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Simon EL, Deshmukh A, Marcus C, Wolfe J, Krizo J. Optimizing care pathways: A study of the urgent dispatch program and its impact on emergency department visits. Am J Emerg Med 2024; 85:186-189. [PMID: 39278025 DOI: 10.1016/j.ajem.2024.09.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 08/29/2024] [Accepted: 09/05/2024] [Indexed: 09/17/2024] Open
Abstract
INTRODUCTION The use of acute hospital-level care at home (hospital-at-home) for patients who are chronically ill has led to decreased medical costs, amount of sedentary time, and hospital admissions. Our large integrated healthcare system identified the need to develop a mechanism through which to decrease emergency department (ED) visits in this patient population by creating a home acute care program called Urgent Dispatch. The primary objective of this study was to determine the medical condition for referral and seven and 30-day ED visit rates. METHODS This was a retrospective cohort of all patients referred to the Urgent Dispatch program from April 1, 2021, through February 28, 2022. We assessed encounters for patient demographics, referral source, reason for visit, number of at home visits, total number of days in the program, and determined if the patient had an ED encounter within seven and 30 days of participation in the program. The healthcare system includes 10 hospitals (academic, community and rural), 17 emergency departments (hospital-based and freestanding) and their associated outpatient clinics. RESULTS A total of 2218 orders were placed with 1530 (70.8 %) resulting in enrollment in the Urgent Dispatch program. The majority were elderly (75 ± 15.6), white (70 %), female (64.4 %), and had Medicare as their primary insurance (82 %). The average number of visits made by Urgent Dispatch was 1.46 (SD ± 0.95). The average number of days enrolled in the program was 2.4 (SD ± 4.1). The top three referral sources to the program were outpatient primary care (42 %), home care (28 %) and emergency medicine (20 %). The top body systems requiring a visit were cardiovascular (22 %), general (18 %), and respiratory (17.2 %). Of the 1530 urgent dispatch referrals, 19.8 % (n = 303) had an ED visit within seven days, 12 % (n = 183) had an ED visit within eight to 30 days, and 68.2 % (n = 1044) had no ED visit. CONCLUSION A home-based care model of healthcare delivery for patients with chronic medical conditions can provide effective care, with 80.2 % of patients avoiding an ED visit within seven days and 68.2 % avoiding an ED visit within 30 days.
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Affiliation(s)
- Erin L Simon
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, OH 44307, USA; Northeast Ohio Medical University; 4209 St. OH-44, Rootstown, OH 44272. USA.
| | - Aditi Deshmukh
- Northeast Ohio Medical University; 4209 St. OH-44, Rootstown, OH 44272. USA
| | - Cameron Marcus
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, OH 44307, USA
| | - Judy Wolfe
- Cleveland Clinic Akron General, Department of Enterprise and Safety, 1 Akron General Ave. Akron, OH 44307, USA
| | - Jessica Krizo
- Cleveland Clinic Akron General, Department of Emergency Medicine, 1 Akron General Ave. Akron, OH 44307, USA
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Park YT, Kim D, Jeon JS, Kim KG. Predictors of Medical and Dental Clinic Closure by Machine Learning Methods: Cross-Sectional Study Using Empirical Data. J Med Internet Res 2024; 26:e46608. [PMID: 39213534 PMCID: PMC11399738 DOI: 10.2196/46608] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/12/2024] [Accepted: 07/01/2024] [Indexed: 09/04/2024] Open
Abstract
BACKGROUND Small clinics are important in providing health care in local communities. Accurately predicting their closure would help manage health care resource allocation. There have been few studies on the prediction of clinic closure using machine learning techniques. OBJECTIVE This study aims to test the feasibility of predicting the closure of medical and dental clinics (MCs and DCs, respectively) and investigate important factors associated with their closure using machine running techniques. METHODS The units of analysis were MCs and DCs. This study used health insurance administrative data. The participants of this study ran and closed clinics between January 1, 2020, and December 31, 2021. Using all closed clinics, closed and run clinics were selected at a ratio of 1:2 based on the locality of study participants using the propensity matching score of logistic regression. This study used 23 and 19 variables to predict the closure of MCs and DCs, respectively. Key variables were extracted using permutation importance and the sequential feature selection technique. Finally, this study used 5 and 6 variables of MCs and DCs, respectively, for model learning. Furthermore, four machine learning techniques were used: (1) logistic regression, (2) support vector machine, (3) random forest (RF), and (4) Extreme Gradient Boost. This study evaluated the modeling accuracy using the area under curve (AUC) method and presented important factors critically affecting closures. This study used SAS (version 9.4; SAS Institute Inc) and Python (version 3.7.9; Python Software Foundation). RESULTS The best-fit model for the closure of MCs with cross-validation was the support vector machine (AUC 0.762, 95% CI 0.746-0.777; P<.001) followed by RF (AUC 0.736, 95% CI 0.720-0.752; P<.001). The best-fit model for DCs was Extreme Gradient Boost (AUC 0.700, 95% CI 0.675-0.725; P<.001) followed by RF (AUC 0.687, 95% CI 0.661-0.712; P<.001). The most significant factor associated with the closure of MCs was years of operation, followed by population growth, population, and percentage of medical specialties. In contrast, the main factor affecting the closure of DCs was the number of patients, followed by annual variation in the number of patients, year of operation, and percentage of dental specialists. CONCLUSIONS This study showed that machine running methods are useful tools for predicting the closure of small medical facilities with a moderate level of accuracy. Essential factors affecting medical facility closure also differed between MCs and DCs. Developing good models would prevent unnecessary medical facility closures at the national level.
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Affiliation(s)
- Young-Taek Park
- HIRA Research Institute, Health Insurance Review & Assessment Service, Wonju-si, Republic of Korea
| | - Donghan Kim
- Center for Geospatially Enabled Society, Korea Research Institute for Human Settlements, Sejong-si, Republic of Korea
| | - Ji Soo Jeon
- Department of Biomedical Engineering, College of Medicine, Gil Medical Center, Gachon University, Inchon, Republic of Korea
| | - Kwang Gi Kim
- Department of Biomedical Engineering, College of Medicine, Gil Medical Center, Gachon University, Inchon, Republic of Korea
- KMAIN Corp, Seongnam-si, Republic of Korea
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Hsia RY, Shen YC. Structural Inequities In The Adoption Of Percutaneous Coronary Intervention Services By US Hospitals, 2000-20. Health Aff (Millwood) 2024; 43:1011-1020. [PMID: 38950302 PMCID: PMC11293955 DOI: 10.1377/hlthaff.2023.01649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/03/2024]
Abstract
Percutaneous coronary intervention (PCI) is a procedure that opens blocked arteries and restores blood flow to the heart. Timely access to hospitals offering PCI services can be a matter of life or death for patients experiencing a heart attack; however, hospitals' adoption of PCI services may vary between communities, posing potential barriers to critical care. Our cohort study of US general acute hospitals during the period 2000-20 examined PCI service adoption across communities stratified by race, ethnicity, income, and rurality and further classified as segregated or integrated. Of 5,260 hospitals, 1,621 offered PCI services in 2020 or before, 630 added PCI services between 2001 and 2010, and 225 added PCI services between 2011 and 2020. Hospitals serving Black, racially segregated communities were 48 percent less likely to adopt PCI services compared with hospitals serving non-Black, racially segregated communities, and hospitals serving Hispanic, ethnically segregated communities were 41 percent less likely to do so than those serving non-Hispanic, ethnically segregated communities. Hospitals in high-income, economically integrated communities were 1.8 times more likely to adopt PCI services than those in high-income, economically segregated communities, and rural hospitals were less likely to do so than urban hospitals. Understanding where services are expanding in relation to community need may aid in successful policy interventions.
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Affiliation(s)
- Renee Y Hsia
- Renee Y. Hsia , University of California San Francisco, San Francisco, California
| | - Yu-Chu Shen
- Yu-Chu Shen, Naval Postgraduate School, Monterey, California; and National Bureau of Economic Research, Cambridge, Massachusetts
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Singh P. Macroeconomic antecedents of racial disparities in psychiatric-related emergency department visits. Front Psychiatry 2024; 15:1287791. [PMID: 38932936 PMCID: PMC11200170 DOI: 10.3389/fpsyt.2024.1287791] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Accepted: 05/07/2024] [Indexed: 06/28/2024] Open
Abstract
Objective To test whether monthly declines in aggregate employment precede a rise in African American psychiatric-related ED visits (PREDVs) relative to white visits among low-income, working-age populations. Design This study used repeated cross-sectional time series data for 6.7 million PREDVs among African Americans and white individuals from the State Emergency Department Database in 48 Metropolitan Statistical Areas (MSAs) across four states (Arizona, California, New York, New Jersey) from 2006 to 2011. MSA-level monthly employment data were obtained from the US Bureau of Labor Statistics. The outcome was specified as the race of a PREDV (African American = 1, white = 0). The exposure was operationalized as monthly percent change in MSA-level aggregate employment lagged by 0 to 3 months. Analysis included logistic regressions with county, month and year fixed effects, and clustered standard errors to examine the relation between odds of an African American PREDV (relative to white) following 0 to 3 months lag of MSA-level aggregate employment change. Findings Logistic regression results indicate that the odds of PREDVs for publicly insured, working-age African Americans (relative to white individuals) increase 3 months after ambient employment decline (OR: 0.994, 95% CI: [0.990 0.998]). Conclusion Economic downturns may marginally increase psychiatric help-seeking in EDs among publicly insured (low-income), working-age African Americans relative to white individuals. Findings from this study may contribute to the theoretical understanding of dynamic drivers of racial disparities in psychiatric ED visits.
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Lusk JB, Manandhar P, Thomas LE, O'Brien EC. Association between characteristics of employing healthcare facilities and healthcare worker infection rates and psychosocial experiences during the COVID-19 pandemic. BMC Health Serv Res 2024; 24:659. [PMID: 38783301 PMCID: PMC11119393 DOI: 10.1186/s12913-024-11109-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2023] [Accepted: 05/14/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Healthcare facility characteristics, such as ownership, size, and location, have been associated with patient outcomes. However, it is not known whether the outcomes of healthcare workers are associated with the characteristics of their employing healthcare facilities, particularly during the COVID-19 pandemic. METHODS This was an analysis of a nationwide registry of healthcare workers (the Healthcare Worker Exposure Response and Outcomes (HERO) registry). Participants were surveyed on their personal, employment, and medical characteristics, as well as our primary study outcomes of COVID-19 infection, access to personal protective equipment, and burnout. Participants from healthcare sites with at least ten respondents were included, and these sites were linked to American Hospital Association data to extract information about sites, including number of beds, teaching status, urban/rural location, and for-profit status. Generalized estimating equations were used to estimate linear regression models for the unadjusted and adjusted associations between healthcare facility characteristics and outcomes. RESULTS A total of 8,941 healthcare workers from 97 clinical sites were included in the study. After adjustment for participant demographics, healthcare role, and medical comorbidities, facility for-profit status was associated with greater odds of COVID-19 diagnosis (aOR 1.76, 95% CI 1.02-3.03, p = .042). Micropolitan location was associated with decreased odds of COVID-19 infection after adjustment (aOR = 0.42, 95% CI 0.24, 0.71, p = .002. For-profit facility status was associated with decreased odds of burnout after adjustment (aOR = 0.53, 95% CI 0.29-0.98), p = .044). CONCLUSIONS For-profit status of employing healthcare facilities was associated with greater odds of COVID-19 diagnosis but decreased odds of burnout after adjustment for demographics, healthcare role, and medical comorbidities. Future research to understand the relationship between facility ownership status and healthcare outcomes is needed to promote wellbeing in the healthcare workforce. TRIAL REGISTRATION The registry was prospectively registered: ClinicalTrials.gov Identifier (trial registration number) NCT04342806, submitted April 8, 2020.
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Affiliation(s)
- Jay B Lusk
- Department of Neurology, Duke University, DUMC 3710, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
| | | | - Laine E Thomas
- Duke University Clinical Research Institute, Durham, NC, USA
| | - Emily C O'Brien
- Department of Population Health Sciences, Duke University, Durham, NC, USA
- Duke University Clinical Research Institute, Durham, NC, USA
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Owsley KM, Hasnain-Wynia R, Rooks RN, Tung GJ, Mays GP, Lindrooth RC. US Hospital Service Availability and New 340B Program Participation. JAMA HEALTH FORUM 2024; 5:e240833. [PMID: 38700853 PMCID: PMC11069079 DOI: 10.1001/jamahealthforum.2024.0833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Accepted: 02/16/2024] [Indexed: 05/06/2024] Open
Abstract
Importance The US 340B Drug Pricing Program enables eligible hospitals to receive substantial discounts on outpatient drugs to improve hospitals' financial sustainability and maintain access to care for patients who have low income and/or are uninsured. However, it is unclear whether hospitals use program savings to subsidize access as intended. Objective To evaluate whether the 340B program is associated with improvements in access to hospital-based services and to test whether the association varies by hospital ownership. Design, Setting, and Participants Difference-in-differences and cohort analysis from 2010 to 2019. Never and newly participating 340B general, acute, nonfederal hospitals in the US using data from the American Hospital Association's Annual Survey of Hospitals merged with hospital and market characteristics. Data were analyzed from January 1, 2023, to January 31, 2024. Exposures New enrollment in 340B between 2012 and 2018. Main Outcomes and Measures Total number of unprofitable service lines, ie, substance use, psychiatric (inpatient and outpatient), burn clinic, and obstetrics services; and profitable services, ie, cardiac surgery and orthopedic, oncologic, neurologic, and neonatal intensive services. Results The study sample comprised a total of 2152 hospitals, 1074 newly participating and 1078 not participating in the 340B program. Participating hospitals were more likely than nonparticipating hospitals to be critical access and teaching hospitals, have higher Medicaid shares, and be located in rural areas and in Medicaid expansion states. At public hospitals, participation in the 340B program was associated with a significant increase in total unprofitable services (0.21; 95% CI, 0.04 to 0.38; P = .02) and marginal increases in substance use (5.4 percentage points [pp]; 95% CI, -0.8 pp to 11.6 pp; P = .09) and inpatient psychiatric (6.5 pp; 95% CI, -0.7 pp to 13.7 pp; P = .09) services. Among nonprofit hospitals, there was no significant association between 340B and service offerings (profitable and unprofitable) except for an increase in oncologic services (2.5 pp; 95% CI, 0.0 pp to 5.0 pp; P = .05). Conclusions and Relevance The finding of the cohort study indicate that participation in the 340B program was associated with an increase in unprofitable services among newly participating public hospitals. Nonprofit hospitals were largely unaffected. These findings suggest that public hospitals responded to 340B savings by improving patient access, whereas nonprofits did not. This heterogeneous response should be considered when evaluating the eligibility criteria for the 340B program and how it affects social welfare.
