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Facilitators and Barriers to Reducing Emergency Department Admissions for Chest Pain: A Qualitative Study. Crit Pathw Cardiol 2018; 17:201-207. [PMID: 30418250 DOI: 10.1097/hpc.0000000000000145] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Chest pain of possible cardiac etiology is a leading reason for emergency department (ED) visits and hospitalizations nationwide. Evidence suggests outpatient management is safe and effective for low-risk patients; however, ED admission rates for chest pain vary widely. To identify barriers and facilitators to outpatient management after ED visits, we performed a multicenter qualitative study of key stakeholders. METHODS AND RESULTS We identified Massachusetts hospitals with below-average admission rates for adult ED chest pain visits from 2010 to 2011. We performed a qualitative case study of 27 stakeholders across 4 hospitals to identify barriers and facilitators to outpatient management. Clinicians cited ability to coordinate follow-up care, including stress testing and cardiology consultation, as key facilitators of ED discharge. When these services are unavailable, or inconsistently available, they present a barrier to outpatient management. Clinicians identified pressure to maintain throughput and the lack of observation units as barriers to ED discharge. At 3 of 4 hospitals without observation units, clinicians did not use clinical protocols to guide the admission decision. At the site with a dedicated ED observation unit, low ED admission rates were attributed to clinician adherence to clinical protocols. CONCLUSIONS In conclusion, most participants have not adopted protocols focused on reducing variation in ED chest pain admissions. Robust systems to ensure follow-up care after ED visits may reduce admission rates by mitigating the perceived risk of discharging ED patients with chest pain. Greater use of observation protocols may promote adoption of clinical guidelines and reduce admission rates.
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Warner LSH, Galarraga JE, Litvak O, Davis S, Granovsky M, Pines JM. The Impact of Hospital and Patient Factors on the Emergency Department Decision to Admit. J Emerg Med 2018; 54:249-257.e1. [PMID: 29428057 DOI: 10.1016/j.jemermed.2017.11.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2017] [Revised: 10/16/2017] [Accepted: 11/18/2017] [Indexed: 11/25/2022]
Abstract
BACKGROUND Substantial variation exists in rates of emergency department (ED) admission. We examine this variation after accounting for local and community characteristics. OBJECTIVES Elucidate the factors that contribute to admission variation that are amenable to intervention with the goal of reducing variation and health care costs. METHODS We conducted a retrospective cross-sectional study of 1,412,340 patient encounters across 18 sites from 2012-2013. We calculated the adjusted hospital-level admission rates using multivariate logistic regression. We adjusted for patient, provider, hospital, and community factors to compare admission rate variation and determine the influence of these characteristics on admission rates. RESULTS The average adjusted admission rate was 22.9%, ranging from 16.1% (95% confidence interval [CI] 11.5-22%) to 32% (95% CI 26.0-38.8). There were higher odds of hospital admission with advancing age, male sex (odds ratio [OR] 1.20, 95% CI 1.91-1.21), and patients seen by a physician vs. mid-level provider (OR 2.26, 95% CI 2.23-2.30). There were increased odds of admission with rising ED volume, at academic institutions (OR 2.23, 95% CI 2.20-2.26) and at for-profit hospitals (OR 1.15, 95% CI 1.12-1.18). Admission rates were lower in communities with a higher per capita income, a higher rate of uninsured patients, and in more urban hospitals. In communities with the most primary providers, there were lower odds of admission (OR 0.60, 95% CI 0.57-0.68). CONCLUSION Variation in hospital-level admission rates is associated with a number of local and community characteristics. However, the presence of persistent variation after adjustment suggests there are other unmeasured variables that also affect admission rates that deserve further study, particularly in an era of cost containment.
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Affiliation(s)
- Leah S Honigman Warner
- Department of Emergency Medicine, Northwell Health, Long Island Jewish Medical Center, New Hyde Park, New York
| | - Jessica E Galarraga
- Department of Emergency Medicine, MedStar Washington Hospital Center, Georgetown University School of Medicine, Washington, DC
| | - Ori Litvak
- LogixHealth, Inc., Bedford, Massachusetts
| | | | - Michael Granovsky
- LogixHealth, Inc., Bedford, Massachusetts; Department of Emergency Medicine, The George Washington University, Washington, DC
| | - Jesse M Pines
- Department of Emergency Medicine, The George Washington University, Washington, DC; Center for Healthcare Innovation and Policy Research, The George Washington University School of Medicine and Health Sciences, Washington, DC
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Sabbatini AK, Wright B, Hall MK, Basu A. The cost of observation care for commercially insured patients visiting the emergency department. Am J Emerg Med 2018; 36:1591-1596. [DOI: 10.1016/j.ajem.2018.01.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/09/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022] Open
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Chou SC, Nagurney JM, Weiner SG, Hong AS, Wharam JF. Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy. Am J Emerg Med 2018; 37:1037-1043. [PMID: 30177266 DOI: 10.1016/j.ajem.2018.08.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/12/2018] [Accepted: 08/15/2018] [Indexed: 11/27/2022] Open
Abstract
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.
