Cost reduction strategies for emergency services: insurance role, practice changes and patients accountability

Cost-effectiveness analysis of a 'Termination of Resuscitation' protocol for the management of out-of-hospital cardiac arrest

BACKGROUND

Historically in Singapore, all out-of-hospital cardiac arrests (OHCA) were transported to hospital for pronouncement of death. A 'Termination of Resuscitation' (TOR) protocol, implemented from 2019 onwards, enables emergency responders to pronounce death at-scene in Singapore. This study aims to evaluate the cost-effectiveness of the TOR protocol for OHCA management.

METHODS

Adopting a healthcare provider's perspective, a Markov model was developed to evaluate three competing options: No TOR, Observed TOR reflecting existing practice, and Full TOR if TOR is exercised fully. The model had a cycle duration of 30 days after the initial state of having a cardiac arrest, and was evaluated over a 10-year time horizon. Probabilistic sensitivity analysis was performed to account for uncertainties. The costs per quality adjusted life years (QALY) was calculated.

RESULTS

A total of 3,695 OHCA cases eligible for the TOR protocol were analysed; mean age of 73.0 ± 15.5 years. For every 10,000 hypothetical patients, Observed TOR and Full TOR had more deaths by approximately 19 and 31 patients, respectively, compared to No TOR. Full TOR had the least costs and QALYs at $19,633,369 (95% Uncertainty Interval (UI) 19,469,973 to 19,796,764) and 0 QALYs. If TOR is exercised for every eligible case, it could expect to save approximately $400,440 per QALY loss compared to No TOR, and $821,151 per QALY loss compared to Observed TOR.

CONCLUSION

The application of the TOR protocol for the management of OHCA was found to be cost-effective within acceptable willingness-to-pay thresholds, providing some justification for sustainable adoption.

The COVID-19 impact and characterization on substance use-related emergency department visits for adolescents and young adults in Canada: Practical implications

RATIONALE

Coronavirus (COVID-19)-related stressors precipitated the mental health crisis and increased substance use in Canada and worldwide. As the pandemic continues to evolve, monitoring and updating substance use-related ED visit trends is essential to ensure the stability and quality of ED services under the prolonged pandemic timeline.

AIMS AND OBJECTIVES

This study examined the trends and characterization of substance use-related ED visits during the pandemic among adolescents and young adults (aged 13-25 years) in Ontario, Canada.

METHODS

Descriptive statistics and binary logistic regression analyses were conducted using population-based, repeated cross-sectional data. The volume, patient characteristics (age and sex) and hospital/ED visit features (triage to end time, timing of the visit, triage level and referral source) were compared before (2019) and during COVID-19 (2020 and 2021) by each substance type (alcohol, opioid, cannabis, sedatives, cocaine, stimulants and multiple psychoactive substances).

RESULTS

Substance use-related ED visits decreased by 1.5 times during the pandemic compared to the prepandemic level. However, opioid-related ED visits continued to show an increasing trend and did not recover to the prepandemic level in 2021. Moreover, a significant increase in emergent/life-threatening triage levels (Canadian Triage and Acuity Scales 1 and 2) in substance-related ED visits is alarming (2019 = 36.8%, 2020 = 38.7% and 2021 = 38.4%). We also found a general decrease in weekend visits, overnight visits and visits on statutory holidays, and substance use-related ED patients tended to stay longer (over 6 h) in the ED during the pandemic.

CONCLUSION

Our findings indicate unmet substance use treatment needs due to the limited accessibility and heightened threshold for ED visits during the pandemic. Providing access to substance treatment/programs outside ED is critical to reducing substance use-related complications presenting in the ED. Also, policies addressing the pandemic-related complexities in the ED and Health Human Resource challenges are warranted.

Nonurgent Emergency Department Use by Pediatric Patients in the United States: A Systematic Literature Review

OBJECTIVES

Pediatric use of the emergency department (ED) for nonurgent reasons is common in the United States. Patients with nonurgent conditions can receive more appropriate, cost-efficient care in other settings. We conducted a systematic literature review to understand the breadth of factors that contribute to use of the ED for nonurgent conditions by pediatric patients in the United States.

METHODS

The literature search was conducted according to the PRISMA guidelines for systematic reviews and was guided by the social-ecological model for synthesis of articles. Published articles were identified through a search of Academic Search Ultimate, Google Scholar, and PubMed. All articles were organized and managed using Endnote software and screened for eligibility criteria before full-text review.

RESULTS

The initial search yielded 679 articles with 530 articles remaining after the removal of duplicates. Of these, 31 articles were reviewed in full text with 19 remaining for the final analysis. All articles assessed individual-level factors, including parental perceptions of ED and health literacy. Additional findings of nonurgent use of the ED were shown to pertain to the organizational and public policy levels of the model, including primary care clinic and insurance characteristics.

CONCLUSIONS

The findings of this review suggest tailored interventions to address parents'/caregivers' ED perceptions and health literacy in addition to access (ie, public policy).

The burden of costs on health services from patients with venous leg ulcers in Singapore

Healthcare costs arising from venous leg ulcers (VLU) are expected to increase due to an aging population and increased prevalence of comorbidities. We aim to estimate the healthcare resources incurred by VLU patients, and to quantify the extent to which predictors explain variation in cost-related outcomes. Retrospective patient-level cohort data for VLU patients were analysed using generalised linear regression models. Data were extracted from a tertiary hospital registry in Singapore, between 2013 and 2017. The outcome variables were length of stay per admission; inpatient and outpatient bill per admission; whether a patient underwent a surgical treatment of the venous system; and, whether they visited the emergency department. Cost outcomes were reported in Singapore dollars (S$). A total of 162 VLU patients were included with a mean age of 67.5 (±14.4). For the inpatient setting the mean length of stay was 8.1 days and the mean inpatient bill was S$7886. For outpatients, the mean number of dressings was 29.4, and mean outpatient bill was S$6962. Heart disease patients incurred longer hospital stays and larger inpatient bills per admission and females had greater odds of undergoing a surgical procedure on the venous system. Certain VLU patient groups were found to be associated with larger cost outcomes.