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Affiliation(s)
- Kelsey M. Owsley
- Department of Health Policy and Management, University of Arkansas for Medical Sciences, Little Rock
- Winthrop P. Rockefeller Cancer Institute, University of Arkansas for Medical Sciences, Little Rock
| | - Romana Hasnain-Wynia
- Office of Research, Denver Health and Hospital Authority, Denver, Colorado
- Department of Medicine, University of Colorado-Anschutz Medical Campus, Aurora
| | - Ronica N. Rooks
- Department of Health and Behavioral Sciences, University of Colorado Denver, Denver
| | - Gregory J. Tung
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora
| | - Glen P. Mays
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora
| | - Richard C. Lindrooth
- Department of Health Systems, Management, and Policy, Colorado School of Public Health, University of Colorado-Anschutz Medical Campus, Aurora
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Hsuan C, Vanness DJ, Zebrowski A, Carr BG, Norton EC, Buckler DG, Wang Y, Leslie DL, Dunham EF, Rogowski JA. Racial and ethnic disparities in emergency department transfers to public hospitals. Health Serv Res 2024; 59:e14276. [PMID: 38229568 PMCID: PMC10915485 DOI: 10.1111/1475-6773.14276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2024] Open
Abstract
OBJECTIVE To examine racial/ethnic differences in emergency department (ED) transfers to public hospitals and factors explaining these differences. DATA SOURCES AND STUDY SETTING ED and inpatient data from the Healthcare Cost and Utilization Project for Florida (2010-2019); American Hospital Association Annual Survey (2009-2018). STUDY DESIGN Logistic regression examined race/ethnicity and payer on the likelihood of transfer to a public hospital among transferred ED patients. The base model was controlled for patient and hospital characteristics and year fixed effects. Models II and III added urbanicity and hospital referral region (HRR), respectively. Model IV used hospital fixed effects, which compares patients within the same hospital. Models V and VI stratified Model IV by payer and condition, respectively. Conditions were classified as emergency care sensitive conditions (ECSCs), where transfer is protocolized, and non-ECSCs. We reported marginal effects at the means. DATA COLLECTION/EXTRACTION METHODS We examined 1,265,588 adult ED patients transferred from 187 hospitals. PRINCIPAL FINDINGS Black patients were more likely to be transferred to public hospitals compared with White patients in all models except ECSC patients within the same initial hospital (except trauma). Black patients were 0.5-1.3 percentage points (pp) more likely to be transferred to public hospitals than White patients in the same hospital with the same payer. In the base model, Hispanic patients were more likely to be transferred to public hospitals compared with White patients, but this difference reversed after controlling for HRR. Hispanic patients were - 0.6 pp to -1.2 pp less likely to be transferred to public hospitals than White patients in the same hospital with the same payer. CONCLUSIONS Large population-level differences in whether ED patients of different races/ethnicities were transferred to public hospitals were largely explained by hospital market and the initial hospital, suggesting that they may play a larger role in explaining differences in transfer to public hospitals, compared with other external factors.
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Affiliation(s)
- Charleen Hsuan
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - David J. Vanness
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Alexis Zebrowski
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Brendan G. Carr
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
- Department of Population Health Science and PolicyIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Edward C. Norton
- Department of Health Management and PolicyUniversity of Michigan School of Public HealthAnn ArborMichiganUSA
- Department of EconomicsUniversity of MichiganAnn ArborMichiganUSA
| | - David G. Buckler
- Department of Emergency MedicineIcahn School of Medicine at Mount SinaiNew York CityNew YorkUSA
| | - Yinan Wang
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Douglas L. Leslie
- Department of Public Health Sciences, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Eleanor F. Dunham
- Department of Emergency Medicine, College of MedicinePennsylvania State UniversityState CollegePennsylvaniaUSA
| | - Jeannette A. Rogowski
- Department of Health Policy & AdministrationPennsylvania State UniversityState CollegePennsylvaniaUSA
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Fallahi MJ, Seifbehzad S, Fereidooni M, Farrokhi A, Ranjbar K, Shahriarirad R. The trend of mortality rates following hospitals downgrading and closures due to outbreak of COVID-19 in Fars province: A comparative cohort study. Health Sci Rep 2024; 7:e1850. [PMID: 38299210 PMCID: PMC10826241 DOI: 10.1002/hsr2.1850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Revised: 11/07/2023] [Accepted: 01/09/2024] [Indexed: 02/02/2024] Open
Abstract
Background and Aims Hospitals are one of the most important healthcare centers for providing the patients with different medical needs. Several different factors might cause hospitals to downgrade their services or departments or close down overall. One of the most multifaceted reasons for hospital downgrading or closure is infectious disease outbreaks. In this regard, we aimed to evaluate the effects of hospital closure and downgrading due to the COVID-19 pandemic on the mortality rate of the people residing in Fars province, Iran. Methods We gathered mortality information, including the cause of death, age, sex, place, and time of death of all deceased cases occurring during a period of 3 years, from February 20, 2018 to March 2021 from the forensic medicine and also the Department of Biostatistics in Shiraz University of Medical Sciences. Results A total of 71,331 deaths have been reported since 2018 through the first quarter of 2021, with 57.9% of total mortality cases attributed to male gender. The total mortality counts ranged from 4229 to 9809 deaths per quarter, from which the minimum rate was reported in the first quarter of 2018 and the maximum in the fourth quarter of 2020. Based on the causes of death, diseases of the circulatory system were shown to be the all-time most frequent cause of death, accounting for a total of 42.8% of recorded deaths, followed by neoplasms (9.77%) and diseases of the respiratory system (9.45%). Conclusion Although the large number of deaths at the time of the pandemic are immediately due to COVID-19 infection, deaths due to a notable number of other causes have had a significant increase which, along with the specific trend of place and causes of death, shows that the downgrading and closure of hospitals have had a significant impact on overall population mortality.
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Affiliation(s)
- Mohammad Javad Fallahi
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical SciencesShirazIran
- Department of Internal MedicineShiraz University of Medical SciencesShirazIran
| | - Sarvin Seifbehzad
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | | | - Amirmohammad Farrokhi
- Trauma Research Center, Shahid Rajaee (Emtiaz) Trauma HospitalShiraz University of Medical SciencesShirazIran
| | - Keivan Ranjbar
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
| | - Reza Shahriarirad
- Thoracic and Vascular Surgery Research CenterShiraz University of Medical SciencesShirazIran
- Student Research CommitteeShiraz University of Medical SciencesShirazIran
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Zachrison KS, Beaulieu ND, Mehrotra A. Changing Health Care Markets Have the Potential to Undermine Stroke Systems of Care. JAMA Neurol 2023; 80:1131-1132. [PMID: 37695597 DOI: 10.1001/jamaneurol.2023.3103] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/12/2023]
Abstract
This Viewpoint discusses the importance of prioritizing quality of care for patients with stroke in a changing health care environment.
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Affiliation(s)
- Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital and Harvard Medical School, Boston
| | - Nancy D Beaulieu
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | - Ateev Mehrotra
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Elamin A, Sinan L, Tari SPH, Ahmad BI. Analysis of Variables Influencing Short-Term Complications in Geriatric Patients Undergoing Emergency General Surgery (EGS): A Retrospective Cohort Study. Cureus 2023; 15:e44031. [PMID: 37746435 PMCID: PMC10517432 DOI: 10.7759/cureus.44031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/24/2023] [Indexed: 09/26/2023] Open
Abstract
BACKGROUND Emergency general surgery (EGS) encompasses a wide range of acute surgical conditions that pose significant risks to patient life and well-being. Understanding the factors that contribute to short-term complications in geriatric patients undergoing EGS is crucial for improving patient outcomes. This retrospective single-center cohort study aimed to evaluate the impact of various variables on short-term complications in geriatric patients undergoing EGS. METHODS A total of 212 patients aged 65 and above who underwent emergency abdominal surgery between 2017 and 2018 were included in the study. The analysis focused on several variables, including age, sex, body mass index (BMI), beta-blocker use, open abdomen treatment, blood transfusions, anticoagulant therapy, and vasopressor use. Univariate and multivariate analyses were conducted to assess the association between these variables and short-term complications. RESULTS Among the analyzed variables, blood transfusions and vasopressor use demonstrated a statistically significant association with short-term complications. Patients who received blood transfusions had a significantly higher risk of complications, with an odds ratio (OR) of 3.01 (95% confidence interval, CI: 1.28-7.06, p-value = 0.011). Similarly, the use of vasopressors was strongly correlated with increased short-term complications, with an OR of 14.61 (95% CI: 4.86-43.89, p-value < 0.001). CONCLUSION These findings emphasize the importance of minimizing blood transfusions and careful consideration of vasopressor use in geriatric patients undergoing EGS to reduce the risk of short-term complications. Further research is warranted to explore additional factors and optimize perioperative management strategies to improve outcomes in this vulnerable patient population.
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Affiliation(s)
- Abubaker Elamin
- General Surgery, Humanitas University, Milan, ITA
- Otolaryngology, Nottingham University Hospitals, Nottingham, GBR
| | - Laith Sinan
- Orthopaedic Surgery, Nottingham University Hospitals, Nottingham, GBR
| | | | - Bilal I Ahmad
- Orthopaedic Surgery, United Lincolnshire Hospitals, Lincoln, GBR
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Azari L, Turner K, Hong YR, Alishahi Tabriz A. Adoption of emergency department crowding interventions among US hospitals between 2007 and 2020. Am J Emerg Med 2023; 70:127-132. [PMID: 37270852 DOI: 10.1016/j.ajem.2023.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2022] [Revised: 05/03/2023] [Accepted: 05/23/2023] [Indexed: 06/06/2023] Open
Abstract
BACKGROUND To deal with emergency department (ED) crowding, the American College of Emergency Physicians (ACEP) established a task force to develop a list of low-cost, high-impact solutions. In this study, we report on the trend in the adoption rate of ACEP-recommended ED crowding interventions by US hospitals. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey data from 2007 to 2020 (N = 3874 hospitals). The primary outcome was whether a hospital adopted each of the ACEP-recommended interventions, which were grouped into three overlapping categories: technology-based, flow modifications, and physical-based (e.g., changing ED layout). RESULTS On average, the most frequently adopted intervention was bedside registration (85.1%) and the least frequently adopted intervention was kiosk check-in (8.3%). The adoption of ED crowding interventions increased significantly between 2007 and 2020, except for expanding ED treatment space which declined by 45.0% from 30.3% in 2007 to 15.7% in 2020. The largest adoption rate increase occurred in having a separate operating room for ED cases with a 188.5% increase in adoption rate followed by radio-frequency identification (RFID) tracking (151.2%), and kiosk check-in (144.2%). CONCLUSIONS The adoption rate of ED crowding interventions by hospitals has risen, however most effective ED crowding interventions are still underutilized. The trends for each intervention did not always increase linearly, with certain periods showing greater fluctuations in adoption rate. Hospitals tend to implement technology-based interventions, compared to physical-based interventions and flow modification interventions.
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Affiliation(s)
- Leila Azari
- University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Kea Turner
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA; Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA
| | - Young-Rock Hong
- Department of Health Services Research, Management and Policy, College of Public Health and Health Professions University of Florida, Gainesville, FL, USA; UF Health Cancer Center, Gainesville, FL, USA
| | - Amir Alishahi Tabriz
- Department of Health Outcomes and Behavior, Moffitt Cancer Center, Tampa, FL, USA; Department of Oncological Sciences, University of South Florida Morsani College of Medicine, Tampa, FL, USA.
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HSUAN CHARLEEN, CARR BRENDANG, VANNESS DAVID, WANG YINAN, LESLIE DOUGLASL, DUNHAM ELEANOR, ROGOWSKI JEANNETTEA. A Conceptual Framework for Optimizing the Equity of Hospital-Based Emergency Care: The Structure of Hospital Transfer Networks. Milbank Q 2023; 101:74-125. [PMID: 36919402 PMCID: PMC10037699 DOI: 10.1111/1468-0009.12609] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/16/2023] Open
Abstract
Policy Points Current pay-for-performance and other payment policies ignore hospital transfers for emergency conditions, which may exacerbate disparities. No conceptual framework currently exists that offers a patient-centered, population-based perspective for the structure of hospital transfer networks. The hospital transfer network equity-quality framework highlights the external and internal factors that determine the structure of hospital transfer networks, including structural inequity and racism. CONTEXT Emergency care includes two key components: initial stabilization and transfer to a higher level of care. Significant work has focused on ensuring that local facilities can stabilize patients. However, less is understood about transfers for definitive care. To better understand how transfer network structure impacts population health and equity in emergency care, we proposea conceptual framework, the hospital transfer network equity-quality model (NET-EQUITY). NET-EQUITY can help optimize population outcomes, decrease disparities, and enhance planning by supporting a framework for understanding emergency department transfers. METHODS To develop the NET-EQUITY framework, we synthesized work on health systems and quality of health care (Donabedian, the Institute of Medicine, Ferlie, and Shortell) and the research framework of the National Institute on Minority Health and Health Disparities with legal and empirical research. FINDINGS The central thesis of our framework is that the structure of hospital transfer networks influences patient outcomes, as defined by the Institute of Medicine, which includes equity. The structure of hospital transfer networks is shaped by internal and external factors. The four main external factors are the regulatory, economic environment, provider, and sociocultural and physical/built environment. These environments all implicate issues of equity that are important to understand to foster an equitable population-based system of emergency care. The framework highlights external and internal factors that determine the structure of hospital transfer networks, including structural racism and inequity. CONCLUSIONS The NET-EQUITY framework provides a patient-centered, equity-focused framework for understanding the health of populations and how the structure of hospital transfer networks can influence the quality of care that patients receive.
