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Janke AT, Oskvarek JJ, Zocchi MS, Cai AG, Litvak O, Pines JM, Venkatesh AK. Reliability of a Measure of Admission Intensity for Emergency Physicians. Ann Emerg Med 2024:S0196-0644(24)00082-9. [PMID: 38430082 DOI: 10.1016/j.annemergmed.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/18/2024] [Accepted: 02/02/2024] [Indexed: 03/03/2024]
Abstract
STUDY OBJECTIVE We assess the stability of a measure of emergency department (ED) admission intensity for value-based care programs designed to reduce variation in ED admission rates. Measure stability is important to accurately assess admission rates across sites and among physicians. METHODS We sampled data from 358 EDs in 41 states (January 2018 to December 2021), separate from sites where the measure was derived. The measure is the ED admission rate per 100 ED visits for 16 clinical conditions and 535 included International Classification of Disease 10 diagnosis codes. We used descriptive plots and multilevel linear probability models to assess stability over time across EDs and among physicians. RESULTS Across included 3,571 ED-quarters, the average admission rate was 27.6% (95% confidence interval [CI] 26.0% to 28.2%). The between-facility standard deviation was 9.7% (95% CI 9.0% to 10.6%), and the within-facility standard deviation was 3.0% (95% CI 2.95% to 3.10%), with an intraclass correlation coefficient of 0.91. At the physician-quarter level, the average admission rate was 28.3% (95% CI 28.0% to 28.5%) among 7,002 physicians. Relative to their site's mean in each quarter, the between-physician standard deviation was 6.7% (95% CI 6.6% to 6.8%), and the within-physician standard deviation was 5.5% (95% CI 5.5% to 5.6%), with an intraclass correlation coefficient of 0.59. Moreover, 2.9% of physicians were high-admitting in 80%+ of their practice quarters relative to their peers in the same ED and in the same quarter, whereas 3.9% were low-admitting. CONCLUSION The measure exhibits stability in characterizing ED-level admission rates and reliably identifies high- and low-admitting physicians.
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Affiliation(s)
- Alexander T Janke
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy/Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Jonathan J Oskvarek
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, Summa Health System, Akron, OH
| | - Mark S Zocchi
- US Acute Care Solutions, Canton, OH; Heller School for Social Policy and Management, Braindeis University, Waltham, MA
| | - Angela G Cai
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Wendel SK, Bookman K, Holmes M, Wiler JL. Successful Implementation of Workflow-Embedded Clinical Pathways During the COVID 19 Pandemic. Qual Manag Health Care 2023; 32:205-210. [PMID: 36913774 PMCID: PMC10289068 DOI: 10.1097/qmh.0000000000000408] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/14/2023]
Abstract
BACKGROUND AND OBJECTIVES Clinical pathways have been found effective for improving adherence to evidence-based guidelines, thus providing better patient outcomes. As coronavirus disease-2019 (COVID-19) clinical guidance changed rapidly and evolved, a large hospital system in Colorado established clinical pathways within the electronic health record to guide clinical practice and provide the most up-to-date information to frontline providers. METHODS On March 12, 2020, a system-wide multidisciplinary committee of specialists in emergency medicine, hospital medicine, surgery, intensive care, infectious disease, pharmacy, care management, virtual health, informatics, and primary care was recruited to develop clinical guidelines for COVID-19 patient care based on the limited available evidence and consensus. These guidelines were organized into novel noninterruptive digitally embedded pathways in the electronic health record (Epic Systems, Verona, Wisconsin) and made available to nurses and providers at all sites of care. Pathway utilization data were analyzed from March 14 to December 31, 2020. Retrospective pathway utilization was stratified by each care setting and compared with Colorado hospitalization rates. This project was designated as a quality improvement initiative. RESULTS Nine unique pathways were developed, including emergency medicine, ambulatory, inpatient, and surgical care guidelines. Pathway data were analyzed from March 14 to December 31, 2020, and showed that COVID-19 clinical pathways were used 21 099 times. Eighty-one percent of pathway utilization occurred in the emergency department setting, and 92.4% applied embedded testing recommendations. A total of 3474 distinct providers employed these pathways for patient care. CONCLUSIONS Noninterruptive digitally embedded clinical care pathways were broadly utilized during the early part of the COVID-19 pandemic in Colorado and influenced care across many care settings. This clinical guidance was most highly utilized in the emergency department setting. This shows an opportunity to leverage noninterruptive technology at the point of care to guide clinical decision-making and practice.
