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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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Narayan A, Hong AS, Nguyen OK. Policy in clinical practice: Impact of restoring the 1999 public charge rule on healthcare access for noncitizen immigrants. J Hosp Med 2024; 19:215-218. [PMID: 38358059 DOI: 10.1002/jhm.13296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 12/02/2023] [Accepted: 01/28/2024] [Indexed: 02/16/2024]
Affiliation(s)
- Aman Narayan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Arthur S Hong
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
- Peter J. O'Donnell Jr. School of Public Health, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Oanh K Nguyen
- Division of Hospital Medicine at San Francisco General Hospital, University of California, San Francisco, San Francisco, California, USA
- Center for Vulnerable Populations, University of California, San Francisco, San Francisco, California, USA
- Philip R. Lee Institute for Health Policy Studies, University of California, San Francisco, San Francisco, California, USA
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Aridomi H, Cartier Y, Taira B, Kim HH, Yadav K, Gottlieb L. Implementation and Impacts of California Senate Bill 1152 on Homeless Discharge Protocols. West J Emerg Med 2023; 24:1104-1116. [PMID: 38165193 PMCID: PMC10754197 DOI: 10.5811/westjem.60853] [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: 05/03/2023] [Revised: 08/21/2023] [Accepted: 09/12/2023] [Indexed: 01/03/2024] Open
Abstract
Introduction In recent decades, there has been a growing focus on addressing social needs in healthcare settings. California has been at the forefront of making state-level investments to improve care for patients with complex social and medical needs, including patients experiencing homelessness (PEH). Examples include Medicaid 1115 waivers such as the Whole Person Care pilot program and California Advancing and Innovating Medi-Cal (CalAIM). To date, California is also the only state to have passed a legislative mandate to address concerns related to the hospital discharge of PEH who lack sufficient resources to support self-care. To this end, California enacted Senate Bill 1152 (SB 1152), a unique legislative mandate that requires hospitals to standardize comprehensive discharge processes for PEH by providing (and documenting the provision of) social and preventive services. Understanding the implementation and impact of this law will help inform California and other states considering legislative investments in healthcare activities to improve care for PEH. Methods To understand health system stakeholders' perceived impact of SB 1152 on hospital discharge processes and key barriers and facilitators to SB 1152's implementation, we conducted 32 semi-structured interviews with key informants across 16 general acute care hospitals in Humboldt and Los Angeles counties. Study data were coded and analyzed using thematic analysis informed by the Consolidated Framework for Implementation Research. Results Participants perceived several positive impacts of SB 1152, including streamlined services, increased accountability, and more staff awareness about homelessness. In parallel, participants also underscored concerns about the law's limited scope and highlighted multiple implementation challenges, including lack of clarity about accountability measures, scarcity of implementation supports, and gaps in community resources. Conclusion Our findings suggest that SB 1152 was an important step toward the goal of more universal safe discharge of PEH. However, there are also several addressable concerns. Recommendations to improve future legislation include adding targeted funding for social care staff and improving implementation training. Participants' broader concerns about the parallel need to increase community resources are more challenging to address in the immediate term, but such changes will also be necessary to improve the overall health outcomes of PEH.