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Rhoades CA, Whitacre BE, Davis AF. Community sociodemographics and rural hospital survival. J Rural Health 2022. [DOI: 10.1111/jrh.12728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Affiliation(s)
- Claudia A. Rhoades
- Department of Agricultural Economics Oklahoma State University Stillwater Oklahoma USA
| | - Brian E. Whitacre
- Department of Agricultural Economics Oklahoma State University Stillwater Oklahoma USA
| | - Alison F. Davis
- Department of Agricultural Economics University of Kentucky Lexington Kentucky USA
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14
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Jeyaraman MM, Alder RN, Copstein L, Al-Yousif N, Suss R, Zarychanski R, Doupe MB, Berthelot S, Mireault J, Tardif P, Askin N, Buchel T, Rabbani R, Beaudry T, Hartwell M, Shimmin C, Edwards J, Halas G, Sevcik W, Tricco AC, Chochinov A, Rowe BH, Abou-Setta AM. Impact of employing primary healthcare professionals in emergency department triage on patient flow outcomes: a systematic review and meta-analysis. BMJ Open 2022; 12:e052850. [PMID: 35443941 PMCID: PMC9058787 DOI: 10.1136/bmjopen-2021-052850] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/23/2021] [Accepted: 02/26/2022] [Indexed: 11/13/2022] Open
Abstract
OBJECTIVES To identify, critically appraise and summarise evidence on the impact of employing primary healthcare professionals (PHCPs: family physicians/general practitioners (GPs), nurse practitioners (NP) and nurses with increased authority) in the emergency department (ED) triage, on patient flow outcomes. METHODS We searched Medline (Ovid), EMBASE (Ovid), Cochrane Library (Wiley) and CINAHL (EBSCO) (inception to January 2020). Our primary outcome was the time to provider initial assessment (PIA). Secondary outcomes included time to triage, proportion of patients leaving without being seen (LWBS), length of stay (ED LOS), proportion of patients leaving against medical advice (LAMA), number of repeat ED visits and patient satisfaction. Two independent reviewers selected studies, extracted data and assessed study quality using the National Institute for Health and Care Excellence quality assessment tool. RESULTS From 23 973 records, 40 comparative studies including 10 randomised controlled trials (RCTs) and 13 pre-post studies were included. PHCP interventions were led by NP (n=14), GP (n=3) or nurses with increased authority (n=23) at triage. In all studies, PHCP-led intervention effectiveness was compared with the traditional nurse-led triage model. Median duration of the interventions was 6 months. Study quality was generally low (confounding bias); 7 RCTs were classified as moderate quality. Most studies reported that PHCP-led triage interventions decreased the PIA (13/14), ED LOS (29/30), proportion of patients LWBS (8/10), time to triage (3/3) and repeat ED visits (5/6), and increased the patient satisfaction (8/10). The proportion of patients LAMA did not differ between groups (3/3). Evidence from RCTs (n=8) as well as other study designs showed a significant decrease in ED LOS favouring the PHCP-led interventions. CONCLUSIONS Overall, PHCP-led triage interventions improved ED patient flow metrics. There was a significant decrease in ED LOS irrespective of the study design, favouring the PHCP-led interventions. Evidence from well-designed high-quality RCTs is required prior to widespread implementation. PROSPERO REGISTRATION NUMBER CRD42020148053.
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Affiliation(s)
- Maya M Jeyaraman
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Rachel N Alder
- Max Rady College of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Leslie Copstein
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nameer Al-Yousif
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Roger Suss
- Department of Family Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ryan Zarychanski
- Department of Medical Oncology and Hematology, Cancer Care Manitoba, Winnipeg, Manitoba, Canada
| | - Malcolm B Doupe
- Department of Community Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Simon Berthelot
- Centre de recherche du CHU de Québec-Université Laval, Axe Santé des populations et Pratiques optimales en santé, Laval, Quebec, Canada
| | - Jean Mireault
- HEC Pôle santé, Université de Montréal, Montreal, Quebec, Canada
| | - Patrick Tardif
- Department of Emergency Medicine, Cité de la santé de Laval, Laval, Quebec, Canada
| | - Nicole Askin
- WRHA Virtual Library, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Tamara Buchel
- Manitoba College of Family Physicians, Winnipeg, Manitoba, Canada
| | - Rasheda Rabbani
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Thomas Beaudry
- Patient and Public Engagement Collaborative Partnership, George & Fay Yee Center for Healthcare Innovation, Winnipeg, Manitoba, Canada
| | - Melissa Hartwell
- Primary and Integrated Health care Innovation Network, Edmonton, Alberta, Canada
| | - Carolyn Shimmin
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Jeanette Edwards
- Community Health Quality and Learning, Shared Health Manitoba, Winnipeg, Manitoba, Canada
| | - Gayle Halas
- Manitoba Primary and Integrated Health care Innovation Network, Winnipeg, Manitoba, Canada
| | - William Sevcik
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Andrea C Tricco
- Knowledge Translation Program, St. Michael's Hospital Li Ka Shing Knowledge Institute, Unity Health Toronto, Toronto, Ontario, Canada
| | - Alecs Chochinov
- Department of Emergency Medicine, Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, Alberta, Canada
- School of Public Health, University of Alberta, Edmonton, Alberta, Canada
| | - Ahmed M Abou-Setta
- George and Fay Yee Center for Healthcare Innovation, University of Manitoba, Winnipeg, Manitoba, Canada
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15
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VonAchen P, Davis MM, Cartland J, D'Arco A, Kan K. Closure of Licensed Pediatric Beds in Health Care Markets Within Illinois. Acad Pediatr 2022; 22:431-439. [PMID: 34182159 PMCID: PMC9246323 DOI: 10.1016/j.acap.2021.06.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Revised: 06/11/2021] [Accepted: 06/19/2021] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Our objective was to understand the market characteristics related to closures of licensed pediatric hospital beds that may be related to increasing regionalization of pediatric hospital care. METHODS We performed a retrospective descriptive analysis of 110 hospitals with licensed pediatric hospital beds from a statewide survey of health care facilities (2012-2017) and administrative data of hospital admissions (2013-2018) in Illinois. We quantified closures of licensed pediatric hospital beds and categorized hospital bed closures by hospital and market characteristics. RESULTS From 2012 through 2017, the number of licensed pediatric beds declined from 1706 to 1254 (-26.5%). Over the same time period, annual pediatric inpatient days minimally changed (+1.1%), while annual pediatric inpatient days at hospitals affiliated with the Children's Hospital Association increased (+30.5%). After accounting for re-openings, the 33 hospitals that closed all licensed pediatric beds fit 4 distinct typologies: 1) Hospitals with minimal pediatric volume throughout the study (n = 19); 2) Hospitals that sustained at least 50% of their pediatric volume after closure of licensed pediatric beds (n = 8); 3) Hospitals with low market share in metropolitan areas (n = 5); and 4) Hospital with a decline in pediatric market share, while a nearby hospital saw a corresponding rise in pediatric market share (n = 1). CONCLUSIONS In Illinois, licensed pediatric hospital beds declined while pediatrics inpatient days stayed the same over a recent 6-year period. Typologies of closures describe the nuanced dynamics leading to decline of pediatric hospital beds. Understanding these patterns is critical to ensure that children receive quality pediatric-tailored care.
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Affiliation(s)
- Paige VonAchen
- Mary Ann & J. Milburn Smith Child Health Outreach, Research and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (P VonAchen, MM Davis, J Cartland, A D'Arco, and K Kan), Chicago, Ill; University of Michigan Medical School (P VonAchen), Ann Arbor, Mich.
| | - Matthew M Davis
- Mary Ann & J. Milburn Smith Child Health Outreach, Research and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (P VonAchen, MM Davis, J Cartland, A D'Arco, and K Kan), Chicago, Ill; Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine (MM Davis and K Kan), Chicago, Ill
| | - Jenifer Cartland
- Mary Ann & J. Milburn Smith Child Health Outreach, Research and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (P VonAchen, MM Davis, J Cartland, A D'Arco, and K Kan), Chicago, Ill
| | - Amy D'Arco
- Mary Ann & J. Milburn Smith Child Health Outreach, Research and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (P VonAchen, MM Davis, J Cartland, A D'Arco, and K Kan), Chicago, Ill
| | - Kristin Kan
- Mary Ann & J. Milburn Smith Child Health Outreach, Research and Evaluation Center, Stanley Manne Children's Research Institute, Ann & Robert H. Lurie Children's Hospital of Chicago (P VonAchen, MM Davis, J Cartland, A D'Arco, and K Kan), Chicago, Ill; Division of Advanced General Pediatrics and Primary Care, Department of Pediatrics, Northwestern University Feinberg School of Medicine (MM Davis and K Kan), Chicago, Ill
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Boggs KM, Sullivan AF, Espinola JA, Gao J, Camargo CA. Evaluation of the American Hospital Association Annual Survey for health services research in emergency medicine. J Am Coll Emerg Physicians Open 2022; 3:e12704. [PMID: 35387323 PMCID: PMC8976194 DOI: 10.1002/emp2.12704] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 02/08/2022] [Accepted: 02/23/2022] [Indexed: 11/07/2022] Open
Abstract
Objectives Emergency department (ED) data are often used to address questions about access to and quality of emergency care. Our objective was to compare one of the most commonly used data sources for national ED information, the American Hospital Association (AHA) Annual Survey, with a criterion database: the National Emergency Department Inventory (NEDI)-USA data set. Methods We compared the 2015 and 2016 AHA surveys to the following 3 criterion standards: (1) the 2015 and 2016 NEDI-USA databases, which have information about all US EDs, including merged data from (2) Council of Teaching Hospitals (COTH) and (3) the Critical Access Hospital (CAH) program. We present descriptive results about the number of EDs in each data set; total and median visit volumes; locations in rural areas; and COTH, CAH, and freestanding ED (FSED) status. Results The AHA survey identified 3893 US EDs in 2015. These EDs had a total annual visit volume of 129,197,493 visits, with a median of 22,772 visits (interquartile range, 8311-47,938). Compared with the NEDI-USA, the AHA included 1433 fewer EDs (-27%; 95% confidence interval [CI], -28% to -26%) and 23,615,163 (-15%) fewer visits. Specifically, AHA was missing 245 (-22%; 95% CI, -24% to -19%) of those located in rural areas, 268 (-20%; 95% CI, -22% to -18%) in a CAH, and 240 (-47%; 95% CI, -51% to -42%) FSEDs. We saw similar results using 2016 data. Conclusions Although several aggregated results were similar between the compared data sources, the AHA data set excluded many US EDs, including many rural EDs and FSEDs. Consequently, the AHA underreported total ED visits by 15%. We encourage data users to be cautious when interpreting results from any 1 ED data source, including the AHA.
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Affiliation(s)
- Krislyn M. Boggs
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Ashley F. Sullivan
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Janice A. Espinola
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Jingya Gao
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Carlos A. Camargo
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
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Zachrison KS, Samuels‐Kalow ME, Li S, Yan Z, Reeves MJ, Hsia RY, Schwamm LH, Camargo CA. The relationship between stroke system organization and disparities in access to stroke center care in California. J Am Coll Emerg Physicians Open 2022; 3:e12706. [PMID: 35316966 PMCID: PMC8921441 DOI: 10.1002/emp2.12706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 02/23/2022] [Accepted: 02/25/2022] [Indexed: 11/08/2022] Open
Abstract
Background There are significant racial and ethnic disparities in receipt of reperfusion interventions for acute ischemic stroke. Our objective was to determine whether there are disparities in access to stroke center care by race or ethnicity that help explain differences in reperfusion therapy and to understand whether interhospital patient transfer plays a role in improving access. Methods Using statewide administrating data including all emergency department and hospital discharges in California from 2010 to 2017, we identified all acute ischemic stroke patients. Primary outcomes of interest included presentation to primary or comprehensive stroke center (PSC or CSC), interhospital transfer, discharge from PSC or CSC, and discharge from CSC alone. We used hierarchical logistic regression modeling to identify the relationship between patient- and hospital-level characteristics and outcomes of interest. Results Of 336,247 ischemic stroke patients, 55.4% were non-Hispanic White, 19.6% Hispanic, 10.6% non-Hispanic Asian/Pacific Islander, and 10.3% non-Hispanic Black. There was no difference in initial presentation to stroke center hospitals between groups. However, adjusted odds of reperfusion intervention, interhospital transfer and discharge from CSC did vary by race and ethnicity. Adjusted odds of interhospital transfer were lower among Hispanic (odds ratio [OR] 0.94, 95% confidence interval [CI] 0.89 to 0.98) and non-Hispanic Asian/Pacific Islander patients (OR 0.84, 95% CI 0.79 to 0.90) and odds of discharge from a CSC were lower for Hispanic (OR 0.91, 95% CI 0.85 to 0.97) and non-Hispanic Black patients (OR 0.74, 95% CI 0.67 to 0.81). Conclusions There are racial and ethnic disparities in reperfusion intervention receipt among stroke patients in California. Stroke system of care design, hospital resources, and transfer patterns may contribute to this disparity.