Lipophilic vs. hydrophilic statins and psychiatric hospitalizations and emergency room visits in US Veterans with schizophrenia and bipolar disorder

Objective –

Psychiatric hospitalizations and emergency department (ED) visits are costly, stigmatizing, and often ineffective. Given the immune and kynurenine activation in bipolar disorder (BD) and schizophrenia, as well as the immune-modulatory effects of statins, we aimed to compare the relative risk (RRs) of psychiatric hospitalizations and ED visits between individuals prescribed lipophilic vs. hydrophilic statins vs. no statins. We hypothesized (a) reduced rates of hospitalization and ER utilization with statins versus no statins and (b) differences in outcomes between statins, as lipophilia increases the capability to penetrate the blood–brain barrier with potentially beneficial neuroimmune, antioxidant, neuroprotective, neurotrophic, and endothelial stabilizing effects, and, in contrast, potentially detrimental decreases in brain cholesterol concentrations leading to serotoninergic dysfunction, changes in membrane lipid composition, thus affecting ion channels and receptors.

Methods –

We used VA service utilization data from October 1, 2010 to September 30, 2015. The RRs for psychiatric hospitalization and ED visits, were estimated using robust Poisson regression analyses. The number of individuals analyzed was 683,129.

Results –

Individuals with schizophrenia and BD who received prescriptions for either lipophilic or hydrophilic statins had a lower RR of psychiatric hospitalization or ED visits relative to nonstatin controls. Hydrophilic statins were significantly associated with lower RRs of psychiatric hospitalization but not of ED visits, compared to lipophilic statins.

Conclusion –

The reduction in psychiatric hospitalizations in statin users (vs. nonusers) should be interpreted cautiously, as it carries a high risk of confounding by indication. While the lower RR of psychiatric hospitalizations in hydrophilic statins relative to the lipophilic statins is relatively bias free, the finding bears replication in a specifically designed study. If replicated, important clinical implications for personalizing statin treatment in patients with mental illness, investigating add-on statins for improved therapeutic control, and mechanistic exploration for identifying new treatment targets are natural next steps.

Safety net, gateway, market, sport, and war: Exploring how emergency physicians conceptualize and ascribe meaning to emergency care

BACKGROUND

Metaphorical expressions and conceptualisations are widely used in medical discourse to convey complex and abstract concepts. Our study uses a novel way to examine the spontaneous use of metaphors by emergency physicians as they articulate their experiences of practicing emergency care. These co-constructions shed light on the values and beliefs that shape their emergency care practice.

METHODS

We invited 25 Taiwanese emergency physicians to participate in one-to-one semi-structured interviews.

RESULTS

Drawing on social constructionism theory, systematic metaphor analysis method and Metaphor Identification Procedure (MIP) we identified metaphorical linguistic expressions in their talk, grouping them into five-overarching conceptual metaphors. We argue that these metaphors underpin emergency physicians' experiences of practicing emergency medical care: Safety Net, Gateway, Market, War, and Sport.

DISCUSSION

The Safety Net, Gateway, and Market conceptualisations highlight physician-patient relationships and the social mission, resource allocation, and consumerism aspects of emergency care practice. The Sport and War conceptualisations highlight the physician-physician relationship and the demanding, team-based nature of emergency care practice.

CONCLUSION

We propose that the choice of metaphorical conceptualisation deployed by emergency physicians has implications on their embodiment of professional identities. This discussion of using metaphors to study professional identities contributes to the literature concerned with finding creative and innovative ways to research identities. Future studies may utilize metaphors to gain a comprehensive understanding of physicians' professional identities in other specialties.

A hypothetical implementation of 'Termination of Resuscitation' protocol for out-of-hospital cardiac arrest

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A proportion of out of hospital cardiac arrests are associated with poor prognoses.

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Prolonged resuscitation on medically futile cases results in financial burden for the health system and distress for health care workers.

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‘Termination of Resuscitation’ protocols enable ceasing resuscitation efforts for certain cases.

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Successfully adopting a protocol over existing practices demonstrates fewer cases transported to hospital, fewer emergency treatments and fewer inpatient bed days used.

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The protocol can lead to reduced costs and fewer non-beneficial hospital admissions.

Background

Out-of-hospital cardiac arrests with negligible chance of survival are routinely transported to hospital and many are pronounced dead thereafter. This leads to some potentially avoidable costs. The ‘Termination of Resuscitation’ protocol allows paramedics to terminate resuscitation efforts onsite for medically futile cases. This study estimates the changes in frequency of costly events that might occur when the protocol is applied to out-of-hospital cardiac arrests, as compared to existing practice.

Methods

We used Singapore data from the Pan-Asian Resuscitation Outcomes Study, from 1 Jan 2014 to 31 Dec 2017. A Markov model was developed to summarise the events that would occur in two scenarios, existing practice and the implementation of a Termination of Resuscitation protocol. The model was evaluated for 10,000 hypothetical patients with a cycle duration of 30 days after having a cardiac arrest. Probabilistic sensitivity analysis accounted for uncertainties in the outcomes: number of urgent transports and emergency treatments, inpatient bed days, and total number of deaths.

Results

For every 10,000 patients, existing practice resulted in 1118 (95% Uncertainty Interval 1117 to 1119) additional urgent transports to hospital and subsequent emergency treatments. There were 93 (95% Uncertainty Interval 66 to 120) extra inpatient bed days used, and 3 fewer deaths (95% Uncertainty Interval 2 to 4) in comparison to using the protocol.

