Simulation-based mastery learning compared to standard education for discussing diagnostic uncertainty with patients in the emergency department: a randomized controlled trial

BACKGROUND

Diagnostic uncertainty occurs frequently in emergency medical care, with more than one-third of patients leaving the emergency department (ED) without a clear diagnosis. Despite this frequency, ED providers are not adequately trained on how to discuss diagnostic uncertainty with these patients, who often leave the ED confused and concerned. To address this training need, we developed the Uncertainty Communication Education Module (UCEM) to teach physicians how to discuss diagnostic uncertainty. The purpose of the study is to evaluate the effectiveness of the UCEM in improving physician communications.

METHODS

The trial is a multicenter, two-arm randomized controlled trial designed to teach communication skills using simulation-based mastery learning (SBML). Resident emergency physicians from two training programs will be randomly assigned to immediate or delayed receipt of the two-part UCEM intervention after completing a baseline standardized patient encounter. The two UCEM components are: 1) a web-based interactive module, and 2) a smart-phone-based game. Both formats teach and reinforce communication skills for patient cases involving diagnostic uncertainty. Following baseline testing, participants in the immediate intervention arm will complete a remote deliberate practice session via a video platform and subsequently return for a second study visit to assess if they have achieved mastery. Participants in the delayed intervention arm will receive access to UCEM and remote deliberate practice after the second study visit. The primary outcome of interest is the proportion of residents in the immediate intervention arm who achieve mastery at the second study visit.

DISCUSSION

Patients' understanding of the care they received has implications for care quality, safety, and patient satisfaction, especially when they are discharged without a definitive diagnosis. Developing a patient-centered diagnostic uncertainty communication strategy will improve safety of acute care discharges. Although use of SBML is a resource intensive educational approach, this trial has been deliberately designed to have a low-resource, scalable intervention that would allow for widespread dissemination and uptake.

TRIAL REGISTRATION

The trial was registered at clinicaltrials.gov (NCT04021771). Registration date: July 16, 2019.

Impact of Emergency Department Tele-intake on Left Without Being Seen and Throughput Metrics

OBJECTIVES

More than 2 million patients present to a U.S. emergency department (ED) annually and leave without being seen (LWBS) due to delays in initiating care. We evaluated whether tele-intake at the time of presentation would reduce LWBS rates and ED throughput measures.

METHODS

We conducted a before-and-after study at an urban community hospital. The intervention was use of a tele-intake physician to triage patients from 11 am to 6 pm, 7 days per week. Tele-intake providers performed a triage history and physical examination, documented findings, and initiated orders in the medical record. We assessed the impact of this program using the domains of the National Quality Forum framework evaluating access, provider experience, and effectiveness of care. The main outcome was 24-hour LWBS rate. Secondary outcomes were overall door to provider and door to disposition times, left without treatment complete (LWTC), left against medical advice (AMA), left without treatment (LWOT), and physician experience. We compared the 6-month tele-intake period to the same period from the prior year (October 1 to April 1, 2017 vs. 2016). Additionally, we conducted a survey of our physicians to assess their experience with the program.

RESULTS

Total ED volume was similar in the before and after periods (19,892 patients vs. 19,646 patients). The 24-hour LWBS rate was reduced from 2.30% (95% confidence interval [CI] = 2.0% to 2.5%) to 1.69% (95% CI = 1.51% to 1.87%; p < 0.001). Overall door to provider time decreased (median = 19 [interquartile range {IQR} = 9 to 38] minutes vs. 16.2 [IQR = 7.8 to 34.3] minutes; p < 0.001), but ED length of stay for all patients (defined as door in to door out time for all patients) minimally increased (median = 184 [IQR = 100 to 292] minutes vs. 184.3 [IQR = 104.4 to 300] minutes; p < 0.001). There was an increase in door to discharge times (median = 146 [IQR = 83 to 231] minutes vs. 148 [IQR = 88.2 to 233.6] minutes; p < 0.001) and door to admit times (median = 330 [IQR = 253 to 432] minutes vs. 357.6 [IQR = 260.3 to 514.5] minutes; p < 0.001). We saw an increase in LWTC (0.59% [95% CI = 0.49% to 0.70%] vs. 1.1% [95% CI = 0.9% to 1.2%]; p < 0.001), but no change in AMA (1.4% [95% CI = 1.2% to 1.6%] vs. 1.6% [95% CI = 1.4% to 1.78%]; p = 0.21) or LWOT (4.3% [95% CI = 4.1% to 4.6%] vs. 4.4% [95% CI = 4.1% to 4.7%]; p = 0.7). Tele-intake providers thought tele-intake added value (12/15, 80%) and allowed them to effectively address medical problems (14/15, 95%), but only (10/15, 67%) thought that it was as good as in-person triage. Of the receiving physicians, most agreed with statements that tele-intake did not interfere with care (19/22, 86%), helped complement care (19/21, 90%), and gave the patient a better experience (19/22, 86%).