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Affiliation(s)
- Kori S. Zachrison
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | | | - Sijia Li
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
| | - Zhiyu Yan
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Mathew J. Reeves
- Department of Epidemiology and BiostatisticsMichigan State UniversityEast LansingMichiganUSA
| | - Renee Y. Hsia
- Department of Emergency MedicineUniversity of California San FranciscoSan FranciscoCaliforniaUSA
- Philip R. Lee Institute for Health Policy StudiesUniversity of California San FranciscoSan FranciscoCaliforniaUSA
| | - Lee H. Schwamm
- Department of NeurologyMassachusetts General HospitalBostonMassachusettsUSA
| | - Carlos A. Camargo
- Department of Emergency MedicineMassachusetts General HospitalBostonMassachusettsUSA
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18
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Hsia RY, Zagorov S. Structural Discrimination in Emergency Care: How a Sick System Affects Us All. MED (NEW YORK, N.Y.) 2022; 3:98-103. [PMID: 35224522 PMCID: PMC8880827 DOI: 10.1016/j.medj.2022.01.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
Drawing on evidence of socioeconomic disparities in emergency care, we show how structural discrimination is the most pervasive driver of these disparities, largely because of an inequitable distribution of healthcare services and unequal benefits derived from scientific advancement. We analyze how the market-based healthcare system in the U.S. has created a scenario in which the allocation of emergency care resources does not match community demand for emergency care, resulting in disproportionately poor access, treatment, and outcomes among historically underserved populations. Without fundamental reform, there is little hope for decreasing the health outcome gaps between the "haves" and "have-nots" in the United States.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco,Philip R. Lee Institute of Health Policy Studies, University of California, San Francisco,San Francisco General Hospital and Trauma Center,Correspondence:
| | - Stefany Zagorov
- Department of Emergency Medicine, University of California, San Francisco
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19
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Zachrison KS, Samuels-Kalow ME, Boggs KM, Li S, Hayden EM, Camargo CA. Association of Emergency Department Payer Mix with ED Receipt of Telehealth Services: An Observational Analysis. West J Emerg Med 2022; 23:141-144. [PMID: 35302445 PMCID: PMC8967452 DOI: 10.5811/westjem.2021.9.53014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2021] [Accepted: 09/15/2021] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Telehealth is commonly used to connect emergency department (ED) patients with specialists or resources required for their care. Its infrastructure requires substantial upfront and ongoing investment from an ED or hospital and may be more difficult to implement in lower-resourced settings. Our aim was to examine for an association between ED payer mix and receipt of telehealth services. METHODS Using data from the National Emergency Department Inventory (NEDI)-USA 2016 survey, we categorized EDs based on receipt of telehealth services (yes/no). The NEDI-USA data for EDs in New York state was linked with data from state ED datasets (SEDD) and state inpatient data (SID) to determine EDs' payer mix (percent self-pay or Medicaid). Other ED characteristics of interest were rural location, academic status, and annual ED visit volume. We compared EDs with and without telehealth receipt, and used a logistic regression model to examine the relationship between ED payer mix and telehealth receipt after accounting for other ED characteristics. RESULTS Of the 162 New York EDs in the SEDD-SID dataset, 160 (99%) were linked to the NEDI-USA dataset and 133 of those responded (83%) to the survey. Telehealth receipt was reported by 48 EDs (36%, 95% confidence interval [CI], 28-44%). Emergency departments with and without telehealth receipt were similar (all P >0.40) with respect to rurality (6% vs 9%, respectively), academic status (13% vs 8%), and annual volume (median 36,728 vs 43,000). By contrast, median percent of Medicaid or self-pay patients was lower in telehealth EDs (36%) vs non-telehealth EDs (45%, P = 0.02). In adjusted analysis, increasing proportion of Medicaid and self-pay patients was associated with decreased odds of telehealth receipt (odds ratio 0.87 per 5% increase; 95% CI, 0.77-0.99). Rural location, academic status, and ED volume were not significantly associated with odds of ED telehealth receipt in the adjusted model. CONCLUSION Among EDs in the state of New York, increasing proportion of self-pay and Medicaid patients was associated with decreased odds of ED telehealth receipt, even after accounting for rural location, academic status, and ED volume. The findings support the need for additional infrastructural investment in EDs serving a greater proportion of disadvantaged patients to ensure equitable access.
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Affiliation(s)
- Kori S Zachrison
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Margaret E Samuels-Kalow
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Krislyn M Boggs
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Sijia Li
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Emily M Hayden
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
| | - Carlos A Camargo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
- Harvard Medical School, Department of Emergency Medicine, Boston, Massachusetts
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20
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Deichen Hansen ME, Goldfarb SS, Mercouffer A, Dark T, Lateef H, Harman JS. Racial inequities in emergency department wait times for pregnancy-related concerns. WOMEN'S HEALTH (LONDON, ENGLAND) 2022; 18:17455057221129388. [PMID: 36300291 PMCID: PMC9623347 DOI: 10.1177/17455057221129388] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/30/2022] [Revised: 09/07/2022] [Accepted: 09/12/2022] [Indexed: 11/05/2022]
Abstract
OBJECTIVE Emergency department care is common among US pregnant women. Given the increased likelihood of serious and life-threatening pregnancy-related health conditions among Black mothers, timeliness of emergency department care is vital. The objective of this study was to evaluate racial/ethnic variations in emergency department wait times for receiving obstetrical care among a nationally representative population. METHODS The study used pooled 2016-2018 data from the National Hospital Ambulatory Medical Care Survey, a nationally representative sample of emergency department visits. Regression models were estimated to determine whether emergency department wait time was associated with the race/ethnicity of the perinatal patient. Adjusted models controlled for age, obesity status, insurance type, whether the patient arrived by ambulance, triage status, presence of a patient dashboard, and region. RESULTS There were a total of 821 reported pregnancy-related visits in the National Hospital Ambulatory Medical Care Survey sample of emergency department visits. Of those 821 visits, 40.6% were among White women, 27.7% among Black women, and 27.5% among Hispanic women. Mean wait times differed substantially by race/ethnicity. After adjusting for potential confounders, Black women waited 46% longer than White women with emergency department visits for pregnancy problems (p < .05). Those reporting another race waited 95% longer for pregnancy problems in the emergency department than White women (p < .05). CONCLUSION Findings from this study document significant racial/ethnic differences in wait times for perinatal emergency department care. Although inequities in wait times may emerge across the spectrum of care, documenting the factors influencing racial disparities in wait times are critical to promoting equitable perinatal health outcomes.
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Affiliation(s)
- Megan E Deichen Hansen
- Department of Behavioral Sciences and Social
Medicine, College of Medicine, Florida State University, Tallahassee, FL,
USA
| | - Samantha S Goldfarb
- Department of Behavioral Sciences and Social
Medicine, College of Medicine, Florida State University, Tallahassee, FL,
USA
| | - Ariadna Mercouffer
- Department of Behavioral Sciences and Social
Medicine, College of Medicine, Florida State University, Tallahassee, FL,
USA
| | - Tyra Dark
- Department of Behavioral Sciences and Social
Medicine, College of Medicine, Florida State University, Tallahassee, FL,
USA
| | - Hanna Lateef
- Department of Behavioral Sciences and Social
Medicine, College of Medicine, Florida State University, Tallahassee, FL,
USA
| | - Jeffrey S Harman
- Department of Behavioral Sciences and Social
Medicine, College of Medicine, Florida State University, Tallahassee, FL,
USA
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21
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Cushing AM, Bucholz EM, Chien AT, Rauch DA, Michelson KA. Availability of Pediatric Inpatient Services in the United States. Pediatrics 2021; 148:peds.2020-041723. [PMID: 34127553 PMCID: PMC8642812 DOI: 10.1542/peds.2020-041723] [Citation(s) in RCA: 70] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/19/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVES We sought to evaluate trends in pediatric inpatient unit capacity and access and to measure pediatric inpatient unit closures across the United States. METHODS We performed a retrospective study of 4720 US hospitals using the 2008-2018 American Hospital Association survey. We used linear regression to describe trends in pediatric inpatient unit and PICU capacity. We compared trends in pediatric inpatient days and bed counts by state. We examined changes in access to care by calculating distance to the nearest pediatric inpatient services by census block group. We analyzed hospital characteristics associated with pediatric inpatient unit closure in a survival model. RESULTS Pediatric inpatient units decreased by 19.1% (34 units per year; 95% confidence interval [CI] 31 to 37), and pediatric inpatient unit beds decreased by 11.8% (407 beds per year; 95% CI 347 to 468). PICU beds increased by 16.0% (66.9 beds per year; 95% CI 53 to 81), primarily at children's hospitals. Rural areas experienced steeper proportional declines in pediatric inpatient unit beds (-26.1% vs -10.0%). Most states experienced decreases in both pediatric inpatient unit beds (median state -18.5%) and pediatric inpatient days (median state -10.0%). Nearly one-quarter of US children experienced an increase in distance to their nearest pediatric inpatient unit. Low-volume pediatric units and those without an associated PICU were at highest risk of closing. CONCLUSIONS Pediatric inpatient unit capacity is decreasing in the United States. Access to inpatient care is declining for many children, particularly those in rural areas. PICU beds are increasing, primarily at large children's hospitals. Policy and surge planning improvements may be needed to mitigate the effects of these changes.
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Affiliation(s)
- Anna M. Cushing
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts,Department of Pediatrics, Boston Medical Center, Boston, Massachusetts
| | - Emily M. Bucholz
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Department of Cardiology, Boston Children’s Hospital, Boston, Massachusetts
| | - Alyna T. Chien
- Department of Pediatrics, Boston Medical Center, Boston, Massachusetts,Department of Pediatrics, Harvard Medical School, Boston, Massachusetts
| | - Daniel A. Rauch
- Division of Pediatric Hospital Medicine, Tufts Children’s Hospital, Boston, Massachusetts,Department of Pediatrics, Tufts University School of Medicine, Boston, Massachusetts
| | - Kenneth A. Michelson
- Department of Pediatrics, Harvard Medical School, Boston, Massachusetts,Division of Emergency Medicine, Boston Children’s Hospital, Boston, Massachusetts
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22
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Egan HM, Swanson MB, Ilko SA, Pomeranz KA, Mohr NM, Ahmed A. High-efficiency Practices of Residents in an Academic Emergency Department: A Mixed-methods Study. AEM EDUCATION AND TRAINING 2021; 5:e10517. [PMID: 34027282 PMCID: PMC8122129 DOI: 10.1002/aet2.10517] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Revised: 07/18/2020] [Accepted: 07/27/2020] [Indexed: 06/12/2023]
Abstract
BACKGROUND Emergency department utilization and crowding is increasing, putting additional pressure on emergency medicine (EM) residency programs to train efficient residents who can meet these demands. Specific practices associated with resident efficiency have yet to be identified. The objective of this study was to identify practices associated with enhanced efficiency in EM residents. METHODS A mixed-methods study design was utilized to identify behaviors associated with resident efficiency. In Stage 1, eight EM faculty provided 61 efficiency behaviors during semistructured interviews, which were prioritized into eight behaviors by independent ranking. A total of 31 behaviors were tested, including additions from previous literature and the study team. In Stage 2, two 4-hour observations during separate shifts of 27 EM residents were performed to record minute-by-minute timing and frequency of each behavior. In Stage 3, the association between resident efficiency and each of the behaviors was estimated using multivariable regression models adjusted for training year and clustered on resident. The primary efficiency outcome was 6-month average relative value units/hour. A sensitivity analysis was performed using patients/hour. RESULTS Seven practices were positively associated with efficiency: average patient load, taking initial patient history with nurse present (number/hour, number/new patient), running the board (number/hour), conversations with other care team members (number/hour, % time), dictation use (number/hour, % time), smartphone text communication (number/hour, % time), and nonwork tasks (number/hour). Three practices were negatively associated with efficiency: visits to patient room (number/patient), conversations with attending physicians (% time), and reviewing electronic medical record (number/hour). CONCLUSION Several discrete behaviors were found to be associated with enhanced resident efficiency. These results can be utilized by EM residency programs to improve resident education and inform evaluations by providing specific, evidence-based practices for residents to develop and improve upon throughout training.
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Affiliation(s)
- Haley M. Egan
- Roy A. and Lucille J. Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Morgan B. Swanson
- Roy A. and Lucille J. Carver College of MedicineUniversity of IowaIowa CityIAUSA
- Department of EpidemiologyCollege of Public HealthUniversity of IowaIowa CityIAUSA
| | - Steven A. Ilko
- Roy A. and Lucille J. Carver College of MedicineUniversity of IowaIowa CityIAUSA
| | - Kaila A. Pomeranz
- Department of Emergency MedicineCollege of Public HealthUniversity of IowaIowa CityIAUSA
| | - Nicholas M. Mohr
- Department of EpidemiologyCollege of Public HealthUniversity of IowaIowa CityIAUSA
- Department of AnesthesiaDivision of Critical CareUniversity of IowaIowa CityIAUSA
| | - Azeemuddin Ahmed
- Department of Emergency MedicineCollege of Public HealthUniversity of IowaIowa CityIAUSA
- Tippie College of BusinessUniversity of IowaIowa CityIAUSA
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Wang B, Mehrotra A, Friedman AB. Urgent Care Centers Deter Some Emergency Department Visits But, On Net, Increase Spending. Health Aff (Millwood) 2021; 40:587-595. [PMID: 33819095 DOI: 10.1377/hlthaff.2020.01869] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
There is substantial interest in using urgent care centers to decrease lower-acuity emergency department (ED) visits. Using 2008-19 insurance claims and enrollment data from a national managed care plan, we examined the association within ZIP codes between changes in rates of urgent care center visits and rates of lower-acuity ED visits. We found that although the entry of urgent care deterred lower-acuity ED visits, the impact was small. We estimate that thirty-seven additional urgent care center visits were associated with a reduction of a single lower-acuity ED visit. In addition, each $1,646 lower-acuity ED visit prevented was offset by a $6,327 increase in urgent care center costs. Therefore, despite a tenfold higher price per visit for EDs compared with urgent care centers, use of the centers increased net overall spending on lower-acuity care at EDs and urgent care centers.