Conclusion

The findings provide some evidence for adopting the Termination of Resuscitation protocol. This policy could lead to a reduction in costs and non-beneficial hospital admissions, however there may be a small increase in the number of avoidable deaths.

Blood sampling during nurse triage reduces patient length of stay in the emergency department: A propensity score-weighted, population-based study

BACKGROUND

Increases in patients' length of stay (LOS) in the emergency department (ED) have led to overcrowding.

OBJECTIVES

In this study, the implementation of blood sampling during triage in lower priority level patients was assessed as a possible means to reduce LOS.

METHODS

A retrospective study was performed from January 2018 to January 2019. Lower priority level patients who required blood sampling for further diagnosis were considered. Patients who underwent blood sampling during triage evaluation were compared with those who underwent blood sampling after a physician's initial evaluation.

RESULTS

During the study period, 15,596 patients were enrolled. LOS was shorter in patients who underwent triage blood sampling, presenting a median value of 154 min in comparison with the 172 min recorded in the control group (p < 0.001). Using a propensity score-matching to control the two groups' differences, LOS remained lower in the triage-sampling group (151 vs. 175 min; p < 0.001). In the adjusted multivariate model, triage blood sampling was found to be an independent factor for a decrease in the LOS, with standardized coefficient β = 0.857 (0.822-0.894; p < 0.001).

CONCLUSIONS

Performing blood sampling during nurse triage can decrease LOS in ED and also reduce ED permanence after a physician's initial evaluation.

Evaluation of a Multidisciplinary Care Coordination Program for Frequent Users of the Emergency Department

PURPOSE OF STUDY

The purpose of this study was to evaluate the impact of a quality improvement multidisciplinary care coordination program designed to reduce frequent emergency department (ED) utilization and hospital admissions.

PRIMARY PRACTICE SETTING

The single hospital ED is part of a large, integrated, managed care delivery system in Northern California serving the city of Oakland, California.

METHODOLOGY AND SAMPLE

A retrospective cohort study design was used to analyze a multidisciplinary care coordination program on 58 patients during January 2015 and August 2018. Patients were identified from a high-utilization report when they had 10 or more ED visits in a 6-month period, were 18 years of age or older, and members of the integrated delivery system's health plan. Data were collected at initiation and 6 months postintervention. The pre-/postanalysis consisted of descriptive statistics, Wilcoxon signed ranks test, and binary logistic regression.

RESULTS

There was a statistically significant pre-/postdifference of 7.7 ED visits (95% confidence interval [CI] = 4.44-10.97, p < .001). The program did not result in statistically significant reduced hospital admissions (95% CI =-1.24 to 1.45, p = .875). Prior frequent use, number of pre-ED visits, age, sex, complex medical history, and mental health disorder had a significant effect on frequent ED use (χ[6] =17.62, p = .007, McFadden R = .32]. Sex (odds ratio [OR] = 5.13, p = .070), prior frequent use (OR = 2.87, p = .252), and complex medical history (OR = 2.52, p = .412) had the greatest odds of ongoing frequent ED use.

IMPLICATIONS FOR CASE MANAGEMENT PRACTICE

We demonstrated reductions in ED use among frequent users with a low-cost care management intervention. Our multidisciplinary care coordination program confirms the positive impact case management has on utilization and health outcomes. We established that a care coordination program can optimize the overall quality of care and control hospital costs incurred by this vulnerable population. The effectiveness of this program contributes to the advancement of case management efforts in undertaking the challenging health care issue of reducing repeated visits by frequent users, a practice that strains emergency medical services.

Decision Support for the Optimization of Provider Staffing for Hospital Emergency Departments with a Queue-Based Approach

Deployment or distribution of valuable medical resources has emerged as an increasing challenge to hospital administrators and health policy makers. The hospital emergency department (HED) census and workload can be highly variable. Improvement of emergency services is an important stage in the development of the healthcare system and research on the optimal deployment of medical resources appears to be an important issue for HED long-term management. HED performance, in terms of patient flow and available resources, can be studied using the queue-based approach. The kernel point of this research is to approach the optimal cost on logistics using queuing theory. To model the proposed approach for a qualitative profile, a generic HED system is mapped into the M/M/R/N queue-based model, which assumes an R-server queuing system with Poisson arrivals, exponentially distributed service times and a system capacity of N. A comprehensive quantitative mathematical analysis on the cost pattern was done, while relevant simulations were also conducted to validate the proposed optimization model. The design illustration is presented in this paper to demonstrate the application scenario in a HED platform. Hence, the proposed approach provides a feasibly cost-oriented decision support framework to adapt a HED management requirement.

Socioeconomic disparities in the complexity of hernias evaluated at Emergency Departments across the United States

BACKGROUND

Hernias represent one of the most common surgical conditions with a high-burden on health expenditures. We examined the impact of socioeconomic-status and complexity of presentation among patients in the Emergency Department (ED).

METHODS

Retrospective analysis of 2006-2014 data from the Nationwide Emergency Department Sample, identified adult discharges with a diagnosis of inguinal, femoral, and umbilical hernia. Cases were dichotomized: complicated and uncomplicated. Unadjusted and adjusted analyses were used to determine factors that influence ED presentation.

RESULTS

Among 264,484 patients included, 73% presented as uncomplicated hernias and were evaluated at urban hospitals (86%). Uncomplicated presentation was more likely in Medicaid (OR 1.56 95%CI1.50-1.61) and uninsured (OR 1.73 95%CI 1.67-1.78), but less likely for patients within the third and fourth MHI quartile (OR 0.82 95%CI 0.80-0.84 and OR 0.77 95%CI 0.75-0.79), respectively.