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Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Justine M Nagurney
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Institute of Aging Research, Hebrew Senior Life, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Arthur S Hong
- Department of Medicine, Department of Clinical Science, University of Texas Southwestern Medical Center, United States of America.
| | - J Frank Wharam
- Harvard Pilgrim Health Care Institute, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
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Streitz MJ, Oliver JJ, Hyams JM, Wood RM, Maksimenko YM, Long B, Barnwell RM, April MD. A retrospective external validation study of the HEART score among patients presenting to the emergency department with chest pain. Intern Emerg Med 2018; 13:727-748. [PMID: 28895038 DOI: 10.1007/s11739-017-1743-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2017] [Accepted: 08/19/2017] [Indexed: 01/16/2023]
Abstract
Emergency physicians must be able to effectively prognosticate outcomes for patients presenting to the Emergency Department (ED) with chest pain. The HEART score offers a prognostication tool, but external validation studies are limited. We conducted an external retrospective validation study of the HEART score among ED patients presenting to our ED with chest pain from 1 January 2014 to 9 June 2014. We utilized chart review methodology to abstract data from each patient's electronic medical record. We collected data relevant to each of the five elements of the HEART score: history, electrocardiogram (ECG) interpretation, patient age, patient risk factors, and troponin levels. We calculated the diagnostic accuracy of the HEART score (0-10) for predicting the primary outcome of major adverse cardiac events (MACE) over 6 weeks following the ED visit (coronary revascularization, myocardial infarction, or mortality). We randomly selected 10% of patient charts from which a second investigator abstracted all data to assess inter-rater reliability for all study variables. Of 625 charts reviewed, we abstracted data on 417 (66.7%) consecutive patients meeting study inclusion criteria. Thirty-one (7.4%) of these patients experienced 6-week MACE. We observed no instances of MACE within 6 weeks among subjects with a HEART score of 3 or less. The area under the receiver operator curve (AUROC) is 0.885 (95% confidence interval 0.838-0.931). Patients with a HEART score ≤3 are at low risk for 6-week MACE. Hence, these patients may be candidates for outpatient follow-up instead of inpatient admission for cardiac risk stratification.
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Affiliation(s)
- Matthew Jay Streitz
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA.
| | - Joshua James Oliver
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Jessica Marie Hyams
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Richard Michael Wood
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | | | - Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Robert Michael Barnwell
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
| | - Michael David April
- Department of Emergency Medicine, San Antonio Military Medical Center, San Antonio Uniformed Services Health Education Consortium, 3551 Roger Brooke Dr., Fort Sam Houston, San Antonio, TX, 78234, USA
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Bobrovitz N, Heneghan C, Onakpoya I, Fletcher B, Collins D, Tompson A, Lee J, Nunan D, Fisher R, Scott B, O’Sullivan J, Van Hecke O, Nicholson BD, Stevens S, Roberts N, Mahtani KR. Medications that reduce emergency hospital admissions: an overview of systematic reviews and prioritisation of treatments. BMC Med 2018; 16:115. [PMID: 30045724 PMCID: PMC6060538 DOI: 10.1186/s12916-018-1104-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 06/19/2018] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Rates of emergency hospitalisations are increasing in many countries, leading to disruption in the quality of care and increases in cost. Therefore, identifying strategies to reduce emergency admission rates is a key priority. There have been large-scale evidence reviews to address this issue; however, there have been no reviews of medication therapies, which have the potential to reduce the use of emergency health-care services. The objectives of this study were to review systematically the evidence to identify medications that affect emergency hospital admissions and prioritise therapies for quality measurement and improvement. METHODS This was a systematic review of systematic reviews. We searched MEDLINE, PubMed, the Cochrane Database of Systematic Reviews & Database of Abstracts of Reviews of Effects, Google Scholar and the websites of ten major funding agencies and health charities, using broad search criteria. We included systematic reviews of randomised controlled trials that examined the effect of any medication on emergency hospital admissions among adults. We assessed the quality of reviews using AMSTAR. To prioritise therapies, we assessed the quality of trial evidence underpinning meta-analysed effect estimates and cross-referenced the evidence with clinical guidelines. RESULTS We identified 140 systematic reviews, which included 1968 unique randomised controlled trials and 925,364 patients. Reviews contained 100 medications tested in 47 populations. We identified high-to moderate-quality evidence for 28 medications that reduced admissions. Of these medications, 11 were supported by clinical guidelines in the United States, the United Kingdom and Europe. These 11 therapies were for patients with heart failure (angiotensin-converting-enzyme inhibitors, angiotensin II receptor blockers, aldosterone receptor antagonists and digoxin), stable coronary artery disease (intensive statin therapy), asthma exacerbations (early inhaled corticosteroids in the emergency department and anticholinergics), chronic obstructive pulmonary disease (long-acting muscarinic antagonists and long-acting beta-2 adrenoceptor agonists) and schizophrenia (second-generation antipsychotics and depot/maintenance antipsychotics). CONCLUSIONS We identified 11 medications supported by strong evidence and clinical guidelines that could be considered in quality monitoring and improvement strategies to help reduce emergency hospital admission rates. The findings are relevant to health systems with a large burden of chronic disease and those managing increasing pressures on acute health-care services.
