 10 000 person-years) in nonspecific chest pain ED visits and 11.3% (95% CI, -14.0 to -8.6) decrease (absolute change, -1.7 per 10 000 person-years [95% CI, -2.1 to -1.2]) in visits leading to hospitalization. There was no significant decrease in subsequent noninvasive testing or revascularization procedures. An increase in 30-day acute myocardial infarction admissions was not statistically significant (15.9% [95% CI, -1.0 to 32.7]; absolute change, 0.3 per 10 000 person-years [95% CI, -0.01 to 0.5]) but was significant among members from higher-poverty neighborhoods. CONCLUSIONS: Employer-mandated HDHP switches were associated with decreased nonspecific chest pain ED visits and hospitalization from these ED visits, but no significant change in post-ED cardiac testing. However, HDHP enrollment was associated with increased 30-day acute myocardial infarction admission after ED diagnosis of nonspecific chest pain among members from higher-poverty neighborhoods.

Trends in Diagnostic Imaging Utilization among Medicare and Commercially Insured Adults from 2003 through 2016.

Background Trends in noninvasive diagnostic imaging (NDI) utilization rates have predominantly been reported in Medicare enrollees. To the authors' knowledge, there has been no prior direct comparison of utilization rates between Medicare and commercially insured patients. Purpose To analyze trends in NDI utilization rates by modality, comparing Medicare fee-for-service and commercially insured enrollees. Materials and Methods This study was a retrospective trend analysis of NDI performed between 2003 and 2016 as reported in claims databases for all adults enrolled in fee-for-service Medicare and for roughly 9 million commercially insured patients per year. The commercially insured patients were divided into two populations: those aged 18-44 years and those aged 45-64 years. The same procedure code definitions for NDI were applied to both Medicare and commercial claims, rates were calculated per 1000 enrollees, and trends were reported over time in aggregate followed by modality (CT, MRI, nuclear imaging, echocardiography, US, radiography). Join-point regression was used to model annual rates and to identify statistically significant (P < .05) changes in trends. Results In almost all instances, Medicare enrollees had the highest utilization rate for each modality, followed by commercially insured patients aged 45-64 years, then aged 18-44 years. All three populations showed utilization growth through the mid to late 2000s (images per 1000 enrollees per year for Medicare: 91 [95% confidence interval {CI}: 34, 148]; commercially insured patients aged 45-64 years: 158 [95% CI: 130, 186]; aged 18-44 years: 83 [95% CI: 69, 97]), followed by significant declining trends from the late 2000s through early 2010s (images per 1000 enrollees per year for Medicare: -301 [95% CI: -510, -92]; commercially insured patients aged 45-64 years: -54 [95% CI: -69, -39]; aged 18-44 years: -26 [95% CI: -31, -21]) coinciding with code-bundling events instituted by Medicare (CT, nuclear imaging, echocardiography). There were significant trend changes in modalities without code bundling (MRI, radiography, US), although flat trends mostly were exhibited. After the early 2010s, there were significant trend changes largely showing flat utilization growth. The notable exception was a significant trend change to renewed growth of CT imaging among commercially insured patients aged 45-64 years and Medicare enrollees after 2012, although at half the prior rate (images per 1000 enrollees per year for Medicare: 17 [95% CI: 6, 28]; commercially insured patients aged 45-64 years: 11 [95% CI: 2, 20]). Conclusion Noninvasive diagnostic imaging utilization trends among commercially insured individuals are similar to those in Medicare enrollees, although at lower rates. Earlier rapid growth has ceased and, except for CT, utilization has stabilized since the early 2010s. © RSNA, 2019 See also the editorial by Hentel and Wolk in this issue.

Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy.

OBJECTIVES: To describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered "low-value", and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations. METHODS: We analyzed 2002-2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression. RESULTS: From 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: -3.1%; 95%CI -4.7, -1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: -2.2%; 95%CI -3.0, -1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: -0.6%; 95%CI -2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI -1.9, 2.0]; -0.9% [95%CI -3.1, 1.3]; and -1.2% [95%CI -5.3, 2.9], respectively). CONCLUSIONS: Before and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.

Health Literacy, Individual and Community Engagement, and Cardiovascular Risks and Disparities: JACC: CardioOncology State-of-the-Art Review.