CONCLUSION

Uninsured, publicly-insured, and low-MHI patients were more likely to present to ED with uncomplicated hernias. This finding might reflect a lack of access to primary surgical care for non-urgent surgical diseases.

Predictors of mental health service use among individuals with high psychological distress and mental disorders

This study identified predictors of mental health service use over 12 months among 746 individuals with mental disorders and high psychological distress from a catchment area in southwest Montreal, Quebec (Canada). Data collected in 2011 and 2014 were analyzed using Andersen's Behavioral Model of Health Services Use. A hierarchical logistic regression identified predictors of mental health service use. In all, 29% of participants reported using mental health services in the previous 12 months. Three key enabling variables predicted mental health service use: having a family doctor, previous experience with mental health services, and employment. Self-perception of mental health, stressful events, and unmet needs marginally (Needs factors: non-clinical variables) were also associated with the outcome variable. Mental health service utilization depends primarily on organization of the health system, and patient perceptions of its condition (non-clinical needs). Mental health policy should focus on increasing the availability of services and professionals, especially family doctors. Other measures for encouraging service use and overall population wellbeing include raising public awareness around the signs and symptoms of mental illness as a way to promote more rapid response to patient needs, and protecting workplace mental health by reducing stress and stigma toward individuals affected by mental distress.

Insurance Enrollment at a Student-Run Free Clinic After the Patient Protection and Affordable Care Act

The Patient Protection and Affordable Care Act (ACA) aims to increase insurance coverage through government subsidies. Medical student-run free clinics (SRFC) are an important entry point into the healthcare system for the uninsured. SRFCs do not have a standardized approach for navigating the complexities of enrollment. The Weill Cornell Community Clinic (WCCC) developed a unique enrollment model that may inform other SRFCs. Our objective is to describe enrollment processes at SRFCs throughout New York City, and to evaluate enrollment outcomes and persistent barriers to coverage at WCCC. We surveyed SRFC leadership throughout NYC to understand enrollment processes. We evaluated enrollment outcomes at WCCC through chart review and structured phone interviews. Subjects included WCCC patients seen in clinic between October 1, 2013 and September 30, 2015 (N = 140). Demographic information, method of insurance enrollment, and qualitative description of enrollment barriers were collected. SRFCs in New York City have diverse enrollment processes. 48% (N = 42) of WCCC patients obtained health insurance. Immigration status was a barrier to coverage in 21% of patients. Failure to gain coverage was predicted by larger household size (p = 0.02). Gender and employment status were not associated with remaining uninsured. The main barriers to enrollment were inability to afford premiums and lack of interest. Insurance enrollment processes at SRFCs in New York City are mostly ad hoc and outcomes are rarely tracked. Following implementation of the ACA, WCCC stands out for its structured approach, with approximately half of eligible WCCC patients gaining coverage during the study period.

Factors associated with emergency department useamong veteran psychiatric patients

Frequent utilization of emergency department (ED) services contributes substantially to the cost of healthcare nationally and is often driven by psychiatric factors. Using national-level data from the Veterans Health Administration (VHA), the present study examined patient-level factors associated with ED use among veteran psychiatric patients. Veterans who had at least one ED visit with a psychiatric diagnosis in fiscal years 2011-2012 (n = 226,122) were identified in VHA administrative records. Andersen's behavioral model of healthcare utilization was used to identify need, enabling, and predisposing factors associated with frequency of ED use (primary outcome) in multivariate regression models. Greater ED use was primarily linked with need (psychotic, anxiety, personality, substance use, and bipolar disorders) and enabling (detoxification-related service utilization and homelessness) factors. Chronic medical conditions, receipt of an opioid prescription, and predisposing factors (e.g., younger age) were also linked to greater ED use; however, the effect sizes for these factors were markedly lower than those of most psychiatric and psychosocial factors. The findings suggest that intensive case management programs aimed reducing frequent ED use among psychiatric patients may require greater emphasis on homelessness and other psychosocial deficits that are common among these patients, and future research should explore cost-effective approaches to implementing these programs.

The effect on the patient flow in a local health care after implementing reverse triage in a primary care emergency department: a longitudinal follow-up study

OBJECTIVE

Reverse triage means that patients who are not considered to be in need of medical services are not placed on the doctor's list in an emergency department (ED) but are sent, after face-to-face evaluation by a triage nurse, to a more appropriate health care unit. It is not known how an abrupt application of such reverse triage in a combined primary care ED alters the demand for doctors' services in collaborative parts of the health care system.

DESIGN

An observational study.

SETTING

Register-based retrospective quasi-experimental longitudinal follow-up study based on a before-after setting in a Finnish city.

SUBJECTS

Patients who consulted different doctors in a local health care unit.

MAIN OUTCOME MEASURES

Numbers of monthly visits to different doctor groups in public and private primary care, and numbers of monthly referrals to secondary care ED from different sources of primary care were recorded before and after abrupt implementation of the reverse triage.

RESULTS

The beginning of reverse triage decreased the number of patient visits to a primary ED doctor without increasing mortality. Simultaneously, there was an increase in doctor visits in the adjacent secondary care ED and local private sector. The number of patients who came to secondary care ED without a referral or with a referral from the private sector increased.

CONCLUSIONS

The data suggested that the reverse triage causes redistribution of the use of doctors' services rather than a true decrease in the use of these services.

Red blood cell distribution width in patients with limb, chest and head trauma

INTRODUCTION

This study investigated the values of red blood cell distribution width (RDW), an emerging and independent predictor of morbidity and mortality, in patients with limb, chest and head trauma.

MATERIAL AND METHODS

The study sample consisted of all patients who attended the emergency department (ED) of the University Hospital of Parma for limb, chest and head traumas requiring admission to hospital wards during the year 2014. The controls consisted of outpatients living in the same geographical area and undergoing routine laboratory testing for health check-up.