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Affiliation(s)
- Niklas Bobrovitz
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Carl Heneghan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Igho Onakpoya
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Benjamin Fletcher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - Dylan Collins
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Faculty of Medicine, University of British Columbia, Vancouver, Canada
| | - Alice Tompson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Faculty of Public Health and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Joseph Lee
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - David Nunan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Rebecca Fisher
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- The Health Foundation, London, United Kingdom
| | - Brittney Scott
- Department of Critical Care Medicine, University of Calgary, Calgary, Canada
- Snyder Institute for Chronic Diseases, University of Calgary, Calgary, Canada
| | - Jack O’Sullivan
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
| | - Oliver Van Hecke
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - Brian D. Nicholson
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - Sarah Stevens
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
| | - Nia Roberts
- Bodelian Libraries, University of Oxford, Oxford, UK
| | - Kamal R. Mahtani
- Nuffield Department of Primary Care Health Sciences, University of Oxford, Radcliffe Observatory Quarter, Woodstock Road, Oxford, OX2 6GG United Kingdom
- Centre for Evidence-Based Medicine, University of Oxford, Oxford, United Kingdom
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Bottle A, Honeyford K, Chowdhury F, Bell D, Aylin P. Factors associated with hospital emergency readmission and mortality rates in patients with heart failure or chronic obstructive pulmonary disease: a national observational study. HEALTH SERVICES AND DELIVERY RESEARCH 2018. [PMID: 30044581 DOI: 10.3310/hsdr06260] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023] Open
Abstract
BackgroundHeart failure (HF) and chronic obstructive pulmonary disease (COPD) lead to unplanned hospital activity, but our understanding of what drives this is incomplete.ObjectivesTo model patient, primary care and hospital factors associated with readmission and mortality for patients with HF and COPD, to assess the statistical performance of post-discharge emergency department (ED) attendance compared with readmission metrics and to compare all the results for the two conditions.DesignObservational study.SettingEnglish NHS.ParticipantsAll patients admitted to acute non-specialist hospitals as an emergency for HF or COPD.InterventionsNone.Main outcome measuresOne-year mortality and 30-day emergency readmission following the patient’s first unplanned admission (‘index admission’) for HF or COPD.Data sourcesPatient-level data from Hospital Episodes Statistics were combined with publicly available practice- and hospital-level data on performance, patient and staff experience and rehabilitation programme website information.ResultsOne-year mortality rates were 39.6% for HF and 24.1% for COPD and 30-day readmission rates were 19.8% for HF and 16.5% for COPD. Most patients were elderly with multiple comorbidities. Patient factors predicting mortality included older age, male sex, white ethnicity, prior missed outpatient appointments, (long) index length of hospital stay (LOS) and several comorbidities. Older age, missed appointments, (short) LOS and comorbidities also predicted readmission. Of the practice and hospital factors we considered, only more doctors per 10 beds [odds ratio (OR) 0.95 per doctor;p < 0.001] was significant for both cohorts for mortality, with staff recommending to friends and family (OR 0.80 per unit increase;p < 0.001) and number of general practitioners (GPs) per 1000 patients (OR 0.89 per extra GP;p = 0.004) important for COPD. For readmission, only hospital size [OR per 100 beds = 2.16, 95% confidence interval (CI) 1.34 to 3.48 for HF, and 2.27, 95% CI 1.40 to 3.66 for COPD] and doctors per 10 beds (OR 0.98;p < 0.001) were significantly associated. Some factors, such as comorbidities, varied in importance depending on the readmission diagnosis. ED visits were common after the index discharge, with 75% resulting in admission. Many predictors of admission at this visit were as for readmission minus comorbidities and plus attendance outside the day shift and numbers of admissions that hour. Hospital-level rates for ED attendance varied much more than those for readmission, but the omega statistics favoured them as a performance indicator.LimitationsData lacked direct information on disease severity and ED attendance reasons; NHS surveys were not specific to HF or COPD patients; and some data sets were aggregated.ConclusionsFollowing an index admission for HF or COPD, older age, prior missed outpatient appointments, LOS and many comorbidities predict both mortality and readmission. Of the aggregated practice and hospital information, only doctors per bed and numbers of hospital beds were strongly associated with either outcome (both negatively). The 30-day ED visits and diagnosis-specific readmission rates seem to be useful performance indicators.Future workHospital variations in ED visits could be investigated using existing data despite coding limitations. Primary care management could be explored using individual-level linked databases.FundingThe National Institute for Health Research Health Services and Delivery Research programme.
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Affiliation(s)
- Alex Bottle
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Kate Honeyford
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
| | - Faiza Chowdhury
- Department of Acute Medicine, Chelsea and Westminster Hospital, Imperial College London, London, UK
- National Institute for Health Research under the Collaborations for Leadership in Applied Health Research and Care Programme North West London, Imperial College London, London, UK
| | - Derek Bell
- Department of Acute Medicine, Chelsea and Westminster Hospital, Imperial College London, London, UK
- National Institute for Health Research under the Collaborations for Leadership in Applied Health Research and Care Programme North West London, Imperial College London, London, UK
- Royal College of Physicians, Edinburgh, UK
| | - Paul Aylin
- Dr Foster Unit, Department of Primary Care and Public Health, Imperial College London, London, UK
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Pines JM, Zocchi MS, Black BS. A Comparison of Care Delivered in Hospital-based and Freestanding Emergency Departments. Acad Emerg Med 2018; 25:538-550. [PMID: 29380478 DOI: 10.1111/acem.13381] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2017] [Revised: 12/16/2017] [Accepted: 01/23/2018] [Indexed: 11/30/2022]
Abstract
OBJECTIVE We compare case mix, hospitalization rates, length of stay (LOS), and resource use in independent freestanding emergency departments (FSEDs) and hospital-based emergency departments (H-EDs). METHODS Data from 74 FSEDs (2013-2015) in Texas and Colorado were compared to H-ED data from the 2013-2014 National Hospital Ambulatory Medical Care Survey. In the unrestricted sample, large differences in visit characteristics (e.g., payer and case mix) were found between patients that use FSEDs compared to H-EDs. Therefore, we restricted our analysis to patients commonly treated in both settings (<65 years, privately insured, nonambulance) and used inverse propensity score weighting (IPW) to balance the two settings on observable patient characteristics. We then compared ED LOS and as well as hospital admission rates and resource utilization rates in the IPW-weighted samples. RESULTS Before balancing, FSEDs saw more young adults (age 25-44) and fewer older adults (age 45-64) than H-EDs. FSED patients had fewer comorbidities, more injuries and respiratory infections, and fewer diagnoses of chest or abdominal pain. In balanced samples, LOS for FSED visits was 46% shorter (60 minutes) than H-ED patients. Hospital admission rates were 37% lower overall (95% confidence interval = -51% to -23%) in FSEDs and varied considerably by primary discharge diagnosis. X-ray and electrocardiogram use was significantly lower at FSEDs while others measures of resource utilization were similar (ultrasound, computed tomography scans, and laboratory tests). CONCLUSION In this sample of FSEDs, a greater proportion of younger patients with fewer comorbidities and more injuries and respiratory system diseases were evaluated, and almost all patients had private health insurance. When restricted to < 65 years, privately insured, and nonambulance patients in both samples, LOS was considerably shorter and hospital admission rates lower at FSEDs, as well as the use of some diagnostic testing. This study is limited as diagnoses codes may not fully capture severity and patients who perceived greater need of hospital admission may have chosen a H-ED over FSEDs.