Cardiovascular and cancer outcomes intersect within the realm of cardio-oncology survivorship care, marked by disparities across ethnic, racial, social, and geographical landscapes. Although the clinical community is increasingly aware of this complex issue, effective solutions are trailing. To attain substantial public health impact, examinations of cancer types and cardiovascular risk mitigation require complementary approaches that elicit the patient's perspective, scale it to a population level, and focus on actionable population health interventions. Adopting such a multidisciplinary approach will deepen our understanding of patient awareness, motivation, health literacy, and community resources for addressing the unique challenges of cardio-oncology. Geospatial analysis aids in identifying key communities in need within both granular and broader contexts. In this review, we delineate a pathway that navigates barriers from individual to community levels. Data gleaned from these perspectives are critical in informing interventions that empower individuals within diverse communities and improve cardio-oncology survivorship.

Characteristics of self-triaged emergency department visits by adults with cancer.

OBJECTIVES: Adults with a new diagnosis of cancer frequently visit emergency departments (EDs) for disease- and treatment-related issues, although not exclusively. Many cancer care providers have 24/7 clinician phone triage available, but initial recorded phone messages tend to advise patients to go to the nearest ED if they are "experiencing a medical emergency." It is unclear how well patients triage themselves to the optimal site of care. STUDY DESIGN: Cross-sectional study of tumor registry records (university patients diagnosed 2008-2018 and safety-net patients diagnosed 2012-2018) identifiably linked to electronic health records and a regional health information exchange. METHODS: We geoprocessed addresses to calculate driving time distance from the patient's home to the ED. We used mixed-effects regression to predict the diagnosis code-based severity for ED visits within 6 months of diagnosis, clustering visits within patients and hospitals. RESULTS: A total of 39,498 adults made 38,944 ED visits to 67 different hospitals. Patients self-referred for 85.5% of visits and bypassed a median (IQR) of 13 (4-33) closer EDs. Visits closer to home were not significantly more clinically severe; visits were significantly less severe if the patient self-referred (adjusted odds ratio [AOR], 0.89; 95% CI, 0.81-0.97) or they were on weekends (AOR, 0.93; 95% CI, 0.87-0.99). Reanalyzing within each individual health system also showed similar findings. CONCLUSIONS: Adults with cancer infrequently use available clinician advice before visiting the ED and may use factors other than clinical severity to determine their need for emergency care. Future work should explore the challenges that patients face navigating unplanned acute care, including reasons for underusing existing resources.

Recognizing the emergency department's role in oncologic care: a review of the literature on unplanned acute care.

Background: The global prevalence of cancer is rapidly increasing and will increase the acute care needs of patients with cancer, including emergency department (ED) care. Patients with cancer present to the ED across the cancer care continuum from diagnosis through treatment, survivorship, and end-of-life. This article describes the characteristics and determinants of ED visits, as well as challenges in the effort to define preventable ED visits in this population. Findings: The most recent population-based estimates suggest 4% of all ED visits are cancer-related and roughly two thirds of these ED visits result in hospitalization-a 4-fold higher ED hospitalization rate than the general population. Approximately 44% of cancer patients visit the ED within 1 year of diagnosis, and more often have repeat ED visits within a short time frame, though there is substantial variability across cancer types. Similar patterns of cancer-related ED use are observed internationally across a range of different national payment and health system settings. ED use for patients with cancer likely reflects a complex interaction of individual and contextual factors-including provider behavior, health system characteristics, and health policies-that warrants greater attention in the literature. Conclusions: Given the amount and complexity of cancer care delivered in the emergency setting, future research is recommended to examine specific symptoms associated with cancer-related ED visits, the contextual determinants of ED use, and definitions of preventable ED use specific to patients with cancer.

High-deductible health plans and low-value imaging in the emergency department.

OBJECTIVE: To examine the effect of an employer-mandated switch to high-deductible health plans (HDHP) on emergency department (ED) low-value imaging. DATA SOURCES: Claims data of a large national insurer between 2003 and 2014. STUDY DESIGN: Difference-in-differences analysis with matched control groups. DATA COLLECTION/EXTRACTION METHODS: The primary outcome is low-value imaging during ED visits for syncope, headache, or low back pain. We included members aged 19-63 years whose employers offered only low-deductible (≤$500) plans for one (baseline) year and, in the next (follow-up) year, offered only HDHPs (≥$1000). Contemporaneous members whose employers offered only low-deductible plans for two consecutive years served as controls. The groups were matched by person and employer propensity for HDHP switch, employer size, baseline calendar year, and baseline year quarterly number of total and imaged ED visits for each condition. We modeled the visit-level probability of low-value imaging using multivariable logistic regression with member-clustered standard errors. We also calculated population level monthly cumulative ED visit rates and modeled their trends using generalized linear regression adjusting for serial autocorrelation. PRINCIPAL FINDINGS: After matching, we included 524 998 members in the HDHP group and 5 448 803 in the control group with a mean age of approximately 42 years and 48% female in both groups. On visit-level analyses, there were no significant differential changes in the probability of low-value imaging use in the HDHP and control groups. In population-level analyses, compared with control group members, members who switched to HDHPs experienced a relative decrease of 5.9% (95% CI - 10.3, -1.6) in ED visits for the study conditions and a relative decrease of 5.1% (95%CI -9.6, -0.6) in the subset of ED visits with low-value imaging. CONCLUSION: Though HDHP switches decreased ED utilization, they had no significant effect on low-value imaging use after patients have decided to seek ED care.