RESULTS

The final study sample consisted of 290 patients with limb (n = 97), chest (n = 49) or head (n = 144) trauma and 967 outpatients. Significantly increased RDW values at admission were observed in all trauma patients compared with controls. Although the frequency of increased RDW (> 14.6%) was higher in all trauma patients than in controls, a subanalysis revealed that increased RDW values were significantly more frequent in patients with head trauma than in controls, but not in those with limb or chest trauma. In multivariate analysis, a significant association was found between head trauma and hemoglobin (p < 0.001) or RDW (p = 0.005). Head trauma patients had a ~3-fold higher likelihood of increased RDW values than controls. The negative and positive predictive values of increased RDW for predicting the presence of head trauma were 0.90 (95% CI: 0.88-0.92) and 0.24 (95% CI: 0.19-0.30).

CONCLUSIONS

The results of this study highlight that RDW is increased in patients admitted to the ED with head trauma.

Validation of an emergency triage scale for obstetrics and gynaecology: a prospective study

OBJECTIVE

To evaluate the reliability of a four-level triage scale for obstetrics and gynaecology emergencies and to explore the factors associated with an optimal triage.

DESIGN

Thirty clinical vignettes presenting the most frequent indications for obstetrics and gynaecology emergency consultations were evaluated twice using a computerised simulator.

SETTING

The study was performed at the emergency unit of obstetrics and gynaecology at the Geneva University Hospitals.

SAMPLE

The vignettes were submitted to nurses and midwives.

METHODS

We assessed inter- and intra-rater reliability and agreement using a two-way mixed-effects intra-class correlation (ICC). We also performed a generalised linear mixed model to evaluate factors associated triage correctness.

MAIN OUTCOME MEASURES

Triage acuity.

RESULTS

We obtained a total of 1191 evaluations. Inter-rater reliability was good (ICC 0.748; 95% CI 0.633-0.858) and intra-rater reliability was almost perfect (ICC 0.812; 95% CI 0.726-0.889). We observed a wide variability: the mean number of questions varied from 6.9 to 18.9 across individuals and from 8.4 to 16.9 across vignettes. Triage acuity was underestimated in 12.4% of cases and overestimated in 9.3%. Undertriage occurred less frequently for gynaecology compared with obstetric vignettes [odds ratio (OR) 0.45; 95% CI 0.23-0.91; P = 0.035] and decreased with the number of questions asked (OR 0.94; 95% CI 0.88-0.99; P = 0.047). Certification in obstetrics and gynaecology emergencies was an independent factor for the avoidance of undertriage (OR 0.35; 95% CI 0.17-0.70; P = 0.003).

CONCLUSION

The four-level triage scale is a valid and reliable tool for the integrated emergency management of obstetrics and gynaecology patients.

TWEETABLE ABSTRACT

The Swiss Emergency Triage Scale is a valid and reliable tool for obstetrics and gynaecology emergency triage.

Factors Influencing the Frequency of Emergency Department Utilization by Individuals with Substance Use Disorders

This study assessed the characteristics of individuals with substance use disorders (ISUDs) according to their frequency of emergency department (ED) utilization, and examined which variables were associated with an increase in ED visits using Andersen's model. Data linkage of administrative databanks from three sources [addiction rehabilitation centre registry, physician billing systems, and hospital discharge databank] for 4526 ISUDs was performed. Predisposing, enabling and need factors associated with number of ED visits were determined using a negative binomial regression model and generalised estimating equations. The rate of ED utilization for this population was 9.6 %. Increased number of ED visits was associated with the following variables: older age, social fragmentation, number of consultations with general practitioners, number of consultations with psychiatrists, number of consultations with other types of physicians, alcohol abuse, drug abuse, schizophrenia, anxiety disorders, personality disorders, co-occurring substance dependence and mental disorders, co-occurring substance dependence and chronic physical disorders, and co-occurring mental health disorders and chronic physical disorders. By contrast, a diagnosis of substance dependence, co-occurring drug and alcohol abuse, and a co-occurring diagnosis of substance dependence with mental health and chronic physical disorders decreased ED visits. Efforts to reduce avoidable use of EDs should focus on chronic-disease management and other related strategies aimed at reinforcing services to ISUDs in the community, especially for ISUDs with a co-occurring diagnosis of either mental health disorders or chronic physical disorders.

Alternative Destination Transport? The Role of Paramedics in Optimal Use of the Emergency Department

Introduction

Alternative destination transportation by emergency medical services (EMS) is a subject of hot debate between those favoring all patients being evaluated by an emergency physician (EP) and those recognizing the need to reduce emergency department (ED) crowding. This study aimed to determine whether paramedics could accurately assess a patient’s acuity level to determine the need to transport to an ED.

Methods

We performed a prospective double-blinded analysis of responses recorded by paramedics and EPs of arriving patients’ acuity level in a large Level II trauma center between April 2015 and November 2015. Under-triage was defined as lower acuity assessed by paramedics but higher acuity by EPs. Over-triage was defined as higher acuity assessed by paramedics but lower acuity by EPs. The degree of agreement between the paramedics and EPs’ evaluations of patient’s acuity level was compared using Chi-square test.

Results

We included a total of 503 patients in the final analysis. For paramedics, 2 51 (49.9%) patients were assessed to be emergent, 178 (35.4%) assessed as urgent, and 74 (14.7%) assessed as non-emergent/non-urgent. In comparison, the EPs assessed 296 (58.9%) patients as emergent, 148 (29.4%) assessed as urgent, and 59 (11.7%) assessed as non-emergent/non-urgent. Paramedics agreed with EPs regarding the acuity level assessment on 71.8% of the cases. The overall under- and over-triage were 19.3% and 8.9%, respectively. A moderate Kappa=0.5174 indicated moderate inter-rater agreement between paramedics’ and EPs’ assessment on the same cohort of patients.

