Where Are All the Specialists? Current Challenges of Integrating Specialty Care Into Population-Based Total Cost of Care Payment Models.

The Centers for Medicare & Medicaid Services Innovation Center (CMMI) has set the goal for 100% of traditional Medicare beneficiaries to be part of an accountable care relationship by 2030. Lack of meaningful financial incentives, intolerable or unpredictable risk, infrastructure costs, patient engagement, voluntary participation, and operational complexity have been noted by the provider and health care delivery community as barriers to participation or reasons for exiting programs. In addition, most piloted and implemented population-based total cost of care (PB-TCOC) payment models have focused on the role of the primary care physician being the accountability (that is, attributable) leader of a patient's multifaceted care team as well as acting as the mayor of the "medical neighborhood," leaving the role of specialty care physicians undefined. Successful provider specialist integration into PB-TCOC models includes meaningful participation of specialists in achieving whole-person, high-value care where all providers are financially motivated to participate; there is unambiguous prospective attribution and clearly defined accountability for each participating party throughout the care journey or episode; there is a known care attribution transition accountability plan; there is actionable, transparent, and timely data available with appropriate data development and basic analytic costs covered; and there is advanced payment to the accountable person or entity for management of the care episode that is part of a longitudinal care plan. Payment models should be created to address the 7 challenges raised here if specialists are to be incented to join TCOC models that achieve CMMI's goal.

Emergency department hospice care pathway associated with decreased ED and hospital length of stay.

INTRODUCTION: While increasing evidence shows that hospice and palliative care interventions in the ED can benefit patients and systems, little exists on the feasibility and effectiveness of identifying patients in the ED who might benefit from hospice care. Our aim was to evaluate the effect of a clinical care pathway on the identification of patients who would benefit from hospice in an academic medical center ED setting. METHODS: We instituted a clinical pathway for ED patients with potential need for or already enrolled in hospice. This pathway was digitally embedded in the electronic health record and made available to ED physicians, APPs and staff in a non-interruptive fashion. Patient and visit characteristics were evaluated for the six months before (05/04/2021-10/4/2021) and after (10/5/2021-05/04/2022) implementation. RESULTS: After pathway implementation, more patients were identified as appropriate for hospice and ED length of stay (LOS) for qualifying patients decreased by a median of 2.9 h. Social work consultation for hospice evaluation increased, and more patients were discharged from the ED with hospice. As more patients were identified with end-of-life care needs, the number of patients admitted to the hospital increased. However, more patients were admitted under observation status, and admission LOS decreased by a median of 18.4 h. CONCLUSION: This non-interruptive, digitally embedded clinical care pathway provided guidance for ED physicians and APPs to initiate hospice referrals. More patients received social work consultation and were identified as hospice eligible. Those patients admitted to the hospital had a decrease in both ED and hospital admission LOS.

Novel Electronic Health Records-Based Consultation Workflow Improves Time to Operating Room for Vascular Surgery Patients in an Acute Setting.

BACKGROUND: Inefficient clinical workflows can have downstream effects of increased costs, poor resource utilization, and worse patient outcomes. The surgical consultation process can be complex with unclear communication, potentially delaying care for patients requiring time-sensitive intervention in an acute setting. A novel electronic health records (EHR)-based workflow was implemented to improve the consultation process. After implementation, we assessed the impact of this initiative in patients requiring vascular surgery consultation. METHODS: An EHR-driven consultation workflow was implemented at a single institution, standardizing the process across all consulting services. This order-initiated workflow automated notification to clinicians of consult requests, communication of patient data, patient addition to consultants' lists, and tracking consult completion. Preimplementation (1/1/2020-1/31/2022) and postimplementation (2/1/2022-12/4/2022) vascular surgery consultation cohorts were compared to evaluate the impact of this initiative on timeliness of care. RESULTS: There were 554 inpatient vascular surgery consultations (255 preimplementation and 299 postimplementation); 45 and 76 consults required surgery before and after implementation, respectively. The novel workflow resulted in placement of a consult note 32 min faster than preimplementation (preimplementation: 462 min, postimplementation: 430 min, P = 0.001) for all vascular surgery consults. Furthermore, vascular surgery patients with ASA class III or IV status requiring an urgent or emergent operation were transported to the operating room 63.3% faster after implementation of the workflow (preimplementation: 284 min, postimplementation: 180 min, P = 0.02). There were no differences in procedure duration, postoperative disposition, or intraoperative complication rates. CONCLUSIONS: We implemented a novel workflow utilizing the EHR to standardize and automate the consultation process in the acute inpatient setting. This institutional initiative significantly improved timeliness of care for vascular surgery patients, including decreased time to operation. Innovations such as this can be further disseminated across shared EHR platforms across institutions, representing a powerful tool to increase the value of care in vascular surgery and healthcare overall.