CONCLUSIONS

Remote tele-intake provided in an urban community hospital ED reduced LWBS and time to provider but increased LWTC rates and had no impact on LWOT.

Reasons Patients Choose the Emergency Department over Primary Care: a Qualitative Metasynthesis

BACKGROUND

To enhance the acute care delivery system, a comprehensive understanding of the patient's perspectives for seeking care in the emergency department (ED) versus primary care (PC) is necessary.

METHODS

We conducted a qualitative metasynthesis on reasons patients seek care in the ED instead of PC. A comprehensive literature search in PubMed, CINAHL, Psych Info, and Web of Science was completed to identify qualitative studies relevant to the research question. Articles were critically appraised using the McMaster University Critical Review Form for Qualitative Studies. We excluded pediatric articles and nonqualitative and mixed-methods studies. The metasynthesis was completed with an interpretive approach using reciprocal translation analyses.

RESULTS

Nine articles met criteria for inclusion. Eleven themes under four domains were identified. The first domain was acuity of condition that led to the ED visit. In this domain, themes included pain: "it's urgent because it hurts," and concern for severe illness. The second domain was barriers associated with PC, which included difficulty accessing PC when ill: "my doctor said he was booked up and he instructed me to go to the ED." The third domain was related to multiple advantages associated with ED care: "my doctor cannot do X-rays and laboratory tests, while the ED has all the technical support." In this domain, patients also identified 24/7 accessibility of the ED and no need for an immediate copay at the ED as advantageous. The fourth domain included fulfillment of medical needs. Themes in this domain included the alleviation of pain and the perceived expertise of the ED healthcare providers.

CONCLUSIONS

In this qualitative metasynthesis, reasons patients visit the ED over primary care included (1) urgency of the medical condition, (2) barriers to accessing primary care, (3) advantages of the ED, and (4) fulfillment of medical needs and quality of care in the ED.

Identifying Emergency Department Symptom-Based Diagnoses with the Unified Medical Language System

INTRODUCTION

Many patients who are discharged from the emergency department (ED) with a symptom-based discharge diagnosis (SBD) have post-discharge challenges related to lack of a definitive discharge diagnosis and follow-up plan. There is no well-defined method for identifying patients with a SBD without individual chart review. We describe a method for automated identification of SBDs from ICD-10 codes using the Unified Medical Language System (UMLS) Metathesaurus.

METHODS

We mapped discharge diagnosis, with use of ICD-10 codes from a one-month period of ED discharges at an urban, academic ED to UMLS concepts and semantic types. Two physician reviewers independently manually identified all discharge diagnoses consistent with SBDs. We calculated inter-rater reliability for manual review and the sensitivity and specificity for our automated process for identifying SBDs against this "gold standard."

RESULTS

We identified 3642 ED discharges with 1382 unique discharge diagnoses that corresponded to 875 unique ICD-10 codes and 10 UMLS semantic types. Over one third (37.5%, n = 1367) of ED discharges were assigned codes that mapped to the "Sign or Symptom" semantic type. Inter-rater reliability for manual review of SBDs was very good (0.87). Sensitivity and specificity of our automated process for identifying encounters with SBDs were 84.7% and 96.3%, respectively.

CONCLUSION

Use of our automated process to identify ICD-10 codes that classify into the UMLS "Sign or Symptom" semantic type identified the majority of patients with a SBD. While this method needs refinement to increase sensitivity of capture, it has potential to automate an otherwise highly time-consuming process. This novel use of informatics methods can facilitate future research specific to patients with SBDs.

Patient experience and challenges in group concept mapping for clinical research

Background and objective

Group concept mapping (GCM) is a research method that engages stakeholders in generating, structuring and representing ideas around a specific topic or question. GCM has been used with patients to answer questions related to health and disease but little is known about the patient experience as a participant in the process. This paper explores the patient experience participating in GCM as assessed with direct observation and surveys of participants.