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Affiliation(s)
- Jesse M. Pines
- Center for Healthcare Innovation & Policy Research Departments of Emergency Medicine and Health Policy George Washington University Washington DC
| | - Mark S. Zocchi
- Center for Healthcare Innovation & Policy Research, School of Medicine and Health Sciences George Washington University Washington DC
| | - Bernard S. Black
- Pritzker School of Law and Kellogg School of Management Northwestern University Chicago IL
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Emergency Physician Risk Estimates and Admission Decisions for Chest Pain: A Web-Based Scenario Study. Ann Emerg Med 2018; 72:511-522. [PMID: 29685372 DOI: 10.1016/j.annemergmed.2018.03.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2017] [Revised: 09/06/2017] [Accepted: 02/28/2018] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE We conducted this study to better understand how emergency physicians estimate risk and make admission decisions for patients with low-risk chest pain. METHODS We created a Web-based survey consisting of 5 chest pain scenarios that included history, physical examination, ECG findings, and basic laboratory studies, including a negative initial troponin-level result. We administered the scenarios in random order to emergency medicine residents and faculty at 11 US emergency medicine residency programs. We randomized respondents to receive questions about 1 of 2 endpoints, acute coronary syndrome or serious complication (death, dysrhythmia, or congestive heart failure within 30 days). For each scenario, the respondent provided a quantitative estimate of the probability of the endpoint, a qualitative estimate of the risk of the endpoint (very low, low, moderate, high, or very high), and an admission decision. Respondents also provided demographic information and completed a 3-item Fear of Malpractice scale. RESULTS Two hundred eight (65%) of 320 eligible physicians completed the survey, 73% of whom were residents. Ninety-five percent of respondents were wholly consistent (no admitted patient was assigned a lower probability than a discharged patient). For individual scenarios, probability estimates covered at least 4 orders of magnitude; admission rates for scenarios varied from 16% to 99%. The majority of respondents (>72%) had admission thresholds at or below a 1% probability of acute coronary syndrome. Respondents did not fully differentiate the probability of acute coronary syndrome and serious outcome; for each scenario, estimates for the two were quite similar despite a serious outcome being far less likely. Raters used the terms "very low risk" and "low risk" only when their probability estimates were less than 1%. CONCLUSION The majority of respondents considered any probability greater than 1% for acute coronary syndrome or serious outcome to be at least moderate risk and warranting admission. Physicians used qualitative terms in ways fundamentally different from how they are used in ordinary conversation, which may lead to miscommunication during shared decisionmaking processes. These data suggest that probability or utility models are inadequate to describe physician decisionmaking for patients with chest pain.
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Novel Emergency Department Risk Score Discriminates Acute Coronary Syndrome Among Chest Pain Patients With Known Coronary Artery Disease. Crit Pathw Cardiol 2017; 15:138-144. [PMID: 27846005 DOI: 10.1097/hpc.0000000000000091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND Patients with known coronary artery disease presenting to the emergency department (ED) with chest pain are often admitted, yet may not be having an acute coronary syndrome (ACS). METHODS We assessed whether the use of a novel risk score and a modified thrombolysis in myocardial infarction risk score obtained in the ED could discriminate which of these high-risk patients have ACS. Chart review was performed on a cohort of 285 patients with known coronary artery disease presenting to the ED with chest pain thought to be of ischemic origin and admitted to the hospital. The ED variables were assessed with logistic regression for their association with eventual ACS diagnosis at hospital discharge. ACS was diagnosed in 74 (26%) of the patients. RESULTS Non-ACS patients had a 2-day median length of stay and $6875 median inpatient (post ED) hospital charges (not including physician fees), totaling 566 hospital bed days and $1,871,250 for the 211 (74%) non-ACS patients. A novel risk score, including (1) history of prior revascularization, (2) comorbid chronic kidney disease, (3) onset of chest discomfort at rest, (4) dynamic electrocardiogram changes in the ED, (5) elevated troponin I (>0.05 ng/mL) in the ED, and (6) associated illness at presentation, discriminated ACS and non-ACS with a c statistic of 0.767; the c statistic for a modified thrombolysis in myocardial infarction risk score was 0.712. CONCLUSIONS Application of these risk scores may reduce the number of potentially avoidable admissions and their associated hazards and costs.