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Affiliation(s)
- Haruna Aridomi
- University of California San Francisco, School of Medicine, San Francisco, California
| | - Yuri Cartier
- Social Interventions Research Evaluation Network, San Francisco, California
| | - Breena Taira
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
| | - Hyung Henry Kim
- Olive View-UCLA Medical Center, Department of Emergency Medicine, Sylmar, California
| | - Kabir Yadav
- Harbor-UCLA Medical Center, Department of Emergency Medicine, Torrance, California
- The Lundquist Institute for Biomedical Research, West Carson, California
| | - Laura Gottlieb
- Social Interventions Research Evaluation Network, San Francisco, California
- University of California San Francisco, Department of Family and Community Medicine, San Francisco, California
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LaPelusa M, Verduzco-Aguirre H, Diaz F, Aldaco F, Soto-Perez-de-Celis E. Cross-border utilization of cancer care by patients in the US and Mexico - a survey of Mexican oncologists. Global Health 2023; 19:78. [PMID: 37891675 PMCID: PMC10612194 DOI: 10.1186/s12992-023-00983-0] [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] [Received: 05/21/2023] [Accepted: 10/24/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND The US-Mexico border is the busiest in the world, with millions of people crossing it daily. However, little is known about cross-border utilization of cancer care, or about the reasons driving it. We designed a cross sectional online survey to understand the type of care patients with cancer who live in the US and Mexico seek outside their home country, the reasons why patients traveled across the border to receive care, and the barriers faced when seeking cross-border care. RESULTS The online survey was sent to the 248 cancer care providers working in the six Mexican border states who were registered members of the Mexican Society of Oncology. Responses were collected between September-November 2022. Sixty-six providers (response rate 26%) completed the survey. Fifty-nine (89%) reported interacting with US-based patients traveling to Mexico to receive various treatment modalities, with curative surgery (n = 38) and adjuvant chemotherapy (n = 31) being the most common. Forty-nine (74%) reported interacting with Mexico-based patients traveling to the US to receive various treatment modalities, with immunotherapy (n = 29) and curative surgery (n = 27) being the most common. The most frequently reported reason US-based patients sought care in Mexico was inadequate health insurance (n = 45). The most frequently reported reason Mexico-based patients sought care in the US was patients' perception of superior healthcare (n = 38). CONCLUSIONS Most Mexican oncologists working along the Mexico-US border have interacted with patients seeking or receiving binational cancer care. The type of care sought, as well as the reasons for seeking it, differ between US and Mexico-based patients. These patterns of cross-border healthcare utilization highlight unmet needs for patients with cancer in both countries and call for policy changes to improve outcomes in border regions.
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Affiliation(s)
- Michael LaPelusa
- Department of Internal Medicine, Vanderbilt University Medical Center, Nashville, TN, USA
| | - Haydeé Verduzco-Aguirre
- Department of Hemato-Oncology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico
| | - Fernando Diaz
- Lineberger Comprehensive Cancer Center, University of North Carolina - Chapel Hill, Chapel Hill, NC, United States
| | - Fernando Aldaco
- Servicio de Oncología Medica, Centro Médico Nacional 20 de Noviembre, Mexico City, Mexico
| | - Enrique Soto-Perez-de-Celis
- Department of Geriatrics, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga 15, 14080, Tlalpan, Mexico City, Mexico.
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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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Riegler J. Insurance-based inequities in emergency interhospital transfers: an argument for the prioritisation of patient care. JOURNAL OF MEDICAL ETHICS 2021; 47:766-769. [PMID: 33509791 DOI: 10.1136/medethics-2020-107074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/17/2020] [Accepted: 01/05/2021] [Indexed: 06/12/2023]
Abstract
Currently there is an inequity in transfer rates of uninsured patients versus their insured counterparts. While this may vary by hospital system, studies indicate that this is a national trend, especially in emergency situations, and represents a prioritisation of profits over ethical obligations. This creates a variety of ethical issues for patients and society that generates a concordance between deontological and utilitarian viewpoints, two generally opposed schools of thought. The prioritisation of profit maximisation in order to provide better care for a select population is insufficient to justify deleterious health outcomes, stress and financial burden on patients. Current policy regarding patient transfers in the emergency department is insufficient to protect the uninsured and must be reevaluated.