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Affiliation(s)
- Sarah K. Wendel
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Kelly Bookman
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Molly Holmes
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
| | - Jennifer L. Wiler
- Department of Emergency Medicine, University of Virginia, Charlottesville (Dr Wendel); Department of Emergency Medicine, University of Colorado, Aurora (Drs Bookman and Wiler); and Clinical Quality Department, University of Colorado Hospital, Aurora (Ms Holmes and Dr Wiler)
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Melnick ER, Nath B, Dziura JD, Casey MF, Jeffery MM, Paek H, Soares WE, Hoppe JA, Rajeevan H, Li F, Skains RM, Walter LA, Patel MD, Chari SV, Platts-Mills TF, Hess EP, D'Onofrio G. User centered clinical decision support to implement initiation of buprenorphine for opioid use disorder in the emergency department: EMBED pragmatic cluster randomized controlled trial. BMJ 2022; 377:e069271. [PMID: 35760423 PMCID: PMC9231533 DOI: 10.1136/bmj-2021-069271] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To determine the effect of a user centered clinical decision support tool versus usual care on rates of initiation of buprenorphine in the routine emergency care of individuals with opioid use disorder. DESIGN Pragmatic cluster randomized controlled trial (EMBED). SETTING 18 emergency department clusters across five healthcare systems in five states representing the north east, south east, and western regions of the US, ranging from community hospitals to tertiary care centers, using either the Epic or Cerner electronic health record platform. PARTICIPANTS 599 attending emergency physicians caring for 5047 adult patients presenting with opioid use disorder. INTERVENTION A user centered, physician facing clinical decision support system seamlessly integrated into user workflows in the electronic health record to support initiating buprenorphine in the emergency department by helping clinicians to diagnose opioid use disorder, assess the severity of withdrawal, motivate patients to accept treatment, and complete electronic health record tasks by automating clinical and after visit documentation, order entry, prescribing, and referral. MAIN OUTCOME MEASURES Rate of initiation of buprenorphine (administration or prescription of buprenorphine) in the emergency department among patients with opioid use disorder. Secondary implementation outcomes were measured with the RE-AIM (reach, effectiveness, adoption, implementation, and maintenance) framework. RESULTS 1 413 693 visits to the emergency department (775 873 in the intervention arm and 637 820 in the usual care arm) from November 2019 to May 2021 were assessed for eligibility, resulting in 5047 patients with opioid use disorder (2787 intervention arm, 2260 usual care arm) under the care of 599 attending physicians (340 intervention arm, 259 usual care arm) for analysis. Buprenorphine was initiated in 347 (12.5%) patients in the intervention arm and in 271 (12.0%) patients in the usual care arm (adjusted generalized estimating equations odds ratio 1.22, 95% confidence interval 0.61 to 2.43, P=0.58). Buprenorphine was initiated at least once by 151 (44.4%) physicians in the intervention arm and by 88 (34.0%) in the usual care arm (1.83, 1.16 to 2.89, P=0.01). CONCLUSIONS User centered clinical decision support did not increase patient level rates of initiating buprenorphine in the emergency department. Although streamlining and automating electronic health record workflows can potentially increase adoption of complex, unfamiliar evidence based practices, more interventions are needed to look at other barriers to the treatment of addiction and increase the rate of initiating buprenorphine in the emergency department in patients with opioid use disorder. TRIAL REGISTRATION ClinicalTrials.gov NCT03658642.
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Affiliation(s)
- Edward R Melnick
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Bidisha Nath
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
| | - James D Dziura
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
| | - Martin F Casey
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Molly M Jeffery
- Department of Emergency Medicine and Division of Health Care Delivery Research, Mayo Clinic, Rochester, MN, USA
| | - Hyung Paek
- Yale School of Public Health, New Haven, CT, USA
| | - William E Soares
- Department of Emergency Medicine, University of Massachusetts Medical School, Springfield, MA, USA
| | - Jason A Hoppe
- Department of Emergency Medicine, University of Colorado, Aurora, CO, USA
| | | | - Fangyong Li
- Yale School of Public Health, New Haven, CT, USA
| | - Rachel M Skains
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Lauren A Walter
- Department of Emergency Medicine, University of Alabama at Birmingham Heersink School of Medicine, Birmingham, AL, USA
| | - Mehul D Patel
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | - Srihari V Chari
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| | | | - Erik P Hess
- Department of Emergency Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT, USA
- Yale School of Public Health, New Haven, CT, USA
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Cao J, Ge Z, Zhao H, Ma K, Xia Z. Practice and Evaluation of a Protocol for Collating Information Related to the Emergency Clinical Pathway for Patients With Acute ST-Segment Elevation Myocardial Infarction. Front Cardiovasc Med 2022; 9:840715. [PMID: 35571198 PMCID: PMC9091446 DOI: 10.3389/fcvm.2022.840715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/03/2022] [Indexed: 11/13/2022] Open
Abstract
Acute ST elevation myocardial infarction (STEMI) is a common acute and critical disease that requires rapid treatment within a limited window of time. In this study, we attempt to introduce a clinical pathway for the whole-process management of emergency STEMI based on the creation of a specific information system that matches the characteristics of emergency clinical work and evaluates their clinical value by quality control analysis. We deployed this system for 3 years and found that complications, heart failure, and medical costs during hospitalization were significantly reduced (p = 0.019) in patients with STEMI. By analyzing each link in the clinical pathway, our research indicates the clear clinical importance of developing methods to continuously improve data quality. Collectively, out research led to the optimization of an information system that will facilitate the clinical management of patients with STEMI.
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Kao DP. Electronic Health Records and Heart Failure. Heart Fail Clin 2022; 18:201-211. [PMID: 35341535 PMCID: PMC9167063 DOI: 10.1016/j.hfc.2021.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Increasing the global adoption of electronic health records (EHRs) is transforming the delivery of clinical care. EHRs offer tools that are useful in the care of heart failure ranging from individualized risk stratification and decision support to population management. EHR tools can be combined to target specific areas of need such as the standardization of care, improved quality of care, and resource management. Leveraging EHR functionality has been shown to improve select outcomes including guideline-based therapies, reduction in adverse clinical outcomes, and improved cost-efficiency. Central to success is participation by clinicians and patients in the design and feedback of EHR tools.
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Affiliation(s)
- David P Kao
- University of Colorado School of Medicine, 12700 East 19th Avenue Box B-139, Research Center 2 Room 8005, Aurora, CO 80045, USA.
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