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Smulowitz PB, Dizitzer Y, Tadiri S, Thibodeau L, Jagminas L, Novack V. Impact of implementation of the HEART pathway using an electronic clinical decision support tool in a community hospital setting. Am J Emerg Med 2017; 36:408-413. [PMID: 28869099 DOI: 10.1016/j.ajem.2017.08.047] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2017] [Revised: 08/17/2017] [Accepted: 08/20/2017] [Indexed: 10/19/2022] Open
Affiliation(s)
- Peter B Smulowitz
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, United States.
| | - Yotam Dizitzer
- Clinical Research Center, Soroka University Medical Center, Beer Sheba, Israel
| | - Sarah Tadiri
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, United States
| | - Lara Thibodeau
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School, United States
| | - Liudvikas Jagminas
- Department of Emergency Medicine, Beth Israel Deaconess Hospital, Plymouth, United States
| | - Victor Novack
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Department of Internal Medicine, Be'er Sheva, Israel
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Macht R, Cassidy R, Cabral H, Kazis LE, Ghaferi A. Evaluating organizational factors associated with postoperative bariatric surgery readmissions. Surg Obes Relat Dis 2017; 13:1004-1009. [DOI: 10.1016/j.soard.2016.12.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2016] [Revised: 12/05/2016] [Accepted: 12/29/2016] [Indexed: 10/20/2022]
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Yiadom MYAB, Liu X, McWade CM, Liu D, Storrow AB. Acute Coronary Syndrome Screening and Diagnostic Practice Variation. Acad Emerg Med 2017; 24:701-709. [DOI: 10.1111/acem.13184] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2017] [Revised: 02/18/2017] [Accepted: 02/27/2017] [Indexed: 01/16/2023]
Affiliation(s)
| | - Xulei Liu
- Department of Biostatistics; Vanderbilt University; Nashville TN
| | - Conor M. McWade
- Schools of Medicine and Public Health; Vanderbilt University; Nashville TN
| | - Dandan Liu
- Department of Biostatistics; Vanderbilt University; Nashville TN
| | - Alan B. Storrow
- Department of Emergency Medicine; Vanderbilt University; Nashville TN
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Smulowitz PB, Barrett O, Hall MM, Grossman SA, Ullman EA, Novack V. Physician Variability in Management of Emergency Department Patients with Chest Pain. West J Emerg Med 2017; 18:592-600. [PMID: 28611878 PMCID: PMC5468063 DOI: 10.5811/westjem.2017.2.32747] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2016] [Revised: 01/12/2017] [Accepted: 02/01/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Chest pain is a common emergency department (ED) presentation accounting for 8–10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level. Methods We conducted a single-institution retrospective observational study of ED patients with a diagnosis of chest pain as determined by diagnostic code from our hospital administrative database. We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram (ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into two groups: “admission” (this included observation and inpatients) and “discharged.” We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values. Results Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89–172). Average admission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’ characteristics, years elapsed since finishing medical school demonstrated a trend towards association with a higher admission probability. Conclusion There is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role.
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Affiliation(s)
- Peter B Smulowitz
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Orit Barrett
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Department of Medicine and Clinical Research Center, Be'er Sheva, Israel
| | - Matthew M Hall
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Shamai A Grossman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Edward A Ullman
- Beth Israel Deaconess Medical Center, Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Victor Novack
- Soroka University Medical Center and Faculty of Health Sciences, Ben-Gurion University of the Negev, Department of Internal Medicine, Be'er Sheva, Israel
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The relative contribution of provider and ED-level factors to variation among the top 15 reasons for ED admission. Am J Emerg Med 2017; 35:1291-1297. [PMID: 28410917 DOI: 10.1016/j.ajem.2017.03.074] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2016] [Revised: 02/28/2017] [Accepted: 03/30/2017] [Indexed: 11/23/2022] Open
Abstract
STUDY OBJECTIVE We examine adult emergency department (ED) admission rates for the top 15 most frequently admitted conditions, and assess the relative contribution in admission rate variation attributable to the provider and hospital. METHODS This was a retrospective, cross-sectional study of ED encounters (≥18years) from 19 EDs and 603 providers (January 2012-December 2013), linked to the Area Health Resources File for county-level information on healthcare resources. "Hospital admission" was the outcome, a composite of inpatient, observation, or intra-hospital transfer. We studied the 15 most commonly admitted conditions, and calculated condition-specific risk-standardized hospital admission rates (RSARs) using multi-level hierarchical generalized linear models. We then decomposed the relative contribution of provider-level and hospital-level variation for each condition. RESULTS The top 15 conditions made up 34% of encounters and 49% of admissions. After adjustment, the eight conditions with the highest hospital-level variation were: 1) injuries, 2) extremity fracture (except hip fracture), 3) skin infection, 4) lower respiratory disease, 5) asthma/chronic obstructive pulmonary disease (A&C), 6) abdominal pain, 7) fluid/electrolyte disorders, and 8) chest pain. Hospital-level intra-class correlation coefficients (ICC) ranged from 0.042 for A&C to 0.167 for extremity fractures. Provider-level ICCs ranged from 0.026 for abdominal pain to 0.104 for chest pain. Several patient, hospital, and community factors were associated with admission rates, but these varied across conditions. CONCLUSION For different conditions, there were different contributions to variation at the hospital- and provider-level. These findings deserve consideration when designing interventions to optimize admission decisions and in value-based payment programs.