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Affiliation(s)
- Bill Wang
- Bill Wang is a research assistant in the Department of Health Care Policy, Harvard Medical School, in Boston, Massachusetts
| | - Ateev Mehrotra
- Ateev Mehrotra is an associate professor of health care policy and medicine in the Department of Health Care Policy, Harvard Medical School
| | - Ari B Friedman
- Ari B. Friedman is an assistant professor of emergency medicine, medical ethics, and health policy in the Departments of Emergency Medicine and Medical Ethics and Health Policy and senior fellow of the Leonard Davis Institute, University of Pennsylvania, in Philadelphia, Pennsylvania
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Brenner JM, Blutinger E, Ricke B, Vearrier L, Kluesner NH, Moskop JC. Ethical issues in the access to emergency care for undocumented immigrants. J Am Coll Emerg Physicians Open 2021; 2:e12461. [PMID: 34095898 PMCID: PMC8164497 DOI: 10.1002/emp2.12461] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 04/30/2021] [Accepted: 05/05/2021] [Indexed: 11/24/2022] Open
Abstract
Patients who are undocumented immigrants (UIs) frequently present to emergency departments in the United States, especially in communities with large immigrant populations. Emergency physicians confront important ethical issues when providing care for these patients. This article examines those ethical issues and recommends best practices in emergency care for UIs. After a brief introduction and description of the UI population, the article proposes central principles of emergency medical ethics as a framework for emergency physician decisions and actions. It then considers the role of law and public policy in health care for UIs, including the Emergency Medical Treatment and Labor Act, the Patient Protection and Affordable Care Act, and current practices of the US Immigration and Customs Enforcement agency. The article concludes with discussion of the scope of emergency physician practice and with recommendations regarding best practices in ED care for UIs.
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Affiliation(s)
- Jay M. Brenner
- Department of Emergency MedicineSUNY‐Upstate Medical UniversitySyracuseNew YorkUSA
| | - Erik Blutinger
- Department of Emergency MedicineIcahn School of MedicineNew YorkNew YorkUSA
| | - Brandon Ricke
- Department of Emergency MedicineUniversity of KansasKansas CityKansasUSA
| | - Laura Vearrier
- Department of Emergency MedicineUniversity of Mississippi Medical CenterJacksonMississippiUSA
| | | | - John C. Moskop
- Department of Internal MedicineWake Forest School of MedicineWinston‐SalemNorth CarolinaUSA
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National trends in emergency department closures, mergers, and utilization, 2005-2015. PLoS One 2021; 16:e0251729. [PMID: 34015007 PMCID: PMC8136839 DOI: 10.1371/journal.pone.0251729] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Accepted: 04/30/2021] [Indexed: 11/25/2022] Open
Abstract
Study objectives To describe nationwide hospital-based emergency department (ED) closures and mergers, as well as the utilization of emergency departments and inpatient beds, over time and across varying geographic areas in the United States. Methods Observational analysis of the American Hospital Association (AHA) Annual Survey from 2005 to 2015. Primary outcomes were hospital-based ED closure and merger. Secondary outcomes were yearly ED visits per hospital-based ED and yearly hospital admissions per hospital bed. Results The total number of hospital-based EDs decreased from 4,500 in 2005 to 4,460 in 2015, with 200 closures, 138 mergers, and 160 new hospital-based EDs. While yearly ED visits per hospital-based ED exhibited a 28.6% relative increase (from 25,083 to 32,248), yearly hospital admissions per hospital bed had a 3.3% relative increase (from 45.4 to 43.9) from 2005 to 2015. The number of hospital admissions and hospital beds did not change significantly in urban areas and declined in rural areas. ED visits grew more uniformly across urban and rural areas. Conclusions The number of hospital-based ED closures is small when accounting for mergers, but occurs as many more patients are presenting to a stable number of EDs in larger health systems, though rural areas may differentially affected. EDs were managing accelerating patient volumes alongside stagnant inpatient bed capacity.
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Rachh P, Pendley AM, Duong PAT, Hanna TN, Heilbrun ME. Decreasing CT Acquisition Time in the Emergency Department through Lean Management Principles. Radiographics 2021; 41:E81-E89. [PMID: 33939543 DOI: 10.1148/rg.2021200107] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Background Emergency departments (EDs) rely on advanced imaging such as CT for diagnosis. Owing to increased ED volumes at the authors' institution, CT image acquisition became a significant bottleneck in ED patient throughput. Methods A multidisciplinary team was formed to solve this complex patient flow issue. Lean management principles were leveraged to identify process gaps and institute changes to achieve workflow improvements, remove process wastes, and improve patient throughput in the ED CT scanner. Process metrics such as percentage of CT examinations completed within 120 minutes and monthly median examination turnaround time (TAT) were tracked on a monthly basis. To measure impact, outcome metrics such as time savings from elimination of wasted steps were developed. Interventions Four projects including development of an ideal staffing model, a patient flow worksheet, revision of the CT patient screening form, and examination prioritization efforts were tested. Just-do-it activities such as revision of the CT angiography protocol ordering tool, optimizing scanner utilization, and improving communication and collaboration between the radiology department and ED were also attempted. Results After a phased rollout of changes over 6 months, the percentage of ordered ED CT examinations completed within 120 minutes increased by 10% (61%-71%); however, this improvement was sustained for only 6 weeks. Elimination of process inefficiencies resulted in a monthly median TAT reduction from 90-109 minutes to 82-106 minutes, and approximately 6 weeks (268 hours) of annualized full-time technologist time was saved. Conclusion Lean management tools can be leveraged to solve complex ED CT patient flow issues and reduce TAT. Online supplemental material is available for this article. ©RSNA, 2021.
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Affiliation(s)
- Pratik Rachh
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
| | - Andrew M Pendley
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
| | - Phuong-Anh T Duong
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
| | - Tarek N Hanna
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
| | - Marta E Heilbrun
- From the Departments of Radiology and Imaging Sciences (P.R., T.N.H., M.E.H.) and Emergency Medicine (A.M.P.), Emory Healthcare, 1364 Clifton Rd NE, Atlanta, GA 30322-1007; and Department of Radiology and Imaging Sciences, University of Utah Hospital, Salt Lake City, Utah (P.A.T.D.)
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Ingraham AM, Chaffee SM, Ayturk MD, Heh VK, Kiefe CI, Santry HP. Gaps in Emergency General Surgery Coverage in the United States. ANNALS OF SURGERY OPEN 2021; 2:e043. [PMID: 34485983 PMCID: PMC8409136 DOI: 10.1097/as9.0000000000000043] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2020] [Accepted: 01/21/2021] [Indexed: 01/29/2023] Open
Abstract
INTRODUCTION Despite three million adults in the United States (US) being admitted annually for emergency general surgery (EGS) conditions, which disproportionately affect vulnerable populations, we lack an understanding of the barriers to round-the-clock EGS care. Our objective was to measure gaps in round-the-clock EGS care. METHODS From August 2015 to December 2015, we surveyed all US-based, adult acute care general hospitals that have an emergency room and ≥1 operating room and provide EGS care, utilizing paper and electronic methods. Surgeons or chief medical officers were queried regarding EGS practices. RESULTS Of 2,811 hospitals, 1,634 (58.1%) responded; 279 (17.1%) were unable to always provide round-the-clock EGS care. Rural location, smaller bed size, and non-teaching status were associated with lack of round-the-clock care. Inconsistent surgeon coverage was the primary reason for lacking round-the-clock EGS care (n=162; 58.1%). However, lack of a tiered system for booking emergency cases, no anesthesia availability overnight, and no stipend for EGS call were also associated with the inability to provide round-the-clock EGS care. DISCUSSION We found significant gaps in access to EGS care, often attributable to workforce deficiencies.
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Affiliation(s)
| | - Scott M. Chaffee
- Department of Surgery, The Ohio State University, Columbus, OH
- Center for Surgical Health Assessment, Research, and Policy (SHARP), The Ohio State University, Columbus, OH
| | - M. Didem Ayturk
- §Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Victor K. Heh
- Department of Surgery, The Ohio State University, Columbus, OH
- Center for Surgical Health Assessment, Research, and Policy (SHARP), The Ohio State University, Columbus, OH
| | - Catarina I. Kiefe
- §Department of Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA
| | - Heena P. Santry
- Department of Surgery, The Ohio State University, Columbus, OH
- Center for Surgical Health Assessment, Research, and Policy (SHARP), The Ohio State University, Columbus, OH
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Woolhandler S, Himmelstein DU, Ahmed S, Bailey Z, Bassett MT, Bird M, Bor J, Bor D, Carrasquillo O, Chowkwanyun M, Dickman SL, Fisher S, Gaffney A, Galea S, Gottfried RN, Grumbach K, Guyatt G, Hansen H, Landrigan PJ, Lighty M, McKee M, McCormick D, McGregor A, Mirza R, Morris JE, Mukherjee JS, Nestle M, Prine L, Saadi A, Schiff D, Shapiro M, Tesema L, Venkataramani A. Public policy and health in the Trump era. Lancet 2021; 397:705-753. [PMID: 33581802 DOI: 10.1016/s0140-6736(20)32545-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2020] [Revised: 09/22/2020] [Accepted: 11/13/2020] [Indexed: 12/12/2022]
Affiliation(s)
- Steffie Woolhandler
- Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - David U Himmelstein
- School of Urban Public Health, City University of New York at Hunter College, New York, NY, USA; Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA.
| | - Sameer Ahmed
- Harvard Immigration and Refugee Clinical Program, Harvard Law School, Harvard University, Boston, MA, USA
| | - Zinzi Bailey
- Medical Oncology Division, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Mary T Bassett
- Francois-Xavier Bagnoud Center for Health and Human Rights, Harvard University, Boston, MA, USA
| | | | - Jacob Bor
- School of Public Health, Boston University, Boston, MA, USA
| | - David Bor
- Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Olveen Carrasquillo
- Division of General Internal Medicine, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | | | - Samantha Fisher
- Program for Global Public Health and the Common Good, Boston College, Chestnut Hill, MA, USA
| | - Adam Gaffney
- Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Sandro Galea
- School of Public Health, Boston University, Boston, MA, USA
| | | | - Kevin Grumbach
- Department of Family and Community Medicine, University of California, San Francisco, CA, USA
| | - Gordon Guyatt
- Department of Health Research Methods, Evidence & Impact and Department of Medicine, McMaster University, Hamilton, ON, Canada
| | - Helena Hansen
- Research Theme in Translational Social Science and Health Equity, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Philip J Landrigan
- Program for Global Public Health and the Common Good, Boston College, Chestnut Hill, MA, USA
| | | | - Martin McKee
- Department of Health Services Research & Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Danny McCormick
- Cambridge Health Alliance, Harvard University, Boston, MA, USA; Harvard Medical School, Harvard University, Boston, MA, USA
| | - Alecia McGregor
- Department of Community Health, Tufts University, Medford, MA, USA
| | - Reza Mirza
- Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - Juliana E Morris
- Harvard Medical School, Harvard University, Boston, MA, USA; Department of Medicine and Department of Pediatrics, Massachusetts General Hospital, Boston, MA, USA
| | - Joia S Mukherjee
- Harvard Medical School, Harvard University, Boston, MA, USA; Partners in Health, Boston, MA, USA; Department of Medicine, Brigham and Women's Hospital, Boston, MA, USA
| | - Marion Nestle
- Department of Nutrition and Food Studies, New York University, New York, NY, USA
| | - Linda Prine
- Department of Family and Community Medicine, Mount Sinai School of Medicine, New York, NY, USA
| | - Altaf Saadi
- Harvard Medical School, Harvard University, Boston, MA, USA; Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
| | - Davida Schiff
- Harvard Medical School, Harvard University, Boston, MA, USA; Division of General Academic Pediatrics, MassGeneral Hospital for Children, Boston, MA, USA
| | - Martin Shapiro
- Department of Medicine, Weill Cornell Medical College, New York, NY, USA
| | - Lello Tesema
- Department of Public Health, Los Angeles County, Los Angeles, CA, USA
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Opioid-related emergencies in New York City after the Great Recession. J Subst Abuse Treat 2021; 125:108311. [PMID: 34016298 DOI: 10.1016/j.jsat.2021.108311] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2020] [Revised: 01/02/2021] [Accepted: 01/19/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND The rise in opioid-related mortality and opioid-related emergency department (ED) visits has stimulated research on whether broader economic declines, such as the Great Recession, affect opioid-related morbidity. We examine in New York City whether one measure of morbidity-opioid-related ED visits-responded acutely to the large negative "shock" of the Great Recession. METHODS Data comprise outpatient "treat and release" opioid-related ED visits in New York City for the 72 months spanning January 2006 to December 2011, taken from the Statewide Emergency Department Database (n = 150,246). We modeled the monthly incidence of opioid-related ED visits using Autoregressive, Integrated, Moving Average (ARIMA) time-series methods to control for patterning in ED visits before examining its potential association with the economic shock of the Great Recession. RESULTS New York City shows a mean of 1761 outpatient ED visits per month for opioid dependence and abuse. Unexpectedly large drops in employment coincide with fewer than expected opioid dependence and abuse ED visits in that same month. The result (coefficient = 0.046, 95% Confidence Interval [CI]: 0.002, 0.090) represents a 0.8% drop in overall incidence of opioid dependence and abuse ED visits during the Great Recession. We, however, observe no association between the Great Recession and ED visits for prescription opioid overdose or heroin overdose, or with inpatient ED visits for opioid dependence and abuse. CONCLUSIONS Findings, if replicated, indicate distinct short-term reductions in opioid-related morbidity following the Great Recession. This result diverges from previous findings of increased opioid use following extended economic downturns.
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Disparities in the Use of Emergency Department Advanced Imaging in Medicare Beneficiaries. AJR Am J Roentgenol 2020; 216:519-525. [PMID: 33356434 DOI: 10.2214/ajr.20.23161] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE. The purpose of our study was to assess potential disparities in the utilization of advanced imaging during emergency department (ED) visits. MATERIALS AND METHODS. This retrospective study was conducting using 5% Research Identifiable Files. All CT and MRI (together defined as "advanced imaging") examinations associated with ED visits in 2015 were identified for continuously enrolled Medicare beneficiaries. Individuals with medical claims 30 days before the index ED event were excluded, and encounters that occurred in hospitals without advanced imaging capabilities were also excluded. Patient characteristics were identified using Medicare files and hospital characteristics using the American Hospital Association Annual Survey of Hospitals. Multivariate logistic regression was used for the analysis. RESULTS. Of 86,976 qualifying ED encounters, 52,833 (60.74%) ED encounters were for female patients; 29.03% (n = 25,245) occurred at rural hospitals and 15.81% (n = 13,750) at critical access hospitals. Race distribution was 83.13% White, 11.05% Black, and 5.82% Other. Compared with ED patients at urban hospitals, those at rural and critical access hospitals were 6.9% less likely (odds ratio [OR] = 0.931, p = 0.015) and 18.0% less likely (OR = 0.820, p < 0.0001), respectively, to undergo advanced imaging. Compared with White patients, Black patients were 31.6% less likely (OR = 0.684, p < 0.0001) to undergo advanced imaging. Relative to their urban counterparts, both White (OR = 0.941, p = 0.05) and Black (OR = 0.808, p = 0.047) rural ED patients were less likely to undergo advanced imaging. CONCLUSION. Among Medicare beneficiaries receiving care in U.S. EDs, significant disparities exist in advanced imaging utilization. Although imaging appropriateness was not investigated, these findings suggest inequity. Further research is necessary to understand why consistent health benefits do not translate into consistent imaging access among risk-adjusted ED patients.