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Affiliation(s)
- Jacob Riegler
- College of Medicine, University of Central Florida, Orlando, Florida, USA
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Ray A, Curti S, Pegues J, Su D, Darsey D, Jordan R, Stringer S. Secondary overtriage of isolated facial trauma. Am J Otolaryngol 2021; 42:103043. [PMID: 33887629 DOI: 10.1016/j.amjoto.2021.103043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2021] [Accepted: 04/04/2021] [Indexed: 11/19/2022]
Abstract
DESIGN Retrospective chart review. SETTING Academic, tertiary care, level I trauma center in a rural state. BACKGROUND Unnecessary transfer of certain facial trauma patients results in a burden of time, money, and other resources on both the patient and healthcare system; identification and development of outpatient treatment pathways for these patients is a significant opportunity for cost savings. OBJECTIVES To investigate the treatment and disposition of un-complicated, stable, isolated facial trauma injuries transferred from outside hospitals and determine the significance of secondary overtriage. METHODS Retrospective chart review utilizing our institutional trauma database, including patients transferred to our emergency department between January 2012 and December 2017. Patients were identified by ICD9 or ICD10 codes and only those with isolated facial trauma were included. RESULTS We identified 538 isolated facial trauma patients who were transferred to our institution during the study period. The majority of those patients were transferred via ground ambulance for an average of 76 miles. Overall, 82% of patients (N = 440) were discharged directly from our institution's emergency department. Almost 30% of patients did not require any formal treatment for their injuries; the potential savings associated with elimination of these unnecessary transfers was estimated to be between $388,605 and $771,372. CONCLUSIONS We identified a high rate of patients with stable, isolated facial trauma that could potentially be evaluated and treated without emergent transfer. The minimization of these unnecessary transfers represents a significant opportunity for cost and resource utilization savings. LEVEL OF EVIDENCE 2b- Economic and Cost Analysis.
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Affiliation(s)
- Amrita Ray
- University of Mississippi Medical Center, Department of Otolaryngology, United States of America.
| | - Steven Curti
- University of Mississippi Medical Center, Department of Otolaryngology, United States of America.
| | - J'undra Pegues
- University of Mississippi Medical Center, School of Medicine, United States of America.
| | - Dan Su
- University of Mississippi Medical Center, Department of Data Science, United States of America
| | - Damon Darsey
- University of Mississippi Medical Center, Department of Emergency Medicine, United States of America.
| | - Randall Jordan
- University of Mississippi Medical Center, Department of Otolaryngology, United States of America.
| | - Scott Stringer
- University of Mississippi Medical Center, Department of Otolaryngology, United States of America.
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Cheng TW, Farber A, Forsyth AM, Levin SR, Haqqani M, Kalish JA, Siracuse JJ. Vascular surgery-related violations of the Emergency Medical Treatment and Labor Act. J Vasc Surg 2021; 74:599-604.e1. [PMID: 33548417 DOI: 10.1016/j.jvs.2020.12.110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2020] [Accepted: 12/31/2020] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law established in 1986 to ensure that patients who present to an emergency department receive medical care regardless of means. Violations are reported to the Centers for Medicare and Medicaid Services and can result in significant financial penalties. Our objective was to assess all available EMTALA violations for vascular-related issues. METHODS EMTALA violations in the Centers for Medicare and Medicaid Services publicly available hospital violations database from 2011 to 2018 were evaluated for vascular-related issues. Details recorded were case type, hospital type, hospital region, reasons for violation, disposition, and mortality. RESULTS There were 7001 patients identified with any EMTALA violation and 98 (1.4%) were deemed vascular related. The majority (82.7%) of EMTALA violations occurred at urban/suburban hospitals. Based on the Association of American Medical Colleges United States region, vascular-related EMTALA violations occurred in the Northeast (7.1%), Southern (56.1%), Central (18.4%), and Western (18.4%) United States. Case types included cerebrovascular (28.6%), aortic related (22.4%; which consisted of ruptured aortic aneurysms [8.2%], aortic dissection [11.2%], and other aortic [3.1%]), vascular trauma (15.3%), venous-thromboembolic (15.3%), peripheral arterial disease (9.2%), dialysis access (5.1%), bowel ischemia (3.1%), and other (1%) cases. Patients were transferred to another facility in 41.8% of cases. The most common reasons for violation were specialty refusal or unavailability (30.6%), inappropriate documentation (29.6%), misdiagnosis (18.4%), poor communication (17.3%), inappropriate triage (13.3%), failure to obtain diagnostic laboratory tests or imaging (12.2%), and ancillary or nursing staff issues (7.1%). The overall mortality was 19.4% and 31.6% died during the index emergency department visit. Vascular conditions associated with death were venous thromboembolism (31.6%), ruptured aortic aneurysm (21.1%), aortic dissection (21.1%), other aortic causes (10.5%), vascular trauma (10.5%), and bowel ischemia (5.3%). CONCLUSIONS Although the frequency of vascular-related EMTALA violations was low, improvements in communication, awareness of vascular disease among staff, specialty staffing, and the development of referral networks and processes are needed to ensure that patients receive adequate care and that institutions are not placed at undue risk.