Differences in cardiac testing resource utilization using two different risk stratification schemes.

OBJECTIVE: Assess whether changing an emergency department (ED) chest pain pathway from utilizing the Thrombolysis in Myocardial Infarction (TIMI) score for risk stratification to an approach utilizing the History, EKG, Age, Risk, Troponin (HEART) score was associated with reductions in healthcare resource utilization. METHODS: A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications evaluated all ED patients with a chest pain encounter from 8/2015 to 7/2019 at a large academic medical center. We included patients age ≥ 18 with negative troponin testing discharged from the ED. Our standardized care pathway utilized TIMI for risk stratification until 09/2017 and HEART thereafter. We evaluated patients undergoing hospital-based cardiac diagnostic testing (CDT), length of stay (LOS), and 30-day Major Adverse Cardiovascular Events (MACE) at the intervention site before and after the pathway change and compared these outcomes to a similar control site within the health system for the difference-in-differences specification. RESULTS: During the study period, 6.3% (450 of 7117) of patients in the TIMI cohort and 7.2% (546 of 7623) in the HEART cohort among 400,965 total ED visits underwent CDT. In a multivariable analysis, transition to the HEART pathway was associated with greater odds of receiving CDT (odds ratio 2.88 [95% CI 1.21 to 6.86]), a reduction in LOS of 34 min (95% CI 2.2 to 67.6), and no significant difference in 30-day MACE. CONCLUSION: The transition from TIMI to HEART was associated with mixed consequences for healthcare resource utilization, including increased CDT but reduced length of stay.

Self-reporting and screening: Data with right-censored, left-censored, and complete observations.

We consider survival data that combine three types of observations: uncensored, right-censored, and left-censored. Such data arises from screening a medical condition, in situations where self-detection arises naturally. Our goal is to estimate the failure-time distribution, based on these three observation types. We propose a novel methodology for distribution estimation using both semiparametric and nonparametric techniques. We then evaluate the performance of these estimators via simulated data. Finally, as a case study, we estimate the patience of patients who arrive at an emergency department and wait for treatment. Three categories of patients are observed: those who leave the system and announce it, and thus their patience time is observed; those who get service and thus their patience time is right-censored by the waiting time; and those who leave the system without announcing it. For this third category, the patients' absence is revealed only when they are called to service, which is after they have already left; formally, their patience time is left-censored. Other applications of our proposed methodology are discussed.

The Case for Virtual Sepsis Surveillance and Intervention.

Study Objective:To determine whether deployment of an integrated virtual sepsis surveillance program could improve time to antibiotics and mortality in a longitudinal cohort of non-present on admission (NPOA) sepsis cases.Methods:We used an uncontrolled pre- and poststudy design to compare time to antibiotics and mortality between a time-based cohort of NPOA sepsis cases separated by the deployment of a virtual sepsis surveillance program.Results:A total of 566 NPOA sepsis cases were included in this study. Three hundred and thirty-five cases compromised the preintervention arm, whereas the postintervention cohort included 231 cases. After deployment of the virtual sepsis surveillance program, median time to antibiotics improved from 92 to 59 min (p < 0.001). Mortality was reduced from 30% to 21% (p = 0.015).Conclusion:Deployment of a virtual sepsis surveillance program resulted in a decreased time to antibiotics and an overall reduction in NPOA sepsis mortality.

Characteristics and Operational Performance of Hospital-affiliated Freestanding Emergency Departments.