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Hsia RY, Krumholz H, Shen YC. Evaluation of STEMI Regionalization on Access, Treatment, and Outcomes Among Adults Living in Nonminority and Minority Communities. JAMA Netw Open 2020; 3:e2025874. [PMID: 33196809 PMCID: PMC7670311 DOI: 10.1001/jamanetworkopen.2020.25874] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
IMPORTANCE Cardiac care regionalization, specifically for patients with ST-segment elevation myocardial infarction (STEMI), has been touted as a potential mechanism to reduce systematic disparities by protocolizing the treatment of these conditions. However, it is unknown whether such regionalization arrangements have widened or narrowed disparities in access, treatment, and outcomes for minority communities. OBJECTIVE To determine the extent to which disparities in access, treatment, and outcomes have changed for patients with STEMI living in zip codes that are in the top tertile of the Black or Hispanic population compared with patients in nonminority zip codes in regionalized vs nonregionalized counties. DESIGN, SETTING, AND PARTICIPANTS This cohort study used a quasi-experimental approach exploiting the different timing of regionalization across California. Nonpublic inpatient data for all patients with STEMI from January 1, 2006, to October 31, 2015, were analyzed using a difference-in-difference-in-differences estimation approach. EXPOSURE Exposure to the intervention was defined as on and after the year a patient's county was exposed to regionalization. MAIN OUTCOMES AND MEASURES Access to percutaneous coronary intervention (PCI)-capable hospital, receipt of PCI on the same day and at any time during the hospitalization, and time-specific all-cause mortality. RESULTS This study included 139 494 patients with STEMI; 61.9% of patients were non-Hispanic White, 5.6% Black, 17.8% Hispanic, and 9.0% Asian; 32.8% were women. Access to PCI-capable hospitals improved by 6.3 percentage points (95% CI, 5.5 to 7.1 percentage points; P < .001) when patients in nonminority communities were exposed to regionalization. Patients in minority communities experienced a 1.8-percentage point smaller improvement in access (95% CI, -2.8 to -0.8 percentage points; P < .001), or 28.9% smaller, compared with those in nonminority communities when both were exposed to regionalization. Regionalization was associated with an improvement to same-day PCI and in-hospital PCI by 5.1 percentage points (95% CI, 4.2 to 6.1 percentage points; P < .001) and 5.0 percentage points (95% CI, 4.2 to 5.9 percentage points; P < .001), respectively, for patients in nonminority communities. Patients in minority communities experienced only 33.3% and 15.1% of that benefit. Only White patients in nonminority communities experienced mortality improvement from regionalization. CONCLUSIONS AND RELEVANCE Although regionalization was associated with improved access to PCI hospitals and receipt of PCI treatment, patients in minority communities derived significantly smaller improvement relative to those in nonminority communities.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Harlan Krumholz
- Section of Cardiovascular Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
- Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut
- Center for Outcomes Research and Evaluation, Yale–New Haven Hospital, New Haven, Connecticut
| | - Yu-Chu Shen
- Graduate School of Defense Management, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
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Boggs KM, Teferi MM, Espinola JA, Sullivan AF, Hasegawa K, Zachrison KS, Samuels-Kalow ME, Camargo CA. Consolidating Emergency Department-specific Data to Enable Linkage with Large Administrative Datasets. West J Emerg Med 2020; 21:141-145. [PMID: 33207159 PMCID: PMC7673880 DOI: 10.5811/westjem.2020.8.48305] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 08/27/2020] [Indexed: 12/04/2022] Open
Abstract
Introduction The American Hospital Association (AHA) has hospital-level data, while the Centers for Medicare & Medicaid Services (CMS) has patient-level data. Merging these with other distinct databases would permit analyses of hospital-based specialties, units, or departments, and patient outcomes. One distinct database is the National Emergency Department Inventory (NEDI), which contains information about all EDs in the United States. However, a challenge with merging these databases is that NEDI lists all US EDs individually, while the AHA and CMS group some EDs by hospital network. Consolidating data for this merge may be preferential to excluding grouped EDs. Our objectives were to consolidate ED data to enable linkage with administrative datasets and to determine the effect of excluding grouped EDs on ED-level summary results. Methods Using the 2014 NEDI-USA database, we surveyed all New England EDs. We individually matched NEDI EDs with corresponding EDs in the AHA and CMS. A “group match” was assigned when more than one NEDI ED was matched to a single AHA or CMS facility identification number. Within each group, we consolidated individual ED data to create a single observation based on sums or weighted averages of responses as appropriate. Results Of the 195 EDs in New England, 169 (87%) completed the NEDI survey. Among these, 130 (77%) EDs were individually listed in AHA and CMS, while 39 were part of groups consisting of 2–3 EDs but represented by one facility ID. Compared to the individually listed EDs, the 39 EDs included in a “group match” had a larger number of annual visits and beds, were more likely to be freestanding, and were less likely to be rural (all P<0.05). Two grouped EDs were excluded because the listed ED did not respond to the NEDI survey; the remaining 37 EDs were consolidated into 19 observations. Thus, the consolidated dataset contained 149 observations representing 171 EDs; this consolidated dataset yielded summary results that were similar to those of the 169 responding EDs. Conclusion Excluding grouped EDs would have resulted in a non-representative dataset. The original vs consolidated NEDI datasets yielded similar results and enabled linkage with large administrative datasets. This approach presents a novel opportunity to use characteristics of hospital-based specialties, units, and departments in studies of patient-level outcomes, to advance health services research.
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Affiliation(s)
- Krislyn M Boggs
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Maranatha M Teferi
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Janice A Espinola
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Ashley F Sullivan
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Kohei Hasegawa
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Kori S Zachrison
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | | | - Carlos A Camargo
- Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Michelson KA, Rees CA, Sarathy J, VonAchen P, Wornow M, Monuteaux MC, Neuman MI. Inter-Region Transfers for Pandemic Surges. Clin Infect Dis 2020; 73:e4103-e4110. [PMID: 33038215 PMCID: PMC7665371 DOI: 10.1093/cid/ciaa1549] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Indexed: 11/12/2022] Open
Abstract
Background Hospital inpatient and intensive care unit (ICU) bed shortfalls may arise due to regional surges in volume. We sought to determine how inter-region transfers could alleviate bed shortfalls during a pandemic. Methods We used estimates of past and projected inpatient and ICU cases of COVID-19 from February 4, 2020 to October 1, 2020. For regions with bed shortfalls (where the number of patients exceeded bed capacity), transfers to the nearest region with unused beds were simulated using an algorithm that minimized total inter-region transfer distances across the U.S. Model scenarios used a range of predicted COVID-19 volumes (lower, mean, and upper bounds) and non-COVID-19 volumes (20%, 50%, or 80% of baseline hospital volumes). Scenarios were created for each day of data, and worst-case scenarios were created treating all regions’ peak volumes as simultaneous. Mean per-patient transfer distances were calculated by scenario. Results For the worst-case scenarios, national bed shortfalls ranged from 669 to 58,562 inpatient beds and 3,208 to 31,190 ICU beds, depending on model volume parameters. Mean transfer distances to alleviate daily bed shortfalls ranged from 23 to 352 miles for inpatient and 28 to 423 miles for ICU patients, depending on volume. Under all worst-case scenarios except the highest-volume ICU scenario, inter-regional transfers could fully resolve bed shortfalls. To do so, mean transfer distances would be 24 to 405 miles for inpatients and 73 to 476 miles for ICU patients. Conclusions Inter-region transfers could mitigate regional bed shortfalls during pandemic hospital surges.
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Affiliation(s)
- Kenneth A Michelson
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Chris A Rees
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Jayshree Sarathy
- Harvard John A. Paulson School of Engineering and Applied Sciences, Cambridge, MA, United States
| | - Paige VonAchen
- Department of Pediatrics, Boston Children's Hospital and Boston Medical Center, Boston, MA, United States
| | - Michael Wornow
- Harvard John A. Paulson School of Engineering and Applied Sciences, Cambridge, MA, United States
| | - Michael C Monuteaux
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
| | - Mark I Neuman
- Division of Emergency Medicine, Boston Children's Hospital, Boston, MA, United States
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Bittencourt RJ, Stevanato ADM, Bragança CTNM, Gottems LBD, O'Dwyer G. Interventions in overcrowding of emergency departments: an overview of systematic reviews. Rev Saude Publica 2020; 54:66. [PMID: 32638885 PMCID: PMC7319499 DOI: 10.11606/s1518-8787.2020054002342] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2020] [Accepted: 04/15/2020] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To present an overview of systematic reviews on throughput interventions to solve the overcrowding of emergency departments. METHODS Electronic searches for reviews published between 2007 and 2018 were made on PubMed, Cochrane Library, EMBASE, Health Systems Evidence, CINAHL, SciELO, LILACS, Google Scholar and the CAPES periodicals portal. Data of the included studies was extracted into a pre-formatted sheet and their methodological quality was assessed using AMSTAR 2 tool. Eventually, 15 systematic reviews were included for the narrative synthesis. RESULTS The interventions were grouped into four categories: (1) strengthening of the triage service; (2) strengthening of the ED’s team; (3) creation of new care zones; (4) change in ED’s work processes. All studies observed positive effect on patient’s length of stay, expect for one, which had positive effect on other indicators. According to AMSTAR 2 criteria, eight revisions were considered of high or moderate methodological quality and seven, low or critically low quality. There was a clear improvement in the quality of the studies, with an improvement in focus and methodology after two decades of systematic studies on the subject. CONCLUSIONS Despite some limitations, the evidence presented on this overview can be considered the cutting edge of current scientific knowledge on the topic.
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Affiliation(s)
- Roberto José Bittencourt
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Angelo de Medeiros Stevanato
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Carolina Thomé N M Bragança
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Leila Bernarda Donato Gottems
- Escola Superior de Ciências da Saúde, Fundação de Ensino e Pesquisa em Ciências da Saúde, Secretaria de Estado de Saúde do Distrito Federal, Distrito Federal, Brasil
| | - Gisele O'Dwyer
- Departamento de Administração e Planejamento em Saúde, Escola Nacional de Saúde Pública Sérgio Arouca, Fundação Oswaldo Cruz, Rio de Janeiro, RJ, Brasil
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Yiadom MYAB, Napoli A, Granovsky M, Parker RB, Pilgrim R, Pines JM, Schuur J, Augustine J, Jouriles N, Welch S. Managing and Measuring Emergency Department Care: Results of the Fourth Emergency Department Benchmarking Definitions Summit. Acad Emerg Med 2020; 27:600-611. [PMID: 32248605 DOI: 10.1111/acem.13978] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Revised: 03/24/2020] [Accepted: 03/25/2020] [Indexed: 11/29/2022]
Abstract
BACKGROUND A shared language and vocabulary are essential for managing emergency department (ED) operations. This Fourth Emergency Department Benchmarking Alliance (EDBA) Summit brought together experts in the field to review, update, and add to key definitions and metrics of ED operations. OBJECTIVE Summit objectives were to review and revise existing definitions, define and characterize new practices related to ED operations, and introduce financial and regulatory definitions affecting ED reimbursement. METHODS Forty-six ED operations, data management, and benchmarking experts were invited to participate in the EDBA summit. Before arrival, experts were provided with documents from the three prior summits and assigned to update the terminology. Materials and publications related to standards of ED operations were considered and discussed. Each group submitted a revised set of definitions prior to the summit. Significantly revised, topical, or controversial recommendations were discussed among all summit participants. The goal of the in-person discussion was to reach consensus on definitions. Work group leaders made changes to reflect the discussion, which was revised with public and stakeholder feedback. RESULTS The entire EDBA dictionary was updated and expanded. This article focuses on an update and discussion of definitions related to specific topics that changed since the last summit, specifically ED intake, boarding, diversion, and observation care. In addition, an extensive new glossary of financial and regulatory terminology germane to the practice of emergency medicine is included. CONCLUSIONS A complete and precise set of operational definitions, time intervals, and utilization measures is necessary for timely and effective ED care. A common language of financial and regulatory definitions that affect ED operations is included for the first time. This article and its companion dictionary should serve as a resource to ED leadership, researchers, informatics and health policy leaders, and regulatory bodies.
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Affiliation(s)
- Maame Y. A. B. Yiadom
- From the Department of Emergency Medicine Emergency Care Health Services Research Data Coordinating Center Vanderbilt University Nashville TNUSA
| | - Anthony Napoli
- the Department of Emergency Medicine Brown University Providence RIUSA
| | | | | | | | | | - Jeremiah Schuur
- the Department of Emergency Medicine Brown University Providence RIUSA
| | - James Augustine
- National Clinical Governance BoardUS Acute Care Solutions CantonOHUSA
| | - Nicholas Jouriles
- the Department of Emergency Medicine Northeast Ohio Medical University Rootstown OHUSA
| | - Shari Welch
- and the Center for Health Design Intermountain Healthcare Salt Lake City UT USA
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Hsia RY, Shen YC. Emergency Department Closures And Openings: Spillover Effects On Patient Outcomes In Bystander Hospitals. Health Aff (Millwood) 2020; 38:1496-1504. [PMID: 31479367 DOI: 10.1377/hlthaff.2019.00125] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
High-occupancy hospitals may be sensitive to neighboring emergency department (ED) closures and openings, as they already operate at or near capacity. We conducted a retrospective analysis using data for the period 2001-13 to examine outcomes of and treatment received by patients with acute myocardial infarction at so-called bystander EDs that had been exposed to nearby ED closures or openings. We used changes in driving time between an ED and the next-closest one as a proxy for a closure or opening: If driving time increased, for instance, it meant that a nearby ED had closed. When a high-occupancy ED was exposed to a closure that resulted in increased driving time of thirty minutes or more to the next-closest ED, one-year mortality and thirty-day readmission rates increased by 2.39 and 2.00 percentage points, respectively, while the likelihood of receiving percutaneous coronary intervention (PCI) declined by 2.06 percentage points. Exposure to ED openings that resulted in decreased driving times of thirty minutes or more was associated with reductions in thirty-day mortality at bystander hospitals and an increased likelihood of receiving PCI. Our findings suggest that limited resources at high-occupancy bystander hospitals make them sensitive to changes in the availability of emergency care in neighboring communities.