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Affiliation(s)
- Thomas W Cheng
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Alik Farber
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Alexandra M Forsyth
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Scott R Levin
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Maha Haqqani
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey A Kalish
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass
| | - Jeffrey J Siracuse
- Division of Vascular and Endovascular Surgery, Boston Medical Center, Boston University School of Medicine, Boston, Mass.
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Brown HL. Emergency Care EMTALA Alterations During the COVID-19 Pandemic in the United States. J Emerg Nurs 2020; 47:321-325. [PMID: 33388166 PMCID: PMC7704064 DOI: 10.1016/j.jen.2020.11.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2020] [Revised: 11/02/2020] [Accepted: 11/23/2020] [Indexed: 11/24/2022]
Abstract
The coronavirus 2019 pandemic has affected almost every aspect of health care delivery in the United States, and the emergency medicine system has been hit particularly hard while dealing with this public health crisis. In an unprecedented time in our history, medical systems and clinicians have been asked to be creative, flexible, and innovative, all while continuing to uphold the important standards in the US health care system. To continue providing quality services to patients during this extraordinary time, care providers, organizations, administrators, and insurers have needed to alter longstanding models and procedures to respond to the dynamics of a pandemic. The Emergency Medicine Treatment and Active Labor Act of 1986, or EMTALA, is 1 example of where these alterations have allowed health care facilities and clinicians to continue their work of caring for patients while protecting both the patients and the clinicians themselves from infectious exposures at the same time.
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The Association Between Hospital Characteristics and Emergency Medical Treatment and Labor Act Citation Events. Med Care 2020; 58:793-799. [PMID: 32826744 DOI: 10.1097/mlr.0000000000001360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The Emergency Medical Treatment and Labor Act (EMTALA) is a federal law enacted in 1986 prohibiting patient dumping (refusing or transferring patients with emergency medical conditions without appropriate stabilization), and discrimination based upon ability to pay. We evaluate hospital-level features associated with citation for EMTALA violation. MATERIALS AND METHODS A retrospective analysis of observational data on EMTALA enforcement (2005-2013). Regression analysis evaluates the association between facility-level features and odds of EMTALA citation by hospital-year. RESULTS Among 4916 EMTALA-obligated hospitals there were 1925 EMTALA citation events at 1413 facilities between 2005 and 2013, with 4.3% of hospitals cited per year. In adjusted analyses, increased odds of EMTALA citations were found at hospitals that were: for-profit [odds ratio (OR): 1.61; 95% confidence interval (CI): 1.32-1.96], in metropolitan areas (OR: 1.32; 95% CI: 1.11-1.57); that admitted a higher proportion of Medicaid patients (OR: 1.01; 95% CI: 1.0-1.01); and were in the top quartiles of hospital size (OR: 1.48; 95% CI: 1.10-1.99) and emergency department (ED) volume (OR: 1.56; 95% CI: 1.14-2.12). Predicted probability of repeat EMTALA citation in the year following initial citation was 17% among for-profit and 11% among other hospital types. Among citation events for patients presenting to the same hospital's ED, there were 1.30 EMTALA citation events per million ED visits, with 1.04 at private not-for-profit, 1.47 at government-owned, and 2.46 at for-profit hospitals. CONCLUSIONS For-profit ownership is associated with increased odds of EMTALA citations after adjusting for other characteristics. Efforts to improve EMTALA might be considered to protect access to emergency care for vulnerable populations, particularly at large, urban, for-profit hospitals admitting high proportions of Medicaid patients.