BACKGROUND: As there has been increasing pressure on acute care services to redefine how their care is delivered, hospital-affiliated freestanding emergency departments (FREDs) have rapidly expanded in some markets. Little is known about the populations served or the quality of care provided by these facilities. OBJECTIVE: The objective of this study was to compare patient visit characteristics, geographic catchment areas, and operational performance between hospital-affiliated FREDs and hospital-based emergency departments (HEDs). RESEARCH DESIGN: This was a population-based retrospective observational analysis of 19 FREDs and 5 HEDs in a single health system over a 1-year period. We abstracted patient visit data from the electronic health record and supplemented catchment area data with the 2016 American Community Survey. We analyzed lengths of stay using generalized linear models adjusted for age, severity, and insurance status. RESULTS: FREDs had lower proportions of visits from nonwhite patients and more visits from privately insured patients than HEDs, with similar proportions of uninsured patient visits. These trends were mirrored in catchment area analyses. FRED visits were lower acuity, with fewer imaging and laboratory tests performed. The adjusted mean length of stay for discharged patients was 109 minutes for FREDs compared with 169 minutes for HEDs. For admitted or transferred patients, adjusted lengths of stay were 213 minutes at FREDs and 287 minutes at HEDs. CONCLUSIONS: Hospital-affiliated FREDs serve more affluent and less diverse patient populations and geographic communities. Relative to HEDs, they have lower acuity patient visits with fewer tests, and they have shorter lengths of stay, even after adjustment for patient visit characteristics.

Effect of Accountable Care Organizations on Emergency Medicine Payment and Care Redesign: A Qualitative Study.

STUDY OBJECTIVE: Accountable care organizations are provider networks aiming to improve quality while reducing costs for populations. It is unknown how value-based care within accountable care organizations affects emergency medicine care delivery and payment. Our objective was to describe how accountable care has impacted emergency care redesign and payment. METHODS: We performed a qualitative study of accountable care organizations, consisting of semistructured interviews with emergency department (ED) and accountable care organization leaders responsible for strategy, care redesign, and payment. We analyzed transcripts for key themes, using thematic analysis techniques. RESULTS: We performed 22 interviews across 7 accountable care organizations. All sites were enrolled in the Medicare Shared Savings Program; however, sites varied in region and maturity with respect to population health initiatives. Nearly all sites were focused on reducing low-value ED visits, expanding alternate venues for acute unscheduled care, and redesigning care to reduce ED admission rates through expanded care coordination, including programs targeting high-risk populations such as older adults and frequent ED users, telehealth, and expanded use of direct transfer to skilled nursing facilities from the ED. However, there has been no significant reform of payment for emergency medical care within these accountable care organizations. Nearly all informants expressed concern in regard to reduced ED reimbursement, given accountable care organization efforts to reduce ED utilization and increase clinician participation in alternative payment contracts. No participants expressed a clear vision for reforming payment for ED services. CONCLUSION: Care redesign within accountable care organizations has focused on outpatient access and alternatives to hospitalization. However, there has been little influence on emergency medicine payment, which remains fee for service. Evidence-based policy solutions are urgently needed to inform the adoption of value-based payment for acute unscheduled care.

Designing efficient emergency departments: Discrete event simulation of internal-waiting areas and split flow sorting.

OBJECTIVE: Evaluate nine different models, the interaction of three flow models (ESI, intake attending physician, and no split flow) and three physical design typologies (zero, one, and two internal-waiting areas), on Emergency Department (ED) flow and patient-centered metrics. METHODS: Discrete Event Simulation (DES) was used to systematically manipulate flow and physical design. Three base models were developed and validated using ED and patient specific data. Subsequently, systematic manipulations of flow and internal-waiting areas were performed on other models. Five outcomes of interest were tracked - length of stay (LOS), bed utilization rate, door to provider time, left without being seen rate, and number of movements per patient. Models were compared for statistical significance and effect size using ANOVA, and linear and non-linear regression. RESULTS: The shortest LOS (mean 175.2 min) and highest bed utilization rate (5.02 patients/bed/day) were obtained with flow split by an intake attending physician with two internal-waiting areas. These represented improvements of 54 min and 1.48 patients/bed/day over the control model. Two-way ANOVA demonstrated that both physical design and flow type were statistically significant predictors of all outcomes of interest (p < .0001). Depending on flow type, adding one additional internal-waiting area resulted in decreased LOS (range 10.6-21.8 min), increased bed utilization (range 0.23-0.40 patients/bed/day), decreased D2P (range 1.3-4.8 min), and decreased LWBS (0.66%-2.0%). CONCLUSION: Based on a DES model with empirical data from a single institution, combining flow split by an intake attending physician and multiple internal-waiting areas resulted in improved ED operational and patient-centered metrics.