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A predictive model for diagnosis of lower extremity cellulitis: A cross-sectional study. J Am Acad Dermatol 2017; 76:618-625.e2. [DOI: 10.1016/j.jaad.2016.12.044] [Citation(s) in RCA: 36] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2016] [Revised: 11/30/2016] [Accepted: 12/23/2016] [Indexed: 11/22/2022]
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Obermeyer Z, Cohn B, Wilson M, Jena AB, Cutler DM. Early death after discharge from emergency departments: analysis of national US insurance claims data. BMJ 2017; 356:j239. [PMID: 28148486 PMCID: PMC6168034 DOI: 10.1136/bmj.j239] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
OBJECTIVE To measure incidence of early death after discharge from emergency departments, and explore potential sources of variation in risk by measurable aspects of hospitals and patients. DESIGN Retrospective cohort study. SETTING Claims data from the US Medicare program, covering visits to an emergency department, 2007-12. PARTICIPANTS Nationally representative 20% sample of Medicare fee for service beneficiaries. As the focus was on generally healthy people living in the community, patients in nursing facilities, aged ≥90, receiving palliative or hospice care, or with a diagnosis of a life limiting illnesses, either during emergency department visits (for example, myocardial infarction) or in the year before (for example, malignancy) were excluded. MAIN OUTCOME MEASURE Death within seven days after discharge from the emergency department, excluding patients transferred or admitted as inpatients. RESULTS Among discharged patients, 0.12% (12 375/10 093 678, in the 20% sample over 2007-12) died within seven days, or 10 093 per year nationally. Mean age at death was 69. Leading causes of death on death certificates were atherosclerotic heart disease (13.6%), myocardial infarction (10.3%), and chronic obstructive pulmonary disease (9.6%). Some 2.3% died of narcotic overdose, largely after visits for musculoskeletal problems. Hospitals in the lowest fifth of rates of inpatient admission from the emergency department had the highest rates of early death (0.27%)-3.4 times higher than hospitals in the highest fifth (0.08%)-despite the fact that hospitals with low admission rates served healthier populations, as measured by overall seven day mortality among all comers to the emergency department. Small increases in admission rate were linked to large decreases in risk. In multivariate analysis, emergency departments that saw higher volumes of patients (odds ratio 0.84, 95% confidence interval 0.81 to 0.86) and those with higher charges for visits (0.75, 0.74 to 0.77) had significantly fewer deaths. Certain diagnoses were more common among early deaths compared with other emergency department visits: altered mental status (risk ratio 4.4, 95% confidence interval 3.8 to 5.1), dyspnea (3.1, 2.9 to 3.4), and malaise/fatigue (3.0, 2.9 to 3.7). CONCLUSIONS Every year, a substantial number of Medicare beneficiaries die soon after discharge from emergency departments, despite no diagnosis of a life limiting illnesses recorded in their claims. Further research is needed to explore whether these deaths were preventable.
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Affiliation(s)
- Ziad Obermeyer
- Department of Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Brent Cohn
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Michael Wilson
- Department of Emergency Medicine, Harvard Medical School, Boston, MA 02115, USA
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA 02115, USA
| | - David M Cutler
- Department of Economics, Harvard University, Cambridge, MA 02138, USA
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Nedza SM, Fry DE, DesHarnais S, Spencer E, Yep P. Emergency Department Visits Following Joint Replacement Surgery in an Era of Mandatory Bundled Payments. Acad Emerg Med 2017; 24:236-245. [PMID: 27611713 DOI: 10.1111/acem.13080] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Revised: 08/26/2016] [Accepted: 09/02/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVES The Center for Medicare & Medicaid Services (CMS) is actively testing bundled payments models. This study sought to identify relevant details for 90-day postdischarge emergency department (ED) visits of Medicare beneficiaries following total joint replacement (TJR) surgery meeting eligibility for a CMS bundled payment program. METHODS The CMS research identifiable file for the State of Texas for 2011-2012 was used to identify patients who underwent TJR. Qualifying inpatient claims were linked to 90-day postdischarge ED claims. The claims associated with live discharge were divided into three cohorts: elective total hip replacement (THR), emergent (THR), and total knee replacement. The frequency, distribution, diagnoses, and disposition for these ED visits were identified and stratified by timing within the postdischarge period as well as discharge diagnosis. Visits were correlated with age, sex, joint replaced, and fracture. RESULTS There were 50,838 TJR surgeries in Texas in 2011-2012 that would have been eligible for inclusion in the CMS defined CJR program. A total of 12,747 ED visits by 9,299 patients occurred in the 90-day postdischarge period. Visits to the ED by patients 85 and older predominated in the case of THR performed secondary to a hip fracture. Patients 65-74 years predominated in both elective surgery categories. There were 2,370 ED visits within 90 days of 10,786 elective THRs, of which 55.5% were discharged home, 34.6% were hospitalized or transferred, and 6.9% were admitted to observation. Of the 3,438 ED visits among 8,475 emergent hip replacement cases, 22.4% were discharged home, 50.2% were hospitalized or transferred, and 5.3% were admitted to observation. Of the 6,939 visits among 31,387 knee replacement cases, 61.9% were discharged home, 30.6% were readmitted or transferred, and 7.1% were admitted to observation. The discharge diagnoses varied by volume and timing in the postdischarge period. The most prevalent diagnoses across groups included injury/trauma, physiologic decompensation, cardiopulmonary events, and infection. CONCLUSIONS ED services are frequent for Medicare TJR bundle-eligible patients within the postdischarge period. ED utilization, discharge diagnosis and disposition varied by age, and elective and emergent surgeries. The ED is an important site for identifying and managing postoperative adverse outcomes.