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Elevated chronic bronchitis diagnosis risk among women in a local emergency department patient population associated with the 2012 heatwave and drought in Douglas county, NE USA. Heart Lung 2020; 49:934-939. [PMID: 32522416 DOI: 10.1016/j.hrtlng.2020.03.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Revised: 03/20/2020] [Accepted: 03/26/2020] [Indexed: 02/05/2023]
Abstract
BACKGROUND Concerns about global climate change force local public health agencies to assess potential local disease risk. OBJECTIVE Determine if risk of an emergency department chronic bronchitis diagnosis in Douglas County, NE, was higher during the 2012 heatwave compared to the same calendar period in 2011. METHODS Retrospective, observational, case-control design selecting subjects from 2011 and 2012 emergency department (ED) admissions. Risk was estimated by conditional logistic regression. RESULTS The odds of an ED chronic bronchitis diagnosis among females was 3.77 (95% CI =1.37-10.21) times higher during the 2012 risk period compared to females admitted to the ED during the 2011 risk period. Chronic bronchitis ED diagnosis odds were 1.05 (95%CI=1.04 - 1.06) times higher for each year of age. ED, gender, and race modified the risk (i.e., effect). The overall chronic bronchitis ED risk estimate was 1.61 (95%CI=0.81 - 3.21) times higher during the 2012 risk period compared to the 2011 risk period. The mean ambient absolute humidity upon admission was 11.44 gr/m3 (95%CI; 10.40 - 12.47) among chronic bronchitis cases and 12.67 gr/m3 (95%CI; 12.63 - 12.71) among controls. CONCLUSION The odds of ED chronic bronchitis diagnosis was higher among female subjects admitted during the 2012 risk period compared to females admitted during the 2011 risk period. Age also increased chronic bronchitis ED diagnosis risk among 2012 risk period admissions compared to 2011 risk period admissions.
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Zhou JY, Amanatullah DF, Frick SL. EMTALA (Emergency Medical Treatment and Active Labor Act) Obligations: A Case Report and Review of the Literature. J Bone Joint Surg Am 2019; 101:e55. [PMID: 31220031 DOI: 10.2106/jbjs.18.01166] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The Emergency Medical Treatment and Active Labor Act (EMTALA) was enacted in 1986 in the United States to address "patient dumping," or refusing to provide emergency care to patients and instead transferring them to other hospitals. Under EMTALA, the "reverse-dumping" provision prevents hospitals from refusing patients who require specialized capabilities or facilities if the hospital has the capacity to treat them. Despite this provision, patients continue to be transferred to distant tertiary care centers. METHODS We reviewed the literature on EMTALA in the context of a critically ill woman with an infection associated with an orthopaedic implant who was rejected from 2 geographically closer tertiary care centers and was ultimately transferred by helicopter ambulance to an academic teaching hospital that was 169 miles away from her home. RESULTS After transfer to our tertiary care, level-I trauma center, the patient spent 61 days in the intensive care unit; she required 9 operative procedures, which totaled 1,520 minutes of operative time. Eighteen medical specialties and 8 ancillary medical consulting teams were involved in her care. She underwent 1,436 laboratory and 83 radiographic studies. The total reimbursement from Medi-Cal (California's Medicaid program) for her care in our tertiary care center was $463,753; the hospital charges were more than tenfold higher. CONCLUSIONS Dumping and reverse dumping continue despite compromise of patient care and the high financial burden of the accepting institutions. This may be due to ineffective monitoring and enforcement, lack of uniformity among the courts, and lack of incentive to receive uninsured or poorly funded patients. Under EMTALA, it is difficult for tertiary care centers to argue lack of specialized capabilities or capacity to accept patients, and neither hospitals nor physicians are compensated for the charges of providing care to uninsured or underinsured patients. Moving forward, efforts to better align financial incentives through cost-sharing between community hospitals and tertiary care centers, increased clinician literacy regarding the provisions of EMTALA, and increased transparency with hospital transfers may help improve EMTALA compliance and patient care.