Methods

This is a secondary analysis performed within a larger study in which 3 GCM iterations were performed to engage patients in identifying patient-important outcomes for diabetes care. Researchers tracked the frequency and type of assistance required by each participant to complete the sorting and rating steps of GCM. In addition, a 17-question patient experience survey was administered over the telephone to the participants after they had completed the GCM process. Survey questions asked about the personal impact of participating in GCM and the ease of various steps of the GCM process.

Results

Researchers helped patients 92 times during the 3 GCM iterations, most commonly to address software and computer literacy issues, but also with the sorting phase itself. Of the 52 GCM participants, 40 completed the post-GCM survey. Respondents averaged 56 years of age, were 50% female and had an average hemoglobin A1c of 9.1%. Ninety-two percent (n = 37) of respondents felt that they had contributed something important to this research project and 90% (n = 36) agreed or strongly agreed that their efforts would help others with diabetes. Respondents reported that the brainstorming session was less difficult when compared with sorting and rating of statements.

Discussion

Our results suggest that patients find value in participating in GCM. Patients reported less comfort with the sorting step of GCM when compared with brainstorming, an observation that correlates with our observations from the GCM sessions. Researchers should consider using paper sorting methods and objective measures of sorting quality when using GCM in patient-engaged research to improve the patient experience and concept map quality.

Patient Uncertainty as a Predictor of 30-day Return Emergency Department Visits: An Observational Study

OBJECTIVE

The objective was to examine the relationship between patient uncertainty at the time of emergency department (ED) discharge as measured by the "Uncertainty Scale" (U-Scale) and 30-day return ED visits. We hypothesized that a higher score on the U-Scale predicts a higher likelihood of a 30-day return ED visit.

METHODS

This was a cross-sectional single-site pilot study performed with adult patients discharged from an urban academic ED to assess the relationship of U-Scale total and subscale scores with 30-day return ED visits. We collected demographic and U-Scale scores at the time of ED discharge and subsequent 30-day ED utilization data by follow-up telephone call.

RESULTS

No association was found between the total U-Scale score and subsequent ED utilization. Patients with higher uncertainty on the Treatment Quality subscale of the U-Scale had higher odds of a 30-day return ED visit (adjusted odds ratio [AOR] = 1.16), while patients with lower uncertainty on the Decision to Seek Care subscale had higher odds of a 30-day return ED visit (AOR = 0.68).

CONCLUSION

Patient uncertainty as measured by the U-Scale total score was not predictive of subsequent ED utilization. However, uncertainty related to treatment quality and the decision to seek care as measured by the U-Scale subscales may be important in predicting repeat ED utilization. Unlike individual patient factors such as age and race that have been associated with frequent ED visits in prior studies, these domains of uncertainty are potentially modifiable. Providers and health systems may successfully prevent recurrent acute care encounters through implementation of interventions designed to address patient uncertainty. Further work is needed to refine the U-Scale and test its predictive utility among a larger patient cohort.

Eliciting patient-important outcomes through group brainstorming: when is saturation reached?

PURPOSE

Group brainstorming is a technique for the elicitation of patient input that has many potential uses, however no data demonstrate concept saturation. In this study we explore concept saturation in group brainstorming performed in a single session as compared to two or three sessions.

METHODS

Fifty-two predominately African American adults patients with moderately to poorly controlled Diabetes Mellitus participated in three separate group brainstorming sessions as part of a PCORI-funded group concept mapping study examining comparing methods for the elicitation of patient important outcomes (PIOs). Brainstorming was unstructured, in response to a prompt designed to elicit PIOs in diabetes care. We combined similar brainstormed responses from all three sessions into a 'master list' of unique PIOs, and then compared the proportion obtained at each individual session, as well as those obtained in combinations of 2 sessions, to the master list.

RESULTS

Twenty-four participants generated 85 responses in session A, 14 participants generated 63 in session B, and 14 participants generated 47 in session C. Compared to the master list, the individual sessions contributed 87%, 76%, and 63% of PIOs. Session B added 3 unique PIOs not present in session A, and session C added 2 PIOs not present in either A or B. No single session achieved >90% saturation of the master list, but all 3 combinations of 2 sessions achieved > 90%.

CONCLUSIONS

Single sessions elicited only 63-87% of the patient-important outcomes obtained across all three sessions, however all combinations of two sessions elicited over 90% of the master list, suggesting that 2 sessions are sufficient for concept saturation.

TRIAL REGISTRATION

NCT02792777 . Registered 2 June 2016.