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Affiliation(s)
- Susan M. Nedza
- MPA Healthcare Solutions Chicago IL
- Department of Emergency Medicine Feinberg School of Medicine Northwestern University Chicago IL
| | - Donald E. Fry
- MPA Healthcare Solutions Chicago IL
- Department of Surgery Feinberg School of Medicine Northwestern University Chicago IL
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Long B, Koyfman A. Best Clinical Practice: Current Controversies in Evaluation of Low-Risk Chest Pain-Part 1. J Emerg Med 2016; 51:668-676. [PMID: 27693075 DOI: 10.1016/j.jemermed.2016.07.103] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 07/20/2016] [Accepted: 07/21/2016] [Indexed: 10/20/2022]
Abstract
BACKGROUND Chest pain is a common presentation to the emergency department (ED), though the majority of patients are not diagnosed with acute coronary syndrome (ACS). Many patients are admitted to the hospital due to fear of ACS. OBJECTIVE Our aim was to investigate controversies in low-risk chest pain evaluation, including risk of missed ACS, stress test, and coronary computed tomography angiography (CCTA). DISCUSSION Chest pain accounts for 10 million ED visits in the United States annually. Many patients are at low risk for a major cardiac adverse event (MACE). With negative troponin and nonischemic electrocardiogram (ECG), the risk of MACE and myocardial infarction (MI) is < 1%. The American Heart Association recommends further evaluation in low- to intermediate-risk patients within 72 h. These modalities add little to further risk stratification. These evaluations do not appropriately risk stratify patients who are already at low risk, nor do they diagnose acute MI. CCTA is an anatomic evaluation of the coronary vasculature with literature support to decrease ED length of stay, though it is associated with downstream testing. Literature is controversial concerning further risk stratification in already low-risk patients. CONCLUSIONS With nonischemic ECG and negative cardiac biomarker, the risk of ACS approaches < 1%. Use of stress test and CCTA for risk stratification of low-risk chest pain patients is controversial. These tests may allow prognostication but do not predict ACS risk beyond ECG and troponin. CCTA may be useful for intermediate-risk patients, though further studies are required.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- The University of Texas Southwestern Medical Center, Department of Emergency Medicine, Dallas, Texas
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Long B, Koyfman A. Best Clinical Practice: Current Controversies in the Evaluation of Low-Risk Chest Pain with Risk Stratification Aids. Part 2. J Emerg Med 2016; 52:43-51. [PMID: 27692651 DOI: 10.1016/j.jemermed.2016.07.004] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2016] [Accepted: 07/20/2016] [Indexed: 11/29/2022]
Abstract
BACKGROUND Chest pain accounts for 10% of emergency department (ED) visits annually, and many of these patients are admitted because of potentially life-threatening conditions. A substantial percentage of patients with chest pain are at low risk for a major cardiac adverse event (MACE). OBJECTIVE We investigated controversies in the evaluation of patients with low-risk chest pain, including clinical scores, decision pathways, and shared decision-making. DISCUSSION ED patients with chest pain who have negative biomarker results and nonischemic electrocardiograms are at low risk for MACE. With the large number of chest pain patients evaluated in the ED, several risk scores and pathways are in use based on history, electrocardiographic results, and biomarker results. The Thrombolysis in Myocardial Infarction and Global Registry of Acute Coronary Events scores are older rules with validation; however, they do not have adequate sensitivity or are not easy to use in the ED. The Vancouver chest pain and North American chest pain rules may be used for patients with undifferentiated chest pain in the ED. The Manchester Acute Coronary Syndromes rule uses eight factors, several of which are not available in the United States. The history, electrocardiography, age, risk factors, and troponin (HEART) score and pathway are easy to use, have high sensitivity and negative predictive values, and have better discriminatory capability for categorization. The use of pathways with shared decision-making involves the patient in management, shortens the duration of stay, and decreases risk to both the patient and the provider. CONCLUSIONS Risk stratification of ED patients with chest pain has evolved, and there are many tools available. The HEART pathway, designed for ED use, has several attributes that provide safe and efficient care for patients with chest pain.
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Affiliation(s)
- Brit Long
- Department of Emergency Medicine, San Antonio Military Medical Center, Fort Sam Houston, Texas
| | - Alex Koyfman
- Department of Emergency Medicine, The University of Texas Southwestern Medical Center, Dallas, Texas
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71
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Sabbatini AK, Kocher KE, Basu A, Hsia RY. In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department. JAMA 2016; 315:663-71. [PMID: 26881369 PMCID: PMC8366576 DOI: 10.1001/jama.2016.0649] [Citation(s) in RCA: 74] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care. OBJECTIVE To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED. DESIGN, SETTING, AND PARTICIPANTS Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days. EXPOSURES Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED. MAIN OUTCOMES AND MEASURES In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs. RESULTS Among the 9,036,483 index ED visits to 424 hospitals in the study sample, 1,758,359 patients were admitted to the hospital during the index ED visit. Of these patients, 149,214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228,370 (13.0%) within 14 days, and 349,335 (19.9%) within 30 days, and 76,151 (51.0%), 122,040 (53.4%), and 190,768 (54.6%), respectively, were readmitted to the hospital. Among the 7,278,124 patients who were discharged during the index ED visit, 598,404 (8.2%) had a return visit to the ED within 7 days, 839,386 (11.5%) within 14 days, and 1,205,865 (16.6%) within 30 days. Of these patients, 86,012 (14.4%) were admitted to the hospital within 7 days, 121,587 (14.5%) within 14 days, and 173,279 (14.4%) within 30 days. The 86,012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1,609,145 patients who were admitted during the index ED visit without a return ED visit (2.48%) (odds ratio, 0.73 [95% CI, 0.69-0.78]), lower rates of ICU admission (23.3% vs 29.0%, respectively; odds ratio, 0.73 [95% CI, 0.71-0.76]), lower mean costs ($10,169 vs $10,799; difference, $629 [95% CI, $479-$781]), and longer lengths of stay (5.16 days vs 4.97 days; IRR, 1.04 [95% CI, 1.03-1.05]). Similar outcomes were observed for patients returning to the ED within 14 and 30 days of the index ED visit. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit. CONCLUSIONS AND RELEVANCE Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.