Patterns and Results of Triage Advice Before Emergency Department Visits Made by Patients With Cancer.

PURPOSE: Patients with cancer undergoing treatment frequently visit the emergency department (ED) for commonly anticipated complaints (eg, pain, nausea, and vomiting). Nearly all Medicare Oncology Care Model (OCM) participants prioritized ED use reduction, and the OCM requires that patients have 24-hour telephone access to a clinician, but actual reductions in ED visits have been mixed. Little is known about the use of telephone triage for acute care. METHODS: We identified adults aged 18+ years newly diagnosed with cancer, linked to ED visits from a single institution within 6 months after diagnosis, and then analyzed the telephone and secure electronic messages in the preceding 24 hours. We coded interactions to classify the reason for the call, the main ED referrer, and other attempted management. We compared the acuity of patient self-referred versus clinician-referred ED visits by modeling hospitalization and ED visit severity. RESULTS: From 2011 to 2018, 3,247 adults made 5,371 ED visits to the university hospital and self-referred to the ED 58.5% of the time. Clinicians referred to outpatient or oncology urgent care for 10.3% of calls but referred to the ED for 61.3%. Patient self-referred ED visits were likely to be hospitalized (adjusted Odds Ratio [aOR], 0.89, 95% CI, 0.64 to 1.22) and were not more severe (aOR, 0.75, 95% CI, 0.55 to 1.02) than clinician referred. CONCLUSION: Although patients self-referred for six of every 10 ED visits, self-referred visits were not more severe. When patients called for advice, clinicians regularly recommended the ED. More should be done to understand barriers that patients and clinicians experience when trying to access non-ED acute care.

Prior Frequent Emergency Department Use as a Predictor of Emergency Department Visits After a New Cancer Diagnosis.

PURPOSE: To determine whether emergency department (ED) visit history prior to cancer diagnosis is associated with ED visit volume after cancer diagnosis. METHODS: This was a retrospective cohort study of adults (≥ 18 years) with an incident cancer diagnosis (excluding nonmelanoma skin cancers or leukemia) at an academic medical center between 2008 and 2018 and a safety-net hospital between 2012 and 2016. Our primary outcome was the number of ED visits in the first 6 months after cancer diagnosis, modeled using a multivariable negative binomial regression accounting for ED visit history in the 6-12 months preceding cancer diagnosis, electronic health record proxy social determinants of health, and clinical cancer-related characteristics. RESULTS: Among 35,090 patients with cancer (49% female and 50% non-White), 57% had ≥ 1 ED visit in the 6 months immediately following cancer diagnosis and 20% had ≥ 1 ED visit in the 6-12 months prior to cancer diagnosis. The strongest predictor of postdiagnosis ED visits was frequent (≥ 4) prediagnosis ED visits (adjusted incidence rate ratio [aIRR]: 3.68; 95% CI, 3.36 to 4.02). Other covariates associated with greater postdiagnosis ED use included having 1-3 prediagnosis ED visits (aIRR: 1.32; 95% CI, 1.28 to 1.36), Hispanic (aIRR: 1.12; 95% CI, 1.07 to 1.17) and Black (aIRR: 1.21; 95% CI, 1.17 to 1.25) race, homelessness (aIRR: 1.95; 95% CI, 1.73 to 2.20), advanced-stage cancer (aIRR: 1.30; 95% CI, 1.26 to 1.35), and treatment regimens including chemotherapy (aIRR: 1.44; 95% CI, 1.40 to 1.48). CONCLUSION: The strongest independent predictor for ED use after a new cancer diagnosis was frequent ED visits before cancer diagnosis. Efforts to reduce potentially avoidable ED visits among patients with cancer should consider educational initiatives that target heavy prior ED users and offer them alternative ways to seek urgent medical care.

Trainee-Led Intervention to Motivate Resident Physician Voter Registration.

This quality improvement study describes a trainee-led intervention to improve resident physician voter registration for national elections.

Characteristics of Emergency Department Visits and Select Predictors of Hospitalization for Adults With Newly Diagnosed Cancer in a Safety-Net Health System.