The power of the group: comparison of interviews and group concept mapping for identifying patient-important outcomes of care

BACKGROUND

Data are limited regarding how to effectively and efficiently identify patient priorities for research or clinical care. Our goal was to compare the comprehensiveness and efficiency of group concept mapping (GCM), a group participatory method, to interviews for identifying patient goals when seeking care.

METHODS

We engaged patients with moderately- to poorly-controlled diabetes mellitus in either GCM or an individual interview. The primary outcome was the comprehensiveness of GCM brainstorming (the first stage of GCM) as compared to interviews for eliciting patient-important outcomes (PIOs) related to seeking care. Secondary outcomes included 1) comprehensiveness of GCM brainstorming and interviews compared to a master list of PIOs and 2) efficiency of GCM brainstorming, the entire GCM process and interviews.

RESULTS

We engaged 89 interview participants and 52 GCM participants (across 3 iterations of GCM) to identify outcomes most important to patients when making decisions related to diabetes management. We identified 26 PIOs in interviews, 33 PIOs in the first GCM brainstorming session, and 38 PIOs across all three GCM brainstorming sessions. The initial GCM brainstorming session identified 77% (20/26) of interview PIOs, and all 3 GCM brainstorming sessions combined identified 88% (23/26). When comparing GCM brainstorming and interviews to the master list of PIOs, the initial GCM brainstorming sessions identified 80% (33/41), all 3 GCM brainstorming sessions identified 93% (38/41) and interviews identified 63% (26/41) of all PIOs. Compared to interviews, GCM brainstorming required less research team time, more patient time, and had a lowest cost. The entire GCM process still required less research team time than interviews, though required more patient time and had a higher cost than interviews.

CONCLUSIONS

GCM brainstorming is a powerful tool for effectively and efficiently identifying PIOs in certain scenarios, though it does not provide the breadth and depth of individual interviews or the higher level conceptual organization of the complete process of GCM. Selection of the optimal method for patient engagement should include consideration of multiple factors including depth of patient input desired, research team expertise, resources, and the population to be engaged.

TRIAL REGISTRATION

Registered on ClinicalTrials.gov , NCT02792777. Registration information submitted 6/2/2016, with the registration first posted on the ClinicalTrials.gov website 6/8/2016. Data collection began on 4/29/2016.

Framework to Advance Oncology-Related Telehealth

Purpose

As telehealth is increasingly used across the clinical care spectrum to provide patient-centered care, it is important to have robust measures to assess its impact on patient outcomes and care processes. The National Quality Forum (NQF) developed a Telehealth Framework to organize measures and inform target areas for measure development that includes the following four domains: access to care, financial impact or cost, experience, and effectiveness. Our goal is to identify and categorize within the NQF domains currently existing measures of telehealth applicable to oncology to detect priority areas for future research and measure development.

Methods

We reviewed telehealth-related measures applied to oncology care reported in systematic reviews and identified NQF-endorsed quality measures related to oncology care potentially amenable to telehealth. We organized identified measures by the NQF domains to inform suggestions for advancing the care of patients with cancer through telehealth.

Results

We identified 12 systematic reviews representing 183 studies reporting telehealth-related oncology research. Most studied outcomes related to diagnosis and treatment or user experience and symptom monitoring. Clinical effectiveness measures were most frequently reported (38%), and most were psychosocial. Patient, family, and/or caregiver experience was the next most frequently reported measure. There were only a few other cancer-related clinical effectiveness measures (eg, morbidity). Most NQF-endorsed oncology measures amenable to telehealth applied to the domains of access to care and effectiveness, with a lack of measures informing financial impact or cost and experience.

Conclusion

Overall, there has been a lack of quality measures to assess use of telehealth for the care of oncology patients. Future work should focus on developing measures within each of the NQF-identified domains, with special attention to the financial impact or cost domain.

Presurgical Assessment Using Telemedicine Technology: Impact on Efficiency, Effectiveness, and Patient Experience of Care

BACKGROUND

Preadmission testing (PAT) before surgical procedures ensures patient safety and decreases last minute case cancellations.

INTRODUCTION

PAT before surgery improves efficiency for the health system; however, the process is often inconvenient for the patient. We sought to determine the impact of telemedicine on the presurgical assessment.

MATERIALS AND METHODS

We performed a retrospective review comparing patients who participated in telemedicine-based PAT to patients who had a routine, on-site PAT. Our outcomes aligned with National Quality Forum recommended domains for telehealth measures: access (time spent in evaluation), experience (patient satisfaction), and effectiveness (case cancellation rate).