Conclusion

There is a significant difference in paramedic and physician assessment of patients into emergent, urgent, or non-emergent/non-urgent categories. The field triage of a patient to an alternative destination by paramedics under their current scope of practice and training cannot be supported.

Medicaid beneficiaries who continue to use the ED: a focus on the Illinois Medical Home Network

OBJECTIVES

Frequent, nonurgent emergency department use continues to plague the American health care system through ineffective disease management and unnecessary costs. In 2012, the Illinois Medical Home Network (MHN) was implemented to, in part, reduce an overreliance on already stressed emergency departments through better care coordination and access to primary care. The purpose of this study is to characterize MHN patients and compare them with non-MHN patients for a preliminary understanding of MHN patients who visit the emergency department. Variables of interest include (1) frequency of emergency department use during the previous 12 months, (2) demographic characteristics, (3) acuity, (4) disposition, and (5) comorbidities.

METHODS

We performed a retrospective data analysis of all emergency department visits at a large, urban academic medical center in 2013. Binary logistic regression analyses and analysis of variance were used to analyze data.

RESULTS

Medical Home Network patients visited the emergency department more often than did non-MHN patients. Medical Home Network patients were more likely to be African American, Hispanic/Latino, female, and minors when compared with non-MHN patients. Greater proportions of MHN patients visiting the emergency department had asthma diagnoses. Medical Home Network patients possessed higher acuity but were more likely to be discharged from the emergency department compared with non-MHN patients.

CONCLUSIONS

This research may assist with developing and evaluating intervention strategies targeting the reduction of health disparities through decreased use of emergency department services in these traditionally underserved populations.

Effects of changes in copayment for obstetric emergency room visits on the utilization of obstetric emergency rooms

In view of the growing proportion of "non-urgent" admissions to obstetric emergency rooms (OERs) and recent changes in copayment policies for OER visits in Israel, we assessed factors contributing to OER overcrowding. The changes investigated were (a) exemption from copayment for women with birth contractions, (b) allowing phone referrals to the OER and (c) exemption from copayment during primary care clinic closing hours. We analyzed data of a large tertiary hospital with 37 deliveries per day. Counts of women discharged to home from the OER were an indicator of "non-urgent" visits. The annual number of non-urgent visits increased at a higher rate (3.4%) than the natural increase in deliveries (2.1%). Exemption from copayment for visits during non-working hours of primary care clinics was associated with increases in OER admissions (IRR=1.22) and in non-urgent OER visits (IRR=1.54). Younger and first-time mothers with medically unjustified complaints were more likely to be discharged to home. We showed that the changes in the policy for OER copayment meant to attract new clients to the HMO had an independent impact on OER utilization, and hence, added to the workload of medical personnel. The change in HMO policy regulating OER availability requires rigorous assessment of possible health system implications.

Geographic variation in the demand for emergency care: A local population-level analysis

BACKGROUND

Geographic variation in healthcare has been traditionally studied in large areas such as hospital referral regions or service areas. These analyses are limited by variation that exists within local communities.

MATERIALS AND METHODS

Using a New York claims database, we analyzed variation in emergency department use using 35 million visits from 2008 to 2012 among 4797 Census tracts, a smaller unit than usually studied. Using multivariate analysis, we studied associations between population characteristics and proximity to healthcare with rates of emergency department use. We analyzed how factors associated with emergency department utilization differed among urban, suburban, and rural regions.

RESULTS

We found significant geographic variation in emergency department use among Census tracts. Public insurance and uninsurance were correlated with high emergency department utilization across all types of regions. We found that race, ethnicity, and poverty were only associated with high emergency department use in urban regions. In suburban and rural regions, a lower proportion of elderly residents and shorter distances to the nearest ED were correlated with high emergency department use.

CONCLUSIONS

Significant variation in emergency department use exists locally when studied within small geographic areas. Insurance type is significantly associated with variation in emergency department use across urban, suburban, and rural regions, whereas the significance of other factors depended on urbanicity.

IMPLICATIONS

Studying geographic variation at a more granular level can lead to better understanding of local population health, drivers of healthcare utilization, and inform targeted interventions. Given heterogeneity in emergency department use by Census tract, policies directed at shaping acute care utilization must consider these local geographic differences.

Understanding the value of emergency care: a framework incorporating stakeholder perspectives

BACKGROUND

In the face of escalating spending, measuring and maximizing the value of health services has become an important focus of health reform. Recent initiatives aim to incentivize high-value care through provider and hospital payment reform, but the role of the emergency department (ED) remains poorly defined.

OBJECTIVES

To achieve an improved understanding of the value of emergency care, we have developed a framework that incorporates the perspectives of stakeholders in the delivery of health services.

METHODS

A pragmatic review of the literature informed the design of this framework to standardize the definition of value in emergency care and discuss outcomes and costs from different stakeholder perspectives. The viewpoint of patient, provider, payer, health system, and society is each used to assess value for emergency medical conditions.

RESULTS

We found that the value attributed to emergency care differs substantially by stakeholder perspective. Potential targets to improve ED value may be aimed at improving outcomes or controlling costs, depending on the acuity of the clinical condition.

CONCLUSION

The value of emergency care varies by perspective, and a better understanding is achieved when specific outcomes and costs can be identified, quantified, and measured. Using this framework can help stakeholders find common ground to prioritize which costs and outcomes to target for research, quality improvement efforts, and future health policy impacting emergency care.

How do patients respond when confronted with telephone access barriers to care?

OBJECTIVE

To gain an in-depth understanding of patient barriers to accessing telephone care, subsequent responses to telephone access issues and recommendations for system improvement within a large integrated health-care system.