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Affiliation(s)
- Renee Y Hsia
- Renee Y. Hsia ( ) is a professor in the Department of Emergency Medicine and a core faculty member at the Philip R. Lee Institute for Health Policy Studies, University of California San Francisco
| | - Yu-Chu Shen
- Yu-Chu Shen is a professor of economics in the Graduate School of Business and Public Policy, Naval Postgraduate School, in Monterey, California; and a faculty research fellow at the National Bureau of Economic Research, in Cambridge, Massachusetts
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Using Emergency Department Data to Inform Specialty Strategy: Analyzing the Distribution of 13,777 Consecutive Immediate Orthopaedic Consults in an Urban Community Emergency Department. J Am Acad Orthop Surg Glob Res Rev 2020; 4:JAAOSGlobal-D-20-00005. [PMID: 32440626 PMCID: PMC7209810 DOI: 10.5435/jaaosglobal-d-20-00005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2020] [Accepted: 01/15/2020] [Indexed: 11/18/2022]
Abstract
Although an estimated 20% of emergency department (ED) visits are musculoskeletal in nature, it is unclear which of these require urgent orthopaedic consultation and which orthopaedic subspecialties are best suited for these consults. When an ED's internal staff does not have necessary orthopaedic coverage, transfer to other facilities is required. However, transfers pose major inconveniences and financial burdens to patients and can lead to long ED wait times, hospital financial loss from walk outs, decreased patient safety, and decreased staff morale. Therefore, it is beneficial for a hospital to have the appropriate staff readily available for consults. Data can be used to assess the orthopaedic needs of an ED. We evaluated the nature of urgent ED consults requesting the timely presence of an orthopaedic provider.
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Vogel JA, Rising KL, Jones J, Bowden ML, Ginde AA, Havranek EP. Reasons Patients Choose the Emergency Department over Primary Care: a Qualitative Metasynthesis. J Gen Intern Med 2019; 34:2610-2619. [PMID: 31428988 PMCID: PMC6848423 DOI: 10.1007/s11606-019-05128-x] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 04/18/2019] [Accepted: 05/24/2019] [Indexed: 11/30/2022]
Abstract
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.
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Affiliation(s)
- Jody A Vogel
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA. .,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA. .,Center for Health Systems Research, Denver Health Medical Center, Denver, CO, USA.
| | - Kristin L Rising
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA, USA
| | | | | | - Adit A Ginde
- Department of Emergency Medicine, Denver Health Medical Center, Denver, CO, USA.,Department of Emergency Medicine, University of Colorado School of Medicine, Aurora, CO, USA
| | - Edward P Havranek
- Center for Health Systems Research, Denver Health Medical Center, Denver, CO, USA.,University of Colorado School of Medicine, Aurora, CO, USA.,Department of Medicine, Denver Health Medical Center, Denver, CO, USA
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Hanchate AD, Paasche-Orlow MK, Baker WE, Lin MY, Banerjee S, Feldman J. Association of Race/Ethnicity With Emergency Department Destination of Emergency Medical Services Transport. JAMA Netw Open 2019; 2:e1910816. [PMID: 31490537 PMCID: PMC6735492 DOI: 10.1001/jamanetworkopen.2019.10816] [Citation(s) in RCA: 37] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE Evidence from national studies indicates systematic differences in hospitals in which racial/ethnic minorities receive care, with most care obtained in a small proportion of hospitals. Little is known about the source of these differences. OBJECTIVES To examine the patterns of emergency department (ED) destination of emergency medical services (EMS) transport according to patient race/ethnicity, and to compare the patterns between those transported by EMS and those who did not use EMS. DESIGN, SETTING, AND PARTICIPANTS This cohort study of US EMS and EDs used Medicare claims data from January 1, 2006, to December 31, 2012. Enrollees aged 66 years or older with continuous fee-for-service Medicare coverage (N = 864 750) were selected for the sample. Zip codes with a sizable count (>10) of Hispanic, non-Hispanic black, and non-Hispanic white enrollees were used for comparison of EMS use across racial/ethnic subgroups. Data on all ED visits, with and without EMS use, were obtained. Data analysis was performed from December 18, 2018, to July 7, 2019. MAIN OUTCOMES AND MEASURES The main outcome measure was whether an EMS transport destination was the most frequent ED destination among white patients (reference ED). The secondary outcomes were (1) whether the ED destination was a safety-net hospital and (2) the distance of EMS transport from the ED destination. RESULTS The study cohort comprised 864 750 Medicare enrollees from 4175 selected zip codes who had 458 701 ED visits using EMS transport. Of these EMS-transported enrollees, 26.1% (127 555) were younger than 75 years, and most were women (302 430 [66.8%]). Overall, the proportion of white patients transported to the reference ED was 61.3% (95% CI, 61.0% to 61.7%); this rate was lower among black enrollees (difference of -5.3%; 95% CI, -6.0% to -4.6%) and Hispanic enrollees (difference of -2.5%; 95% CI, -3.2% to -1.7%). A similar pattern was found among patients with high-risk acute conditions; the proportion transported to the reference ED was 61.5% (95% CI, 60.7% to 62.2%) among white enrollees, whereas this proportion was lower among black enrollees (difference of -6.7%; 95% CI, -8.3% to -5.0%) and Hispanic enrollees (difference of -2.6%; 95% CI, -4.5% to -0.7%). In major US cities, a larger black-white discordance in ED destination was observed (-9.3%; 95% CI, -10.9% to -7.7%). Black and Hispanic patients were more likely to be transported to a safety-net ED compared with their white counterparts; the proportion transported to a safety-net ED among white enrollees (18.5%; 95% CI, 18.1% to 18.7%) was lower compared with that among black enrollees (difference of 2.7%; 95% CI, 2.2% to 3.2%) and Hispanic enrollees (difference of 1.9%; 95% CI, 1.3% to 2.4%). Concordance rates of non-EMS-transported ED visits were statistically significantly lower than for EMS-transported ED visits; the concordance rate among white enrollees of 52.9% (95% CI, 52.1% to 53.6%) was higher compared with that among black enrollees (difference of -4.8%; 95% CI, -6.4% to -3.3%) and Hispanic enrollees (difference of -3.0%; 95% CI, -4.7% to -1.3%). CONCLUSIONS AND RELEVANCE This study found race/ethnicity variation in ED destination for patients using EMS transport, with black and Hispanic patients more likely to be transported to a safety-net hospital ED compared with white patients living in the same zip code.
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Affiliation(s)
- Amresh D. Hanchate
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Michael K. Paasche-Orlow
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
- Boston Medical Center, Boston, Massachusetts
| | - William E. Baker
- Boston Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Meng-Yun Lin
- Section of General Internal Medicine, Boston University School of Medicine, Boston, Massachusetts
| | - Souvik Banerjee
- Disparities Research Unit, The Mongan Institute, Massachusetts General Hospital, Boston
| | - James Feldman
- Boston Medical Center, Boston, Massachusetts
- Department of Emergency Medicine, Boston University School of Medicine, Boston, Massachusetts
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Martin DR, Moskop JC, Bookman K, Basford JB, Geiderman JM. Compensation models in emergency medicine: An ethical perspective. Am J Emerg Med 2019; 38:138-142. [PMID: 31378410 DOI: 10.1016/j.ajem.2019.158372] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2019] [Revised: 07/16/2019] [Accepted: 07/26/2019] [Indexed: 10/26/2022] Open
Abstract
There is considerable diversity in compensation models in the specialty of Emergency Medicine (EM). We review different compensation models and examine moral consequences possibly associated with the use of various models. The article will consider how different models may promote or undermine health care's quadruple aim of providing quality care, improving population health, reducing health care costs, and improving the work-life balance of health care professionals. It will also assess how different models may promote or undermine the basic bioethical principles of beneficence, non-maleficence, respect for autonomy, and justice.
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Affiliation(s)
- Daniel R Martin
- Department of Emergency Medicine, Ohio State University, 760 Prior Hall, 376 West 10th Avenue, Columbus, OH 43210, United States of America.
| | - John C Moskop
- Wake Forest School of Medicine, Medical Center Blvd, Winston-Salem, NC 27157-0001, United States of America.
| | - Kelly Bookman
- University of Colorado School of Medicine, Department of Emergency Medicine, 12401 E. 17th Ave, B125, Aurora, CO 80045-2548, United States of America.
| | - Jesse B Basford
- Alabama College of Osteopathic Medicine, 445 Health Sciences Blvd, Dothan, AL 36303, United States of America.
| | - Joel Martin Geiderman
- Department of Emergency Medicine, Ruth and Harry Roman Emergency Department, Cedars Sinai Medical Center ED, 8700 Beverly Blvd, Los Angeles, CA 90048-1804, United States of America.
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Shen YC, Chen G, Hsia RY. Community and Hospital Factors Associated With Stroke Center Certification in the United States, 2009 to 2017. JAMA Netw Open 2019; 2:e197855. [PMID: 31348507 PMCID: PMC6661722 DOI: 10.1001/jamanetworkopen.2019.7855] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE The increased number of stroke centers in the United States may not be equitably distributed across all populations. Anecdotal reports suggest there may be differential proliferation in wealthier and urban communities. OBJECTIVE To examine hospital characteristics and economic conditions of communities surrounding hospitals with and without stroke centers. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all general, short-term, acute hospitals in the continental United States and used merged data from the Joint Commission, Det Norske Veritas, Healthcare Facilities Accreditation Program, state health departments, the Centers for Medicare & Medicaid Services, the American Hospital Association, the Dartmouth Atlas of Health Care, and the US Census Bureau from January 1, 2009, to September 30, 2017, to compare hospital and community characteristics of stroke-certified and non-stroke-certified hospitals and assessed characteristics of early and late adopters of stroke certification. MAIN OUTCOMES AND MEASURES Stroke center certification was the primary outcome. Risk factors were grouped into 3 categories: economic and financial, hospital, and community characteristics. Survival analyses were performed using a Cox proportional hazards regression model. RESULTS The study included 4546 US hospitals. During the study period, 1689 hospitals (37.2%) were stroke certified (961 adopted certification on or before January 1, 2009, 728 afterward). After controlling for other area and hospital characteristics, hospitals in low-income hospital service areas and the lower tertile of profit-margin distribution were less likely to adopt stroke certification (hazard ratio [HR], 0.62; 95% CI, 0.52-0.74 and HR, 0.87; 95% CI, 0.78-0.98, respectively). Urban hospitals had a higher likelihood of stroke certification than rural hospitals (HR, 12.79; 95% CI, 10.64-15.37). CONCLUSIONS AND RELEVANCE This study found that stroke centers have proliferated unevenly across geographic localities, where hospitals in high-income hospital service areas and with higher profit margins have a greater likelihood of being stroke certified. These findings suggest that market-driven factors may be associated with stroke center certification.
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Affiliation(s)
- Yu-Chu Shen
- Graduate School of Business and Public Policy, Naval Postgraduate School, Monterey, California
- National Bureau of Economic Research, Cambridge, Massachusetts
| | | | - Renee Y. Hsia
- Department of Emergency Medicine, University of California at San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California at San Francisco
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Disparities in Emergency Department Visits Among Collocated Racial/Ethnic Medicare Enrollees. Ann Emerg Med 2019; 73:225-235. [PMID: 30798793 DOI: 10.1016/j.annemergmed.2018.09.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/28/2018] [Accepted: 09/05/2018] [Indexed: 11/21/2022]
Abstract
STUDY OBJECTIVE We estimate emergency department (ED) use differences across Medicare enrollees of different race/ethnicity who are residing in the same zip codes. METHODS In this retrospective cohort study, we stratified all Medicare fee-for-service beneficiaries aged 66 years and older (2006 to 2012) by residence zip code and identified zip codes with racial/ethnic diversity, defined as containing at least 1 enrollee from each of 3 racial/ethnic groups: Hispanics, (non-Hispanic) blacks, and (non-Hispanic) whites. Our primary study population consisted of a stratified random sample of approximately equal number of each racial/ethnic group from each zip code with racial/ethnic diversity (N=1,563,631). We identified ED visits, comorbidities, primary-care-treatable status, and patient disposition. We characterized socioeconomic status by zip code poverty rate. The main outcome measure was the ratio of ED visit rate (number of visits/100 person-years) between each minority group and whites. RESULTS Of 38,423 zip codes nationally, 41% met the racial/ethnic diversity criterion; these zip codes contained 85% of the Medicare fee-for-service beneficiaries. Among enrollees from zip codes with racial/ethnic diversity, the ED visit rate among whites was 45.4 (95% confidence interval 45.1 to 45.6), and the ED visit rate ratio was 1.34 (95% confidence interval 1.33 to 1.36) among blacks and 1.23 (95% confidence interval 1.22 to 1.24) among Hispanics. ED visit rate ratios for both minority groups were greater than 1.00 among all subgroups by age, comorbidity, zip code poverty rate, urban/rural area, and primary-care-treatable and disposition status. CONCLUSION Among Medicare enrollees, blacks and Hispanics had higher ED use rates than whites overall and among subgroups by demographics and socioeconomic status.