RESULTS

There were 7,803 people evaluated; 361 with telemedicine and 7,442 without telemedicine. Compared with those not using telemedicine, the telemedicine group spent less time in the PAT by 24 min (95% confidence interval, 21.4-26.5), and had no case cancellations (0% vs. 1.1%; 95% confidence interval for the difference, 0.028-1.25%). Patient experience showed high rates of satisfaction with telemedicine.

DISCUSSION

We found that using telemedicine for PAT had benefits in terms of access, patient experience, and effectiveness, the three domains recommended for use in telehealth quality measures by the National Quality Forum. The improvements in evaluation times are beneficial for both patients and providers.

CONCLUSIONS

PAT utilizing telemedicine reduced overall patient time in the PAT and improved patient satisfaction without increasing the operative case cancellation rate.

Development and preliminary validation of a scale to measure patient uncertainty: The “Uncertainty Scale”

Research suggests that patient uncertainty related to experiencing symptoms may drive decisions to seek care. The only validated measure of patient uncertainty assesses uncertainty related to defined illness. In prior work, we engaged patients to describe uncertainty related to symptoms and used findings to develop the ‘U-Scale’ scale. In this work, we present results from preliminary scale reliability and validity testing. Psychometric testing demonstrated content validity, high internal consistency, and evidence for concurrent validity. Next steps include administration in diverse populations for continued refinement and validation, and exploration of the potential contribution of uncertainty to healthcare utilization.

Emergency Medicine Resident Perceptions About the Need for Increased Training in Communicating Diagnostic Uncertainty

Introduction Diagnostic uncertainty is common in healthcare encounters. Effective communication is important to help patients and providers navigate diagnostic uncertainty, especially at transitions of care. This study sought to assess the experience and training of emergency medicine (EM) residents with communication of diagnostic uncertainty. Methods This was a survey study of a national sample of EM residents. The survey questions elicited quantitative and qualitative responses about experiences with and educational preparation for communication with patients in the setting of diagnostic uncertainty. Results A sample of 263 emergency medicine residents who had trained at over 87 medical schools and 37 residency programs responded to the survey. Nearly half of participants noted they frequently encountered challenges with these conversations;  63% reported having been "somewhat" or less trained to have these conversations during residency, and 51% expressed a strong desire for more training in how to approach these discussions. Survey respondents reported that prior educational experiences in the communication of diagnostic uncertainty were largely informal and that many residents experience frustration in clinical encounters due to inability to meet patients' expectations of reaching a diagnosis at the time of discharge. Conclusion This study found that emergency medicine residents frequently struggle in communicating with patients when there is diagnostic uncertainty upon emergency department discharge and perceived the need for training in how to communicate in these situations. The development of targeted educational strategies for improving communication in the setting of diagnostic uncertainty is consistent with emergency medicine core competencies and may improve patient and provider satisfaction with these clinical encounters.

Effectiveness of a Decision Aid in Potentially Vulnerable Patients: A Secondary Analysis of the Chest Pain Choice Multicenter Randomized Trial

Background. We test the hypotheses that use of the Chest Pain Choice (CPC) decision aid (DA) would be similarly effective in potentially vulnerable subgroups but increase knowledge more in patients with higher education and trust in physicians more in patients from racial minority groups. Methods. This was a secondary analysis of a multicenter randomized trial in adults with chest pain potentially due to acute coronary syndrome. The trial compared an intervention group engaged in shared decision making (SDM) using CPC to a control group receiving usual care (UC). We assessed for subgroup effects based on age, sex, race, income, insurance, education, literacy, and numeracy. We dichotomized each characteristic and tested for interactions using regression models with indicators for arm assignment and study site. Results. Of 898 patients (451 DA, 447 UC), over 50% were female, over one-third were black, nearly one-third had a high school education or less, and over 60% had “low” health literacy. The DA did not increase knowledge more in patients with higher education ( P for interaction = 0.06) but did increase knowledge more in the “typical” than in the “low” numeracy subgroup (10.6% v. 4.7%, absolute difference [AD] = 5.9%, P for interaction = 0.025). The DA did not significantly increase patient trust in physicians in racial minorities ( P for interaction = 0.06) but did increase trust more in patients with “low” literacy compared with those with “typical” literacy (3.7% v. –1.4%, AD = 5.1, P for interaction = 0.011). Conclusions. CPC benefited all sociodemographic groups to a similar extent, with greater knowledge transfer in patients with higher numeracy and greater physician trust in patients with “low” health literacy. Tailoring SDM interventions to patient characteristics may be necessary for optimal effectiveness.