How alternative payment models in emergency medicine can benefit physicians, payers, and patients.

While there has been considerable effort devoted to developing alternative payment models (APMs) for primary care physicians and for episodes of care beginning with inpatient admissions, there has been relatively little attention by payers to developing APMs for specialty ambulatory care, and no efforts to develop APMs that explicitly focus on emergency care. In order to ensure that emergency care is appropriately integrated and valued in future payment models, emergency physicians (EPs) must engage with the stakeholders within the broader health care system. In this article, we describe a framework for the development of APMs for emergency medicine and present four examples of APMs that may be applicable in emergency medicine. A better understanding of how APMs can work in emergency medicine will help EPs develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system.

Implementation of a Front-End Split-Flow Model to Promote Performance in an Urban Academic Emergency Department.

BACKGROUND: In an urban academic emergency department (ED), a front-end split-flow model, which entailed deployment of an attending-physician intake model, implementation of a 16-bed clinic decision unit, expanded point-of-care (POC) testing, and dedicated ED transportation services, was created. METHODS: A retrospective, observational, pre-post intervention comparison study was conducted at a large academic urban hospital with 74,000 ED annual visits that serves as a Level 2 Trauma Center. The new flow model was implemented in April 2013, coincident with the opening of a new ED space. RESULTS: During the six-month pre- (July 2012-December 2012) and postimplementation (July 2013-December 2013) periods, there were 17,307 and 27,443, respectively, walk-in encounters during the intake times. Despite this 59% increase and a 35% increase in overall ED patient census, implementation of the innovative novel process redesign resulted in a clinically meaningful reduction (median minutes pre vs. post and one-year post) in (1) overall length of stay (LOS) for all walk-ins (220 vs. 175 and 140), discharged (216 vs. 170 and 140), and inpatient admissions (249 vs. 217 and 181); (2) door-to-physician time (minutes) (54 vs. 15 and 12); and (3) left without being seen (LWBS) rates (5.5% vs. 0.5% and 0.0%). The left before visit complete (LBVC) rates were 0.8% vs. 1.1% and 0.6%. The average total relative value unit (RVU) per patient discharged from intake was 2.31. During the pre-post analysis periods, no significant increase in reported safety events were identified (10 vs. 9 per 1,000 patient encounters). CONCLUSION: Implementation of a novel multifaceted process redesign including an attending physician-driven intake model had a clinically positive impact on ED flow. Validation of this model should be conducted in other practice settings.

National Trends in Emergency Department Visits by Adults With Mental Health Disorders.

BACKGROUND: Although mental health disorders (MHDs) affect as many as 1 in 4 adults in the U.S., the national trends in emergency department (ED) use for adults who have MHD comorbidities are unknown. OBJECTIVE: To evaluate the role of mental health disorder co-morbidities for adults who use the ED and how this utilization differs by insurance type. METHODS: This is a retrospective analysis of the National Emergency Department Survey (NEDS) dataset of adults 18 to 64 years of age that was conducted from 2006 to 2011. We defined individuals with MHD comorbidities by applying the MHD Clinical Classification Software groupings to any of the 1 to 15 diagnostic fields available in the NEDS. We further evaluated ED visits made for a primary diagnosis of MHD by applying the same aforementioned codes to the primary diagnosis. We constructed ED visit rates using the U.S. Census Bureau's Current Population Survey. We used descriptive statistics and tested for differences in trends in visits and visit rates by payer using an ordinary least squares regression. RESULTS: The number of ED visits increased by 8.6% from 2006 to 2011. The number of ED visits made by adults primarily for MHDs and with MHD comorbidities increased by 20.5% and 53.3%, respectively (p < 0.0001); ED visits made adults without MHDs decreased by 1.1% (p = 0.72) for the same time period. When accounting for the population growth rate, ED visit rates made by adults with MHD comorbidities increased for all insurance types, but decreased for those without MHD comorbidities. CONCLUSION: MHD comorbidities play a significant role in the increasing number of ED visits, regardless of insurance coverage. Additional studies are needed to understand the role of patients with MHDs and ED use.