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Affiliation(s)
- Joanne Y Zhou
- Stanford University School of Medicine, Stanford, California.,Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Derek F Amanatullah
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California
| | - Steven L Frick
- Department of Orthopaedic Surgery, Stanford University School of Medicine, Stanford, California
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Brown HL, Brown TB. EMTALA: The Evolution of Emergency Care in the United States. J Emerg Nurs 2019; 45:411-414. [PMID: 30902349 DOI: 10.1016/j.jen.2019.02.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2018] [Revised: 02/04/2019] [Accepted: 02/16/2019] [Indexed: 10/27/2022]
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Figgs LW. Emergency department asthma diagnosis risk associated with the 2012 heat wave and drought in Douglas County NE, USA. Heart Lung 2019; 48:250-257. [PMID: 30686617 DOI: 10.1016/j.hrtlng.2018.12.005] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2018] [Revised: 12/03/2018] [Accepted: 12/16/2018] [Indexed: 01/09/2023]
Abstract
BACKGROUND Global climate change concerns are forcing local public health agencies to assess potential disease risk. OBJECTIVE Determine if risk of an emergency department asthma diagnosis in Douglas County, NE, was higher during the 2012 heatwave compared to 2011. METHODS Retrospective, observational, case-control design selecting subjects from 2011 and 2012 emergency department (ED) admissions. Risk was estimated by conditional logistic regression. RESULTS The asthma ED risk estimate was 1.23 (95%CI = 0.96-1.57) times higher in 2012 than 2011, for the same calendar period. Asthma ED diagnosis risk was 3.37 (95%CI = 2.27-4.17) times higher among subjects <19years old compared to older subjects, and 3.25 (95%CI = 2.63-4.02) times higher among African-Americans than non-African-Americans, adjusted for heatwave exposure. Absolute humidity appears inversely related to asthma diagnosis risk ( χ2 = 16.6; p < 0.001). CONCLUSION Asthma ED diagnosis risk was not significantly higher in 2012 compared to 2011. Risk was elevated among subjects less than 19years old, and among African Americans; adjusted for heatwave exposure.
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Affiliation(s)
- Larry W Figgs
- Environmental Health Division, Douglas County Health Department, 1111 South 41 Street, Omaha, NE 68105, United States.