Patient Perceptions of Telehealth Primary Care Video Visits

PURPOSE

Telehealth is a care delivery model that promises to increase the flexibility and reach of health services. Our objective is to describe patient experiences with video visits performed with their established primary care clinicians.

METHODS

We constructed semistructured, in-depth qualitative interviews with adult patients following video visits with their primary care clinicians at a single academic medical center. Data were analyzed with a content analysis approach.

RESULTS

Of 32 eligible patients, 19 were successfully interviewed. All patients reported overall satisfaction with video visits, with the majority interested in continuing to use video visits as an alternative to in-person visits. The primary benefits cited were convenience and decreased costs. Some patients felt more comfortable with video visits than office visits and expressed a preference for receiving future serious news via video visit, because they could be in their own supportive environment. Primary concerns with video visits were privacy, including the potential for work colleagues to overhear conversations, and questions about the ability of the clinician to perform an adequate physical examination.

CONCLUSIONS

Primary care video visits are acceptable in a variety of situations. Patients identified convenience, efficiency, communication, privacy, and comfort as domains that are potentially important to consider when assessing video visits vs in-person encounters. Future studies should explore which patients and conditions are best suited for video visits.

Factors associated with hospital admission after an emergency department treat and release visit for older adults with injuries

INTRODUCTION

Emergency Department (ED) visits for injury often precede hospital admissions in older adults, but risk factors for these admissions are poorly characterized. We sought to determine the incidence and risk factors for hospitalization shortly following discharge home from an ED visit for traumatic injury in older adults. We hypothesized higher risk for admission in those with increased age, discharged home after falls, with increased comorbidity burden, and who live in poor neighborhoods.

METHODS

We identified all community-dwelling patients ≥65years old treated and released for traumatic injury at non-federal EDs in Florida using the 2011 State Inpatient Database and State ED Database of the Agency for Healthcare Research and Quality. Outcome measures were hospitalization within 9 and 30days of discharge from the ED. Multivariable logistic regression was used to establish independent risk factors for hospital admission.

RESULTS

Of 163,851 index ED injury visits, 6298 (3.8%) resulted in inpatient admissions within 9days and 12,938 (7.9%) within 30days. Factors associated with increased odds of admission within 9days included: each additional comorbidity, ≥moderate injury to abdomen or pelvis/extremities, and median neighborhood income<$39,000. Additional factors associated with increased odds of admission within 30days included: lack of private insurance supplement and median neighborhood income<$48,000.

CONCLUSION

Among older adults treated and discharged from the ED for an injury, those who have high comorbidity burdens, have abdominal or orthopedic injuries, and live in poor neighborhoods are at increased risk of hospitalization within 9 or 30days of ED discharge.

Geography, Not Health System Affiliations, Determines Patients' Revisits to the Emergency Department

OBJECTIVES

To determine how frequently patients revisit the emergency department after an initial encounter, and to describe revisit capture rates for the same hospital, health system, and geographic region.

DATA SOURCES/STUDY SETTING

Florida state data from January 1, 2010, to June 30, 2011, from the Healthcare Cost and Utilization Project.

STUDY DESIGN

This is a retrospective cohort study of emergency department return visits among Florida adults over an 18-month period. We evaluated pairs of index and 30-day return emergency department visits and compared capture rates for hospital, health system, and geographic units.

DATA COLLECTION/EXTRACTION METHODS

Data were obtained from the Agency for Healthcare Research and Quality's Healthcare Cost and Utilization Project and the American Hospital Association Annual Survey Database.

PRINCIPAL FINDINGS

Among 9,416,212 emergency department visits, 22.6 percent (2,124,441) were associated with a 30-day return. Seventy percent (1,477,772) of 30-day returns occurred to the same hospital. The 30-day return capture rates were highest within the same geographic area: county-level capture at 92 percent (IQR=86-96 percent) versus health system capture at 75 percent (IQR = 68-81 percent).

CONCLUSIONS

Acute care utilization patterns are often independent of health system boundaries. Current population-based health care models that attribute patients to a single provider or health system may be strengthened by considering geographic patterns of acute care utilization.