State laws governing physician assistant practice in the United States and the impact on emergency medicine.

BACKGROUND: Midlevel providers, including physician assistants (PA), have been recommended by some to fill the current inadequate supply of providers nationally, including in emergency medicine. OBJECTIVE: PA practice is governed by state law. We described the differences in qualifications, scope of practice, prescriptive authority, and physician supervision required by individual states for PA practice and describe the impact this may have on emergency medicine. METHODS: A cross-sectional analysis of United States laws governing PA practice by abstraction from each state's public website. State characteristics were collected from the American Academy of Physician Assistants and United States Census websites and dichotomized by median values. RESULTS: Only six states (12%), all of which were larger-population states, required physician review of medical records within 1 week of a PA-only patient encounter. However, one state (Virginia) explicitly required onsite physician presence for PA practice in the emergency department. All states allowed PAs to assist in invasive procedures, but 13 (25%) restricted independent performance. Restriction of this practice was more likely in states with a higher population (38%), lower rural proportion (40%), and lower number of PAs per population (40%). Eleven (22%) states restricted performance of sedation or general anesthesia. An expanded scope of practice for disaster situations was allowed by 24 (47%) states and was more likely in larger population states (62%). All but two states (Florida and Kentucky) allowed PA prescribing of schedule III-V medications, and 37 (73%) allowed prescribing of schedule II medications. CONCLUSIONS: Laws governing PA practice in emergency departments differ by state, but generally allow for a broad scope of practice and limited direct supervision. Smaller, rural states were less likely to have tighter restrictions or oversight.

Characteristics of Medicaid-Covered Emergency Department Visits Made by Nonelderly Adults: A National Study.

BACKGROUND: The Affordable Care Act has added millions of new Medicaid enrollees to the health care system. These patients account for a large proportion of emergency department (ED) utilization. OBJECTIVE: Our aim was to characterize this population and their ED use at a national level. METHODS: We used the 2010 National Hospital Ambulatory Medical Care Survey (NHAMCS) to describe demographics and clinical characteristics of nonelderly adults (≥18 years old and ≤64 years old) with Medicaid-covered ED visits. We defined frequent ED users as individuals who make ≥4 ED visits/year and business hours as 8 am to 5 pm. We used descriptive statistics to describe the epidemiology of Medicaid-covered ED visits. RESULTS: NHAMCS included 21,800 ED visits by nonelderly adults in 2010, of which 5,659 (24.09%) were covered by Medicaid insurance. Most ED visits covered by Medicaid were made by patients who are young (25 and 44 years old) and female (67.95%; 95% confidence interval [CI] 66.00-69.89). A large proportion of the ED visits covered by Medicaid were revisits within 72 h (14.66%; 95% CI 9.13-20.19) and from frequent ED users (32.32%; 95% CI 24.29-40.35). Almost half of all ED visits covered by Medicaid occurred during business hours (45.44%; 95% CI 43.45-47.43). CONCLUSIONS: The vast majority of Medicaid enrollees who used the ED were young females, with a large proportion of visits occurring during business hours. Almost one-third of all visits were from frequent ED users.

National study of health insurance type and reasons for emergency department use.