PURPOSE: There is little description of emergency department (ED) visits and subsequent hospitalizations among a safety-net cancer population. We characterized patterns of ED visits and explored nonclinical predictors of subsequent hospitalization, including time of ED arrival. PATIENTS AND METHODS: This was a retrospective cohort study of patients with cancer (excluding leukemia and nonmelanoma skin cancer) between 2012 and 2016 at a large county urban safety-net health system. We identified ED visits occurring within 180 days after a cancer diagnosis, along with subsequent hospitalizations (observation stay or inpatient admission). We used mixed-effects multivariable logistic regression to model hospitalization at ED disposition, accounting for variability across patients and emergency physicians. RESULTS: The 9,050 adults with cancer were 77.2% nonwhite and 55.0% female. Nearly one-quarter (24.7%) of patients had advanced-stage cancer at diagnosis, and 9.7% died within 180 days of diagnosis. These patients accrued 11,282 ED visits within 180 days of diagnosis. Most patients had at least one ED visit (57.7%); half (49.9%) occurred during business hours (Monday through Friday, 8:00 am to 4:59 pm), and half (50.4%) resulted in hospitalization. More than half (57.5%) of ED visits were for complaints that included: pain/headache, nausea/vomiting/dehydration, fever, swelling, shortness of breath/cough, and medication refill. Patients were most often discharged home when they arrived between 8:00 am and 11:59 am (adjusted odds ratio for hospitalization, 0.69; 95% CI, 0.56 to 0.84). CONCLUSION: ED visits are common among safety-net patients with newly diagnosed cancer, and hospitalizations may be influenced by nonclinical factors. The majority of ED visits made by adults with newly diagnosed cancer in a safety-net health system could potentially be routed to an alternate site of care, such as a cancer urgent care clinic.

Impact of a Cancer Urgent Care Clinic on Regional Emergency Department Visits.

PURPOSE: Did the creation of an urgent care clinic specifically for patients with cancer affect emergency department visits among adults newly diagnosed with cancer? PATIENTS AND METHODS: We applied an interrupted time series analysis to adjusted monthly emergency department visits made by adults age 18 years or older who were diagnosed with cancer between 2009 and 2016 at a comprehensive cancer center. Cancer registry patients were linked to a longitudinal regional database of emergency department and hospital visits. Because the urgent care clinic was closed on weekends, we took advantage of the natural experiment by comparing weekend visits as a control group. Our primary outcome was emergency department visits within 180 days after a cancer diagnosis, compiled as adjusted monthly rates of emergency department visits per 1,000 patient-months. We analyzed subsequent hospitalizations as a secondary outcome. RESULTS: The rate of weekday emergency department visits was increasing at a rate of 0.43 visits (95% CI, 0.29 to 0.57 visits) per month before May 2012, then fell in half to a rate of 0.19 visits (95% CI, 0.11 to 0.28 visits) per month (P = .007) after the urgent care clinic was established. In contrast, the weekend visit rate was growing at a rate of 0.08 visits (95% CI, -0.03 to 0.19 visits) per month before May 2012 and 0.05 (95% CI, -0.02 to 0.13 visits; P = .533) afterward. By the end of 2016, there were 15.3 fewer monthly weekday emergency department visits than expected (P = .005). Trends in weekday hospitalizations were not significantly changed. CONCLUSION: Although only one in eight emergency department-visiting patients also used the urgent care clinic, the growth rate of emergency department visits fell by half after the urgent care clinic was established.

Small Decline In Low-Value Back Imaging Associated With The 'Choosing Wisely' Campaign, 2012-14.

Choosing Wisely was launched by the American Board of Internal Medicine in April 2012 as a patient- and clinician-targeted campaign to reduce potentially unnecessary "low-value" medical services. The campaign's impact on low- and high-value care beyond its first year is unknown; furthermore, it is unknown whether some patients such as members of consumer-directed health plans and people residing in different US regions have responded more than others. To evaluate the impact of Choosing Wisely, we used commercial insurance claims to track changes in the use of low-value imaging (x-ray, computed tomography, and magnetic resonance imaging) for back pain before and after the campaign began, a period running from 2010 to 2014. We selected back pain imaging because it is a prominent target of Choosing Wisely, which considers it low value except in a minority of cases, because of its relatively high out-of-pocket expense, and the large volume of low back pain visits nationally. We found only a 4 percent relative reduction in low-value back imaging 2.5 years after the start of the campaign and some differences in regional trends, but no differences associated with enrollment in consumer-directed health plans. Our findings highlight the ongoing challenge of reducing unnecessary medical care, even when patients have "skin in the game" under consumer-directed health plans.