The 2016 Academic Emergency Medicine Consensus Conference, "Shared Decision Making in the Emergency Department: Development of a Policy-relevant Patient-centered Research Agenda" Diagnostic Testing Breakout Session Report

Diagnostic testing is an integral component of patient evaluation in the emergency department (ED). Emergency clinicians frequently use diagnostic testing to more confidently exclude "worst-case" diagnoses rather than to determine the most likely etiology for a presenting complaint. Increased utilization of diagnostic testing has not been associated with reductions in disease-related mortality but has led to increased overall healthcare costs and other unintended consequences (e.g., incidental findings requiring further workup, unnecessary exposure to ionizing radiation or potentially nephrotoxic contrast). Shared decision making (SDM) presents an opportunity for clinicians to discuss the benefits and harms associated with diagnostic testing with patients to more closely tailor testing to patient risk. This article introduces the challenges and opportunities associated with incorporating SDM into emergency care by summarizing the conclusions of the diagnostic testing group at the 2016 Academic Emergency Medicine Consensus Conference on SDM. Three primary domains emerged: 1) characteristics of a condition or test appropriate for SDM, 2) critical elements of and potential barriers to SDM discussions on diagnostic testing, and 3) financial aspects of SDM applied to diagnostic testing. The most critical research questions to improve engagement of patients in their acute care diagnostic decisions were determined by consensus.

A qualitative analysis of interprofessional healthcare team members' perceptions of patient barriers to healthcare engagement

Background

Healthcare systems increasingly engage interprofessional healthcare team members such as case managers, social workers, and community health workers to work directly with patients and improve population health. This study elicited perspectives of interprofessional healthcare team members regarding patient barriers to health and suggestions to address these barriers.

Methods

This is a qualitative study employing focus groups and semi-structured interviews with 39 interprofessional healthcare team members in Philadelphia to elicit perceptions of patients’ needs and experiences with the health system, and suggestions for positioning health care systems to better serve patients. Themes were identified using a content analysis approach.

Results

Three focus groups and 21 interviews were conducted with 26 hospital-based and 13 ambulatory-based participants. Three domains emerged to characterize barriers to care: social determinants, health system factors, and patient trust in the health system. Social determinants included insurance and financial shortcomings, mental health and substance abuse issues, housing and transportation-related limitations, and unpredictability associated with living in poverty. Suggestions for addressing these barriers included increased financial assistance from the health system, and building a workforce to address these determinants directly. Health care system factors included poor care coordination, inadequate communication of hospital discharge instructions, and difficulty navigating complex systems. Suggestions for addressing these barriers included enhanced communication between care sites, patient-centered scheduling, and improved patient education especially in discharge planning. Finally, factors related to patient trust of the health system emerged. Participants reported that patients are often intimidated by the health system, mistrusting of physicians, and fearful of receiving a serious diagnosis or prognosis. A suggestion for mitigating these issues was increased visibility of the health system within communities to foster trust and help providers gain a better understanding of unique community needs.

Conclusion

This work explored interprofessional healthcare team members’ perceptions of patient barriers to healthcare engagement. Participants identified barriers related to social determinants of health, complex system organization, and patient mistrust of the health system. Participants offered concrete suggestions to address these barriers, with suggestions supporting current healthcare reform efforts that aim at addressing social determinants and improving health system coordination and adding new insight into how systems might work to improve patient and community trust.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1751-5) contains supplementary material, which is available to authorized users.

Patient-centered Outcomes Research in Emergency Care: Opportunities, Challenges, and Future Directions

The Patient-Centered Outcomes Research Institute (PCORI) was established by Congress in 2010 to promote the conduct of research that could better inform patients in making decisions that reflect their desired health outcomes. PCORI has established five national priorities for research around which specific funding opportunities are issued: 1) assessment of prevention, diagnosis, and treatment options; 2) improving healthcare systems; 3) communication and dissemination research; 4) addressing disparities; and 5) improving methods for conducting patient-centered outcomes research. To date, implementation of patient-centered research in the emergency care setting has been limited, in part because of perceived challenges in meeting PCORI priorities such as the need to focus on a specific disease state or to have planned follow up. We suggest that these same factors that have been seen as challenges to performing patient-centered research within the emergency setting are also potential strengths to be leveraged to conduct PCORI research. This paper explores factors unique to patient-centered emergency care research and highlights specific areas of potential alignment within each PCORI priority.