BACKGROUND: The rates of emergency department (ED) utilization vary substantially by type of health insurance, but the association between health insurance type and patient-reported reasons for seeking ED care is unknown. OBJECTIVE: We evaluated the association between health insurance type and self-perceived acuity or access issues among individuals discharged from the ED. DESIGN, PATIENTS: This was a cross-sectional analysis of the 2011 National Health Interview Survey. Adults whose last ED visit did not result in hospitalization (n = 4,606) were asked structured questions about reasons for seeking ED care. We classified responses as 1) perceived need for immediate evaluation (acuity issues), or 2) barriers to accessing outpatient services (access issues). MAIN MEASURES: We analyzed survey-weighted data using multivariable logistic regression models to test the association between health insurance type and reasons for ED visits, while adjusting for sociodemographic characteristics. KEY RESULTS: Overall, 65.0% (95% CI 63.0-66.9) of adults reported ≥ 1 acuity issue and 78.9% (95% CI 77.3-80.5) reported ≥ 1 access issue. Among those who reported no acuity issue leading to the most recent ED visit, 84.2% reported ≥ 1 access issue. Relative to those with private insurance, adults with Medicaid (OR 1.05; 95% CI 0.79-1.40) and those with Medicare (OR 0.98; 95% CI 0.66-1.47) were similarly likely to seek ED care due to an acuity issue. Adults with Medicaid (OR 1.50; 95% CI 1.06-2.13) and Medicaid + Medicare (dual eligible) (OR 1.94; 95% CI 1.18-3.19) were more likely than those with private insurance to seek ED care for access issues. CONCLUSION: Variability in reasons for seeking ED care among discharged patients by health insurance type may be driven more by lack of access to alternate care, rather than by differences in patient-perceived acuity. Policymakers should focus on increasing access to alternate sites of care, particularly for Medicaid beneficiaries, as well as strategies to increase care coordination that involve ED patients and providers.

Patient satisfaction surveys and quality of care: an information paper.

With passage of the Patient Protection and Affordable Care Act of 2010, payment incentives were created to improve the "value" of health care delivery. Because physicians and physician practices aim to deliver care that is both clinically effective and patient centered, it is important to understand the association between the patient experience and quality health outcomes. Surveys have become a tool with which to quantify the consumer experience. In addition, results of these surveys are playing an increasingly important role in determining hospital payment. Given that the patient experience is being used as a surrogate marker for quality and value of health care delivery, we will review the patient experience-related pay-for-performance programs and effect on emergency medicine, discuss the literature describing the association between quality and the patient-reported experience, and discuss future opportunities for emergency medicine.

Successful Implementation of Workflow-Embedded Clinical Pathways During the COVID 19 Pandemic.

BACKGROUND AND OBJECTIVES: Clinical pathways have been found effective for improving adherence to evidence-based guidelines, thus providing better patient outcomes. As coronavirus disease-2019 (COVID-19) clinical guidance changed rapidly and evolved, a large hospital system in Colorado established clinical pathways within the electronic health record to guide clinical practice and provide the most up-to-date information to frontline providers. METHODS: On March 12, 2020, a system-wide multidisciplinary committee of specialists in emergency medicine, hospital medicine, surgery, intensive care, infectious disease, pharmacy, care management, virtual health, informatics, and primary care was recruited to develop clinical guidelines for COVID-19 patient care based on the limited available evidence and consensus. These guidelines were organized into novel noninterruptive digitally embedded pathways in the electronic health record (Epic Systems, Verona, Wisconsin) and made available to nurses and providers at all sites of care. Pathway utilization data were analyzed from March 14 to December 31, 2020. Retrospective pathway utilization was stratified by each care setting and compared with Colorado hospitalization rates. This project was designated as a quality improvement initiative. RESULTS: Nine unique pathways were developed, including emergency medicine, ambulatory, inpatient, and surgical care guidelines. Pathway data were analyzed from March 14 to December 31, 2020, and showed that COVID-19 clinical pathways were used 21 099 times. Eighty-one percent of pathway utilization occurred in the emergency department setting, and 92.4% applied embedded testing recommendations. A total of 3474 distinct providers employed these pathways for patient care. CONCLUSIONS: Noninterruptive digitally embedded clinical care pathways were broadly utilized during the early part of the COVID-19 pandemic in Colorado and influenced care across many care settings. This clinical guidance was most highly utilized in the emergency department setting. This shows an opportunity to leverage noninterruptive technology at the point of care to guide clinical decision-making and practice.