STUDY DESIGN

Cross-sectional qualitative focus group study.

METHODS

One focus group was conducted at each of 17 Veterans Affairs facilities with a total of 123 Veteran users of VA health care. All facilities followed a focus group discussion guide, and purposively sampled patients receiving care at their VA facility in primary and/or specialty care. Focus groups' recordings were sent to the authors' independent evaluation centre, transcribed verbatim and analysed using qualitative content analysis methodology.

RESULTS

Participants described many issues with the phone system that resulted in delays to care needs being addressed, including difficulty getting someone to answer the phone, out-dated phone directories, frequent disconnections and incorrect transfers. Participants most frequently responded to access issues by doing nothing or waiting to contact at a later time, or seeking unscheduled in-person care in the emergency department or primary care clinic. Participants offered recommendations for improving telephone care, including access to direct extensions, and upgrades to the telephone system.

CONCLUSIONS

Telephone access issues could result in increased patient harm and/or increased wait times for in-person primary care or emergency services. Periodic evaluation of telephone systems is necessary to ensure telephone systems adequately meet patient needs while using resources efficiently to optimize the delivery of high quality, safe health care.

National Study of Non-urgent Emergency Department Visits and Associated Resource Utilization

Introduction:

Reducing non-urgent emergency department (ED) visits has been targeted as a method to produce cost savings. To better describe these visits, we sought to compare resource utilization of ED visits characterized as non-urgent at triage to immediate, emergent, or urgent (IEU) visits.

Methods:

We performed a retrospective, cross-sectional analysis of the 2006–2009 National Hospital Ambulatory Medical Care Survey. Urgency of visits was categorized using the assigned 5-level triage acuity score. We analyzed resource utilization, including diagnostic testing, treatment, and hospitalization within each acuity categorization.

Results:

From 2006–2009, 10.1% (95% confidence interval [CI], 9.2–11.2) of United States ED visits were categorized as non-urgent. Most (87.8% [95% CI, 86.3–89.2]) non-urgent visits had some diagnostic testing or treatment in the ED. Imaging was common in non-urgent visits (29.8% [95% CI, 27.8–31.8]), although not as frequent as for IEU visits (52.9% [95% CI, 51.6–54.2]). Similarly, procedures were performed less frequently for non-urgent (34.1% [95% CI, 31.8–36.4]) compared to IEU visits (56.3% [95% CI, 53.5–59.0]). Medication administration was similar between the 2 groups (80.6% [95% CI, 79.5–81.7] vs. 76.3% [95% CI, 74.7–77.8], respectively). The rate of hospital admission was 4.0% (95% CI, 3.3–4.8) vs. 19.8% (95% CI, 18.4–21.3) for IEU visits, with admission to a critical care setting for 0.5% of non-urgent visits (95% CI, 0.3–0.6) vs. 3.4% (95% CI, 3.1–3.8) of IEU visits.

Conclusions:

For most non-urgent ED visits, some diagnostic or therapeutic intervention was performed. Relatively low, but notable proportions of non-urgent ED visits were admitted to the hospital, sometimes to a critical care setting. These data call into question non-urgent ED visits being categorized as “unnecessary,” particularly in the setting of limited access to timely primary care for acute illness or injury.

Characterising emergency department high-frequency users in a rural hospital

OBJECTIVE

Patients who are frequent users (≥4 visits/year) comprise ∼10% of patients, but account for ∼34% of total yearly emergency department (ED) visits. Non-emergent care provided to frequent ED users affects operating costs and usage. The majority of reports characterising frequent ED use are from urban teaching centres. This study describes frequent users of ED services in a rural community setting and the association between counts of patient's visits and discrete diagnoses.

DESIGN

Retrospective study of 1652 frequent ED adult patients from a rural US hospital over a one-year period. Descriptive statistics and Poisson regression were used to explore the characteristics of frequent users and their patterns of diagnoses.

RESULTS

Frequent user visits ranged from 4 to 66 per patient. Frequent users were 9.41% of patient volume accounting for 33.94% of the total visits and were younger compared with patients with <4 visits. Approximately 36% of frequent user visits were generated by 20 diagnoses when the diagnoses were concatenated into domains which covered ∼76% of the visits. There was a high correlation between the number of visits and discrete diagnoses in frequent users.

CONCLUSIONS

These findings suggest a more complex picture of rural ED services and their relationship with primary care and dental services, which needs to be defined before policy development to reduce ED use.

[Cost awareness at emergencies: multicentric survey among prescribers]

AIM

Regular increasing of health-care expense brought about the development of medical implication in prescription control and the will to give more responsibility to prescribers. Emergency departments account for a large part of hospital expenses. This study was carried out to evaluate cost awareness among French emergency physicians.

METHODS

A questionnaire was sent to 160 physicians (junior and senior grade) working at the emergency department of 12 hospitals in the Lyon region (France). Every participant had to estimate the true hospital costs of a selection of drugs, blood products, laboratory tests and imaging modalities.

RESULTS

One hundred and seven questionnaires (68%) were returned and analysed: 48 filled in by juniors (45%), 59 by seniors (55%). Only 26 physicians accurately estimated costs within 50% of the true cost. Response errors were underestimations averaging 4695±226euros, i.e. -59±3% of the total sum (7899euros). Drug prescriptions were significantly (P<0.001) the most underestimated (-74±3%), when compared to both imaging modalities (-23±5%) or blood products prescriptions (-37±6%). High-cost drugs (>1000euros) were the most overestimated pharmaceuticals (-82±2%). Laboratory tests were rather overestimated (+12±8%). Junior grade physicians underestimated more costs than senior physicians (P=0.04).

DISCUSSION

Physicians had a poor understanding of prescription costs at the emergencies, especially regarding high-cost drugs. Much progress is required to integrate the cost-containment problem in daily prescriptions at the emergency department.