The US emergency care system: meeting everyday acute care needs while being ready for disasters

The emergency care system is an essential part of the US health care system. In addition to providing acute resuscitation and life- and limb-saving care, the emergency care system provides considerable support to physicians outside the emergency department and serves as an important safety-net provider. In times of disaster, the emergency care system must be able to surge rapidly to accommodate a massive influx of patients, sometimes with little or no notice. Extreme daily demands on the system can promote innovations and adaptations that are invaluable in responding to disasters. However, excessive and inappropriate utilization is wasteful and can diminish "surge capacity" when it is most needed. Certain features of the US health care system have imposed strains on the emergency care system. We explore policy issues related to moving toward an emergency care system that can more effectively meet both individuals' needs for acute care and the broader needs of the community in times of disaster. Strategies for the redesign of the emergency care system must include the active engagement of both patients and the community and a close look at how to align incentives to reward quality and efficiency throughout the health care system.

Patient returns to the emergency department: the time-to-return curve

OBJECTIVES

Although 72-hour emergency department (ED) revisits are increasingly used as a hospital metric, there is no known empirical basis for this 72-hour threshold. The objective of this study was to determine the timing of ED revisits for adult patients within 30 days of ED discharge.

METHODS

This was a retrospective cohort study of all nonfederal ED discharges in Florida and Nebraska from April 1, 2010, to March 31, 2011, using data from the Agency for Healthcare Research and Quality (AHRQ) Healthcare Cost and Utilization Project (HCUP). ED discharges were followed forward to identify ED revisits occurring at any hospital within the same state within 30 days. The cumulative hazard of an ED revisit was plotted. Parametric and nonparametric modeling was performed to characterize the rate of ED revisits.

RESULTS

There were 4,782,045 ED discharges, with 7.5% (95% confidence interval [CI] = 7.4% to 7.5%) associated with 3-day revisits, and 22.4% (95% CI = 22.3% to 22.4%) associated with 30-day revisits, inclusive of the 3-day revisits. A double-exponential model fit the data best (p < 0.0001), and a single hinge point at 9 days (multivariate adaptive regression splines [MARS] model) yielded the best linear fit to the data, suggesting 9 days as the most reasonable cutoff for identification of acute ED revisits. Multiple stratified and subgroup analyses produced similar results. Future work should focus on identifying primary reasons for potentially avoidable return ED visits instead of on the revisit occurrence itself, thus more directly measuring potential lapses in delivery of high-quality care.

CONCLUSIONS

Almost one-quarter of ED discharges are linked to 30-day ED revisits, and the current 72-hour ED metric misses close to 70% of these patients. Our findings support 9 days as a more inclusive cutoff for studies of ED revisits.

The impact of state medical marijuana legislation on adolescent marijuana use

PURPOSE

The state-level legalization of medical marijuana has raised concerns about increased accessibility and appeal of the drug to youth. The objective of this study was to assess the impact of medical marijuana legalization across the United States by comparing trends in adolescent marijuana use between states with and without legalization of medical marijuana.

METHODS

The study utilized data from the Youth Risk Behavioral Surveillance Survey between 1991 and 2011. States with a medical marijuana law for which at least two cycles of Youth Risk Behavioral Surveillance data were available before and after the implementation of the law were selected for analysis. Each of these states was paired with a state in geographic proximity that had not implemented the law. Chi-squared analysis was used to compare characteristics between states with and without medical marijuana use policies. A difference-in-difference regression was performed to control for time-invariant factors relating to drug use in each state, isolating the policy effect, and then calculated the marginal probabilities of policy change on the binary dependent variable.

RESULTS

The estimation sample was 11,703,100 students. Across years and states, past-month marijuana use was common (20.9%, 95% confidence interval 20.3-21.4). There were no statistically significant differences in marijuana use before and after policy change for any state pairing. In the regression analysis, we did not find an overall increased probability of marijuana use related to the policy change (marginal probability .007, 95% confidence interval -.007, .02).

CONCLUSIONS

This study did not find increases in adolescent marijuana use related to legalization of medical marijuana.

Cardiovascular Admissions, Readmissions, and Transitions of Care

Hospital 30-day readmissions have become a major priority for hospitals. Hospitals face penalties for excessive readmissions for acute myocardial infarction (AMI) and heart failure (HF). Thus, it is important for hospitals to understand the transitions of care that occur for both of these conditions, and what tools are available to guide the processes involved. A multi-disciplinary team including Emergency Medical Service providers, Emergency Medicine providers, cardiologists, hospitalists, pharmacists, nurses, case managers, and outpatient physicians can all be involved in the process of safely transitioning a patient between care settings. Small-scale studies in the geriatric population have shown improved transitions of care and decreased readmissions with these care teams. The emergency department is a key transition point for patients with AMI and HF, yet it is rarely identified and utilized as such in transitions of care interventions. Future research and implementation projects will need to refine and expand the role of the emergency department in the process.