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Abir M, Goldstick JE, Malsberger R, Williams A, Bauhoff S, Parekh VI, Kronick S, Desmond JS. Evaluating the impact of emergency department crowding on disposition patterns and outcomes of discharged patients. Int J Emerg Med 2019; 12:4. [PMID: 31179922 PMCID: PMC6354348 DOI: 10.1186/s12245-019-0223-1] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2018] [Accepted: 01/21/2019] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Crowding is a major challenge faced by EDs and is associated with poor outcomes. OBJECTIVES Determine the effect of high ED occupancy on disposition decisions, return ED visits, and hospitalizations. METHODS We conducted a retrospective analysis of electronic health records of patients evaluated at an adult, urban, and academic ED over 20 months between the years 2012 and 2014. Using a logistic regression model predicting admission, we obtained estimates of the effect of high occupancy on admission disposition, adjusted for key covariates. We then stratified the analysis based on the presence or absence of high boarder patient counts. RESULTS Disposition decisions during a high occupancy hour decreased the odds of admission (OR = 0.93, 95% CI: [0.89, 0.98]). Among those who were not admitted, high occupancy was not associated with increased odds of return in the combined (OR = 0.94, 95% CI: [0.87, 1.02]), with-boarders (OR = 0.96, 95% CI: [0.86, 1.09]), and no-boarders samples (OR = 0.93, 95% CI: [0.83, 1.04]). Among those who were not admitted and who did return within 14 days, disposition during a high occupancy hour on the initial ED visit was not associated with a significant increased odds of hospitalization in the combined (OR = 1.04, 95% CI: [0.87, 1.24]), the with-boarders (OR = 1.12, 95% CI: [0.87, 1.44]), and the no-boarders samples (OR = 0.98, 95% CI: [0.77, 1.24]). CONCLUSION ED crowding was associated with reduced likelihood of hospitalization without increased likelihood of 2-week return ED visit or hospitalization. Furthermore, high occupancy disposition hours with high boarder patient counts were associated with decreased likelihood of hospitalization.
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Affiliation(s)
- Mahshid Abir
- Department of Emergency Medicine, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, NCRC Bldg. 10 Rm G016, 2800 Plymouth Road, Ann Arbor, MI, 48109-2800, USA. .,RAND Corporation, Santa Monica, CA, USA.
| | - Jason E Goldstick
- Department of Emergency Medicine, Acute Care Research Unit, Institute for Healthcare Policy and Innovation, University of Michigan, NCRC Bldg. 10 Rm G016, 2800 Plymouth Road, Ann Arbor, MI, 48109-2800, USA
| | | | | | - Sebastian Bauhoff
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
| | - Vikas I Parekh
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Steven Kronick
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Jeffrey S Desmond
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
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Chan YY, Bin Ibrahim MA, Wong CM, Ooi CK, Chow A. Determinants of antibiotic prescribing for upper respiratory tract infections in an emergency department with good primary care access: a qualitative analysis. Epidemiol Infect 2019; 147:e111. [PMID: 30868987 PMCID: PMC6518493 DOI: 10.1017/s095026881800331x] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2018] [Revised: 10/09/2018] [Accepted: 11/09/2018] [Indexed: 11/25/2022] Open
Abstract
Upper respiratory tract infections (URTIs) account for substantial attendances at emergency departments (EDs). There is a need to elucidate determinants of antibiotic prescribing in time-strapped EDs - popular choices for primary care despite highly accessible primary care clinics. Semi-structured in-depth interviews were conducted with purposively sampled physicians (n = 9) in an adult ED in Singapore. All interviews were analysed using thematic analysis and further interpreted using the Social Ecological Model to explain prescribing determinants. Themes included: (1) reliance on clinical knowledge and judgement, (2) patient-related factors, (3) patient-physician relationship factors, (4) perceived practice norms, (5) policies and treatment guidelines and (6) patient education and awareness. The physicians relied strongly on their clinical knowledge and judgement in managing URTI cases and seldom interfered with their peers' clinical decisions. Despite departmental norms of not prescribing antibiotics for URTIs, physicians would prescribe antibiotics when faced with uncertainty in patients' diagnoses, treating immunocompromised or older patients with comorbidities, and for patients demanding antibiotics, especially under time constraints. Participants had a preference for antibiotic prescribing guidelines based on local epidemiology, but viewed hospital policies on prescribing as a hindrance to clinical judgement. Participants highlighted the need for more public education and awareness on the appropriate use of antibiotics and management of URTIs. Organisational practice norms strongly influenced antibiotic prescribing decisions by physicians, who can be swayed by time pressures and patient demands. Clinical decision support tools, hospital guidelines and patient education targeting at individual, interpersonal and community levels could reduce unnecessary antibiotic use.
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Affiliation(s)
- Y. Y. Chan
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - M. A. Bin Ibrahim
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - C. M. Wong
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
| | - C. K. Ooi
- Department of Emergency Medicine, Tan Tock Seng Hospital, Singapore, Singapore
| | - A. Chow
- Department of Clinical Epidemiology, Office of Clinical Epidemiology, Analytics, and Knowledge, Tan Tock Seng Hospital, Singapore, Singapore
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Ishimine P, Adelgais K, Barata I, Klig J, Kou M, Mahajan P, Merritt C, Stoner MJ, Cloutier R, Mistry R, Denninghoff KR. Executive Summary: The 2018 Academic Emergency Medicine Consensus Conference: Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps. Acad Emerg Med 2018; 25:1317-1326. [PMID: 30461127 DOI: 10.1111/acem.13667] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 11/15/2018] [Accepted: 11/16/2018] [Indexed: 11/29/2022]
Abstract
Emergency care providers share a compelling interest in developing an effective patient-centered, outcomes-based research agenda that can decrease variability in pediatric outcomes. The 2018 Academic Emergency Medicine Consensus Conference "Aligning the Pediatric Emergency Medicine Research Agenda to Reduce Health Outcome Gaps (AEMCC)" aimed to fulfill this role. This conference convened major thought leaders and stakeholders to introduce a research, scholarship, and innovation agenda for pediatric emergency care specifically to reduce health outcome gaps. Planning committee and conference participants included emergency physicians, pediatric emergency physicians, pediatricians, and researchers with expertise in research dissemination and translation, as well as comparative effectiveness, in collaboration with patients, patient and family advocates from national advocacy organizations, and trainees. Topics that were explored and deliberated through subcommittee breakout sessions led by content experts included 1) pediatric emergency medical services research, 2) pediatric emergency medicine (PEM) research network collaboration, 3) PEM education for emergency medicine providers, 4) workforce development for PEM, and 5) enhancing collaboration across emergency departments (PEM practice in non-children's hospitals). The work product of this conference is a research agenda that aims to identify areas of future research, innovation, and scholarship in PEM.
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Affiliation(s)
- Paul Ishimine
- Departments of Emergency Medicine and Pediatrics University of California at San Diego School of Medicine San Diego CA
| | - Kathleen Adelgais
- Department of Pediatrics and Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Isabel Barata
- Departments of Pediatrics and Emergency Medicine Donald and Barbara Zucker School of Medicine at Hofstra/Northwell Hempstead NY
| | - Jean Klig
- Departments of Emergency Medicine and Pediatrics Harvard Medical School Boston MA
| | - Maybelle Kou
- Department of Emergency Medicine George Washington University School of Medicine and Health Sciences Washington DC
| | - Prashant Mahajan
- Departments of Emergency Medicine and Pediatrics University of Michigan Medical School Ann Arbor MI
| | - Chris Merritt
- Departments of Emergency Medicine and Pediatrics Alpert Medical School of Brown University Providence RI
| | - Michael J. Stoner
- Department of Pediatrics The Ohio State University College of Medicine Columbus OH
| | - Robert Cloutier
- Departments of Emergency Medicine and Pediatrics Oregon Health & Science University Portland OR
| | - Rakesh Mistry
- Department of Pediatrics and Emergency Medicine University of Colorado School of Medicine Aurora CO
| | - Kurt R. Denninghoff
- Department of Emergency Medicine University of Arizona College of Medicine Tucson AZ
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Emergency department imaging superusers. Emerg Radiol 2018; 26:161-168. [DOI: 10.1007/s10140-018-1659-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2018] [Accepted: 11/09/2018] [Indexed: 11/27/2022]
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Hsia RY, Huang D, Mann NC, Colwell C, Mercer MP, Dai M, Niedzwiecki MJ. A US National Study of the Association Between Income and Ambulance Response Time in Cardiac Arrest. JAMA Netw Open 2018; 1:e185202. [PMID: 30646394 PMCID: PMC6324393 DOI: 10.1001/jamanetworkopen.2018.5202] [Citation(s) in RCA: 55] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
IMPORTANCE Emergency medical services (EMS) provide critical prehospital care, and disparities in response times to time-sensitive conditions, such as cardiac arrest, may contribute to disparities in patient outcomes. OBJECTIVES To investigate whether ambulance 9-1-1 times were longer in low-income vs high-income areas and to compare response times with national benchmarks of 4, 8, or 15 minutes across income quartiles. DESIGN, SETTING, AND PARTICIPANTS A retrospective cross-sectional study was performed of the 2014 National Emergency Medical Services Information System data in June 2017 using negative binomial and logistic regressions to examine the association between zip code-level income and EMS response times. The study used ambulance 9-1-1 response data for out-of-hospital cardiac arrest from 46 of 50 state repositories (92.0%) in the United States. The sample included 63 600 cardiac arrest encounters of patients who did not die on scene and were transported to the hospital. MAIN OUTCOMES AND MEASURES Four time measures were examined, including response time, on-scene time, transport time, and total EMS time. The study compared response times with EMS response time benchmarks for responding to cardiac arrest calls within 4, 8, and 15 minutes. RESULTS The study sample included 63 600 cardiac arrest encounters of patients (mean [SD] age, 60.6 [19.0] years; 57.9% male), with 37 550 patients (59.0%) from high-income areas and 8192 patients (12.9%) from low-income areas. High-income areas had greater proportions of white patients (70.1% vs 62.2%), male patients (58.8% vs 54.1%), privately insured patients (29.4% vs 15.9%), and uninsured patients (15.3% vs 7.9%), while low-income areas had a greater proportion of Medicaid-insured patients (38.3% vs 15.8%). The mean (SD) total EMS time was 37.5 (13.6) minutes in the highest zip code income quartile and 43.0 (18.8) minutes in the lowest. After controlling for urban zip code, weekday, and time of day in regression analyses, total EMS time remained 10% longer (95% CI, 9%-11%; P < .001), translating to 3.8 minutes longer in the poorest zip codes. The EMS response time to patients in high-income zip codes was more likely to meet 8-minute and 15-minute cutoffs compared with low-income zip codes. CONCLUSIONS AND RELEVANCE Patients with cardiac arrest from the poorest neighborhoods had longer EMS times compared with those from the wealthiest, and response times were less likely to meet national benchmarks in low-income areas, which may lead to increased disparities in prehospital delivery of care over time.
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Affiliation(s)
- Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
| | - Delphine Huang
- Department of Emergency Medicine, University of California, San Francisco
| | - N. Clay Mann
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | | | - Mary P. Mercer
- Department of Emergency Medicine, University of California, San Francisco
| | - Mengtao Dai
- Department of Pediatrics, University of Utah School of Medicine, Salt Lake City
| | - Matthew J. Niedzwiecki
- Department of Emergency Medicine, University of California, San Francisco
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco
- Mathematica Policy Research, Oakland, California
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Ioannides KL, Baehr A, Karp DN, Wiebe DJ, Carr BG, Holena DN, Delgado MK. Measuring Emergency Care Survival: The Implications of Risk Adjusting for Race and Poverty. Acad Emerg Med 2018; 25:856-869. [PMID: 29851207 PMCID: PMC6274627 DOI: 10.1111/acem.13485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/30/2018] [Accepted: 05/25/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care-sensitive conditions mortality that could be used for hospital pay-for-performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients. METHODS We performed a cross-sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST-elevation myocardial infarction. We used multivariable logistic regression models to predict in-hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non-Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient-level covariates. We then ranked each hospital on observed-to-expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models. RESULTS The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19-1.36) and poor patients (aOR = 1.21, 95% CI = 1.12-1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C-statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest-performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest-performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001). CONCLUSIONS Sociodemographic risk adjustment of emergency care-sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay-for-performance programs.
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Affiliation(s)
- Kimon L.H. Ioannides
- Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Avi Baehr
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO
| | - David N. Karp
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Brendan G. Carr
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Daniel N. Holena
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M. Kit Delgado
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA
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Hung P, Henning-Smith CE, Casey MM, Kozhimannil KB. Access To Obstetric Services In Rural Counties Still Declining, With 9 Percent Losing Services, 2004-14. Health Aff (Millwood) 2018; 36:1663-1671. [PMID: 28874496 DOI: 10.1377/hlthaff.2017.0338] [Citation(s) in RCA: 172] [Impact Index Per Article: 28.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Recent closures of rural obstetric units and entire hospitals have exacerbated concerns about access to care for more than twenty-eight million women of reproductive age living in rural America. Yet the extent of recent obstetric unit closures has not yet been measured. Using national data, we found that 9 percent of rural counties experienced the loss of all hospital obstetric services in the period 2004-14. In addition, another 45 percent of rural US counties had no hospital obstetric services at all during the study period. That left more than half of all rural US counties without hospital obstetric services. Counties with fewer obstetricians and family physicians per women of reproductive age and per capita, respectively; a higher percentage of non-Hispanic black women of reproductive age; and lower median household incomes and those in states with more restrictive Medicaid income eligibility thresholds for pregnant women had higher odds of lacking hospital obstetric services. The same types of counties were also more likely to experience the loss of obstetric services, which highlights the challenge of providing adequate geographic access to obstetric care in vulnerable and underserved rural communities.
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Affiliation(s)
- Peiyin Hung
- Peiyin Hung is a PhD candidate in the Division of Health Policy and Management, University of Minnesota School of Public Health, in Minneapolis
| | - Carrie E Henning-Smith
- Carrie E. Henning-Smith is a research associate at the Rural Health Research Center, University of Minnesota School of Public Health
| | - Michelle M Casey
- Michelle M. Casey is a senior research fellow at the Rural Health Research Center, University of Minnesota School of Public Health
| | - Katy B Kozhimannil
- Katy B. Kozhimannil is an associate professor in the Division of Health Policy and Management, University of Minnesota School of Public Health
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