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Affiliation(s)
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor3Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor
| | - Anirban Basu
- Department of Health Services and Economics, University of Washington, Seattle
| | - Renee Y Hsia
- Department of Emergency Medicine, University of California, San Francisco6Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
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Berdahl C, Schuur JD, Fisher NL, Burstin H, Pines JM. Policy Measures and Reimbursement for Emergency Medical Imaging in the Era of Payment Reform: Proceedings From a Panel Discussion of the 2015 Academic Emergency Medicine Consensus Conference. Acad Emerg Med 2015; 22:1393-9. [PMID: 26568025 PMCID: PMC4715479 DOI: 10.1111/acem.12829] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2015] [Accepted: 07/07/2015] [Indexed: 11/28/2022]
Abstract
The Affordable Care Act (ACA) of 2010 is expanding the use of quality measurement and promulgating new payment models that place downward pressure on health care utilization and costs. As emergency department (ED) computed tomography utilization has tripled in the past decade, stakeholders have identified advanced imaging as an area where quality and efficiency measures should expand. On May 12, 2015, Academic Emergency Medicine convened a consensus conference titled "Diagnostic Imaging in the Emergency Department: A Research Agenda to Optimize Utilization." As part of the conference, a panel of health care policy leaders and emergency physicians discussed the effect of the ACA and other quality programs on ED diagnostic imaging, specifically the way that quality metrics may affect ED care and how ED diagnostic imaging fits in the broader strategy of the U.S. government. This article discusses the content of the panel's presentations.
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Affiliation(s)
- Carl Berdahl
- Department of Emergency Medicine, University of Southern California, Los Angeles, CA
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA
| | - Nancy L Fisher
- Centers for Medicare and Medicaid Services, Region 10, Seattle, WA
| | | | - Jesse M Pines
- Departments of Emergency Medicine and Health Policy and Management, The George Washington University, Washington, DC
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Singh S, Lin YL, Nattinger AB, Kuo YF, Goodwin JS. Variation in readmission rates by emergency departments and emergency department providers caring for patients after discharge. J Hosp Med 2015; 10:705-10. [PMID: 26130443 PMCID: PMC4891808 DOI: 10.1002/jhm.2407] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2015] [Revised: 05/20/2015] [Accepted: 05/27/2015] [Indexed: 11/11/2022]
Abstract
BACKGROUND The role of the emergency department (ED) provider and ED facility in readmissions of recently discharged patients who visit the ED has not been studied. OBJECTIVE To determine the variation in readmission rates by ED facility and ED providers caring for patients after discharge. DESIGN Retrospective cohort study using multilevel, multivariable models of 100% Texas Medicare claims data from the years 2007 to 2011. SETTING Texas acute-care hospitals and ED facilities. PATIENTS Medicare beneficiaries who visited an ED within 30 days of discharge from a hospital. INTERVENTION None. MEASUREMENT Readmission after an ED visit within 30 days of discharge from an initial hospitalization defined as a hospitalization starting the day of or the day following the ED visit. RESULTS The mean readmission rate following an ED visit was 52.67%. In 2-level models, 14.2% of ED providers readmitted significantly more patients (mean readmission rate of 67.2%) than the mean; 14.7% of ED providers readmitted significantly fewer patients (mean readmission rate of 36.8%) than the mean. After accounting for the ED facility in 3-level models, the variance for the ED providers decreased 65% from 0.2532 to 0.0893. CONCLUSIONS The risk of readmission varies by ED provider caring for patients after discharge. A large part of this variation is explained by the ED facility in which the ED providers practice. Thus, ED provider practices patterns and ED facility systems of care may be a target for interventions to reduce readmissions.
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Affiliation(s)
- Siddhartha Singh
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
- Address for correspondence and reprint requests: Siddhartha Singh, MD, The Medical College of Wisconsin, 9200 West Wisconsin Avenue, Milwaukee, WI, 53226; Telephone: 414-805-0844; Fax: 414-805-0454;
| | - Yu-Li Lin
- Department of Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - Ann B. Nattinger
- Center for Patient Care and Outcomes Research, Medical College of Wisconsin, Milwaukee, Wisconsin
- Division of General Internal Medicine, Department of Medicine, Medical College of Wisconsin, Milwaukee, Wisconsin
| | - Yong-Fang Kuo
- Department of Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
| | - James S. Goodwin
- Department of Medicine and Sealy Center on Aging, University of Texas Medical Branch, Galveston, Texas
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