Determinants of emergency medical utilization among the elderly population in Taiwan: a national longitudinal cohort study

The aim of this study was to evaluate the potential determinants for emergency medical utilization by elderly patients in Taiwan. The data were drawn from the 'Survey of Health and Living Status of the Elderly in Taiwan', a population-based, longitudinal study of a nationally representative random sample of older adults aged 60 years and older, which was conducted from 1989 to 2007. Face-to-face interviews were conducted at the respondents' homes by trained interviewers accompanied by local health workers. The Andersen Behavioral Model helped us to evaluate the potential determinants for emergency medical utilization that included predisposing factors, enabling factors, and need factors. The measurements of determinants were repeated five times in the period of this study, and the longitudinal data were analyzed through the generalized estimating equation (GEE) by SPSS 17.0 software. The eligibility criteria were that respondents had to be more than 65 years old at baseline in 1993, and then they had to be enrolled in a 14-year follow-up period from 1993 to 2007. At the beginning of this study in 1993, there were 2961 eligible respondents in total, and in 2007, there were 1136 survivors. The loss in follow-up was mainly due to death. The results demonstrated that the significant determinants of emergency medical utilization by the elderly population were gender, age, education, self-ranked health status, chronic disease, and medical accessibility. The GEE model provides a suitable method to predict the long-term trend of emergency medical utilization by the elderly.

A novel approach to identifying targets for cost reduction in the emergency department

This article introduces a novel framework that classifies emergency department (ED) visits according to broad categories of severity, identifying those categories of visits that present the most potential for reducing costs associated with the ED. Although cost savings directly attributable to the ED are apt to be an important emphasis of organizations operating under reformed payment systems, our framework suggests that a focus on diverting low-acuity visits away from the ED would result in far less savings compared with strategies aimed at reducing admissions and to a lesser extent improving the efficiency of ED care for intermediate or complex conditions. We conclude that targeting these categories, rather than minor injuries/illnesses, should be the primary focus of cost-reduction strategies from the ED. Given this understanding, we then discuss the implications of these findings on the financing of an emergency care system that needs to account for the required fixed costs of "stand-by capacity" of the ED and explore ways in which the ED can be better integrated into a patient-centered health care system.

Be careful with triage in emergency departments: interobserver agreement on 1,578 patients in France

BACKGROUND

For several decades, emergency departments (EDs) utilization has increased, inducing ED overcrowding in many countries. This phenomenon is related partly to an excessive number of nonurgent patients. To resolve ED overcrowding and to decrease nonurgent visits, the most common solution has been to triage the ED patients to identify potentially nonurgent patients, i.e. which could have been dealt with by general practitioner. The objective of this study was to measure agreement among ED health professionals on the urgency of an ED visit, and to determine if the level of agreement is consistent among different sub-groups based on following explicit criteria: age, medical status, type of referral to the ED, investigations performed in the ED, and the discharge from the ED.

METHODS

We conducted a multicentric cross-sectional study to compare agreement between nurses and physicians on categorization of ED visits into urgent or nonurgent. Subgroups stratified by criteria characterizing the ED visit were analyzed in relation to the outcome of the visit.

RESULTS

Of 1,928 ED patients, 350 were excluded because data were lacking. The overall nurse-physician agreement on categorization was moderate (kappa = 0.43). The levels of agreement within all subgroups were variable and low. The highest agreement concerned three subgroups of complaints: cranial injury (kappa = 0.61), gynaecological (kappa = 0.66) and toxicology complaints (kappa = 1.00). The lowest agreement concerned two subgroups: urinary-nephrology (kappa = 0.09) and hospitalization (kappa = 0.20). When categorization of ED visits into urgent or nonurgent cases was compared to hospitalization, ED physicians had higher sensitivity and specificity than nurses (respectively 94.9% versus 89.5%, and 43.1% versus 30.9%).

CONCLUSIONS

The lack of physician-nurse agreement and the inability to predict hospitalization have important implications for patient safety. When urgency screening is used to determine treatment priority, disagreement might not matter because all patients in the ED are seen and treated. But using assessments as the basis for refusal of care to potential nonurgent patients raises legal, ethical, and safety issues. Managed care organizations should be cautious when applying such criteria to restrict access to EDs.

Academic medical centers and underserved communities: modern complexities of an enduring relationship

BACKGROUND

Most private academic medical centers are located in underserved areas, yet fiscal pressures have led many to struggle with balancing their commitment to surrounding communities with other missions.

OBJECTIVE

To explore stakeholders' views regarding the ethical, legal, and financial obligations of private academic medical centers to their surrounding neighborhoods.

DESIGN, PARTICIPANTS, AND MEASURES

QualitatiVe analysis of key informant interviews during 2008 with medical students, faculty and community physicians, administrators, and community health leaders at a large urban academic medical center. Grounded theory was used to iteratively review, code, and revise a taxonomy of themes, with abstraction of illustrative quotes.

RESULTS

Nineteen in-depth interviews were conducted. All respondents believed academic medical centers have an obligation to their surrounding communities but characterized the extent of this obigation in a variety of ways. Respondents disagreed about how the core mission of an academic center should be defined, although many recognized the tripartite mission, conflict centered on the balance that should be sought between research and clinical care. A majority of interviewees expressed frustration with the nation's current health care system. Many provided unprompted recommendations regarding how academic medical centers might engage their underserved communities, including conducting formal needs analyses, promoting ongoing dialogue, and using information technology to bridge the provision of clinical care in community and academic settings.

CONCLUSIONS

These data provide enriching perspectives from stakeholders regarding this enduring yet evolving relationship. The diversity of views illustrates one of the challenges that will accompany health care reform impacting academic medical centers and their surrounding, often underserved, communities.