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Adin CA, Moga JL, Keene BW, Fogle CA, Hopkinson HR, Weyhrauch CA, Marks SL, Ruderman RJ, Rosoff PM. Clinical ethics consultation in a tertiary care veterinary teaching hospital. J Am Vet Med Assoc 2019; 254:52-60. [DOI: 10.2460/javma.254.1.52] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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McKenna RM, Purtle J, Nelson KL, Roby DH, Regenstein M, Ortega AN. Examining EMTALA in the era of the patient protection and Affordable Care Act. AIMS Public Health 2018; 5:366-377. [PMID: 30631780 PMCID: PMC6322999 DOI: 10.3934/publichealth.2018.4.366] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2018] [Accepted: 09/21/2018] [Indexed: 11/18/2022] Open
Abstract
Background Little is known regarding the characteristics of hospitals that violate the Emergency Medical Treatment and Labor Act (EMTALA). This study addresses this gap by examining EMTALA settlements from violating hospitals and places these descriptive results within the current debate surrounding the Patient Protection and Affordable Care Act (ACA). Methods We conducted a content analysis of all EMTALA Violations that resulted in civil monetary penalty settlements from 2002–2015 and created a dataset describing the nature of each settlement. These data were then matched with Thomson Healthcare hospital data. We then present descriptive statistics of each settlement over time, plot settlements by type of violation, and provide the geographic distribution of settlements. Results Settlements resulting from EMTALA violations decreased from a high of 46 in 2002 to a low of 6 in 2015, a decline of 87%. Settlements resulting from violations most commonly occurred for failure to screen and failure to stabilize patients in need of emergency care. Settlements were most common in hospitals in the South (48%) and in urban areas (74%). Among Disproportionate Share Hospitals (DSH) with a violation, the majority (62%) were located in the South or in urban areas (65%). Violating hospitals incurred annual settlements of $31,734 on average, for a total $5,299,500 over the study period. Conclusions EMTALA settlements declined prior to and after the implementation of the ACA and were most common in the South and in urban areas. EMTALA's status as an unfunded mandate, scheduled cuts to DSH payments and efforts to repeal the ACA threaten the financial viability of safety-net hospitals and could result in an increase of EMTALA violations. Policymakers should be cognizant of the interplay between the ACA and complementary laws, such as EMTALA, when considering changes to the law.
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Affiliation(s)
- Ryan M McKenna
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA
| | - Jonathan Purtle
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA
| | - Katherine L Nelson
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA
| | - Dylan H Roby
- Department of Health Services Administration, School of Public Health, University of Maryland, 4200 Valley Dr # 2242, College Park, MD 20742, USA
| | - Marsha Regenstein
- Department of Health Policy and Management, Milken Institute School of Public Health, George Washington University, 950 New Hampshire Ave NW, Washington, DC 20052, USA
| | - Alexander N Ortega
- Department of Health Management and Policy, Dornsife School of Public Health, Drexel University, 3215 Market Street, Nesbitt Hall, Philadelphia, PA 19104, USA
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Carpenter CR, Lewis L, Jotte RS, Schwarz ES. A Bridge to Nowhere? Challenging Outpatient Transitions of Care for Acute Pain Patients in the Opioid Epidemic Era. MISSOURI MEDICINE 2018; 115:241-246. [PMID: 30228730 PMCID: PMC6140146] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
Opioid misuse is reducing Americans' life expectancy, thereby catalyzing professional societies and legislators to action. Efforts to combat the opioid epidemic must work hand-in-hand with appropriate efforts to reduce the severity and duration of suffering. Pharmacologic analgesia is temporizing. Current opioid prescribing guidelines focus on reducing the frequency and quantity of narcotics prescribed, but lack attention to alleviation of the source of pain. Conditions eliciting acute pain sometimes require additional specialist management following discharge from the emergency department. Patients frequently lack timely access to these specialists, particularly if underinsured. This essay explores acute dental pain, extremity fractures, and back pain as three common examples whereby complex healthcare systems must efficiently adapt in order to serve the dual objectives of reducing the risk of opioid-related adverse consequences and minimizing the duration of patient suffering.
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Affiliation(s)
- Christopher R Carpenter
- Christopher R. Carpenter, MD, MSc, MSMA member since 2016, Associate Professor, is in the Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Lawrence Lewis
- Lawrence Lewis, MD, Professor, is in the Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Randall S Jotte
- Randall S. Jotte, MD, MSMA member since 2016, Associate Professor, is in the Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Mo
| | - Evan S Schwarz
- Evan S. Schwarz, MD, MSMA member since 2014, Associate Professor, is in the Division of Emergency Medicine, Washington University School of Medicine, St. Louis, Mo
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Dennis BJL. Catastrophic events: Are you prepared? J Healthc Risk Manag 2018; 37:5. [PMID: 29350798 DOI: 10.1002/jhrm.21312] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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