The cost of observation care for commercially insured patients visiting the emergency department

Prior fragility fractures are associated with a higher risk of 8-year complications following total shoulder arthroplasty

Patients who sustain fragility fractures prior to total shoulder arthroplasty have significantly higher risk for bone health-related complications within 8 years of procedure. Identification of these high-risk patients with an emphasis on preoperative, intraoperative, and postoperative bone health optimization may help minimize these preventable complications.

PURPOSE

As the population ages, more patients with osteoporosis are undergoing total shoulder arthroplasty (TSA), including those who have sustained a prior fragility fracture. Sustaining a fragility fracture before TSA has been associated with increased risk of short-term revision rates, periprosthetic fracture (PPF), and secondary fragility fractures but long-term implant survivorship in this patient population is unknown. Therefore, the purpose of this study was to characterize the association of prior fragility fractures with 8-year risks of revision TSA, periprosthetic fracture, and secondary fragility fracture.

METHODS

Patients aged 50 years and older who underwent TSA were identified in a large national database. Patients were stratified based on whether they sustained a fragility fracture within 3 years prior to TSA. Patients who had a prior fragility fracture (7631) were matched 1:1 to patients who did not based on age, gender, Charlson Comorbidity Index (CCI), smoking, obesity, diabetes mellitus, and alcohol use. Kaplan-Meier and Cox Proportional Hazards analyses were used to observe the cumulative incidences of all-cause revision, periprosthetic fracture, and secondary fragility fracture within 8 years of index surgery.

RESULTS

The 8-year cumulative incidence of revision TSA (5.7% vs. 4.1%), periprosthetic fracture (3.8% vs. 1.4%), and secondary fragility fracture (46.5% vs. 10.1%) were significantly higher for those who had a prior fragility fracture when compared to those who did not. On multivariable analysis, a prior fragility fracture was associated with higher risks of revision (hazard ratio [HR], 1.48; 95% confidence interval [CI], 1.24-1.74; p < 0.001), periprosthetic fracture (HR, 2.98; 95% CI, 2.18-4.07; p < 0.001) and secondary fragility fracture (HR, 8.39; 95% CI, 7.62-9.24; p < 0.001).

CONCLUSIONS

Prior fragility fracture was a significant risk factor for revision, periprosthetic fracture, and secondary fragility fracture within 8 years of primary TSA. Identification of these high-risk patients with an emphasis on preoperative and postoperative bone health optimization may help minimize these complications.

LEVEL OF EVIDENCE

III.

Cost analysis of one-time intravenous antibiotic doses in the emergency department

BACKGROUND

Research shows that one-time doses of intravenous (IV) antibiotics do not improve resolution of infection. However, providers continue to use them-especially in the emergency department (ED). Very few studies have aimed to quantify the cost of this practice.

OBJECTIVES

The primary objective was to evaluate the difference in average total cost of ED stay between patients who received a one-time dose of IV antibiotics in the ED before discharging on oral antibiotics and patients who were just discharged on oral antibiotics. Secondary objectives were to evaluate the differences in durations of stay between the 2 groups, as well as the differences in adverse drug effects and need for health care contact after discharge.

METHODS

Chart review was conducted to identify patients who received and did not receive a one-time dose of IV antibiotics in the ED between April 30, 2020, and April 30, 2022. A microcosting approach was used to determine ED-associated costs per patient. Comparisons in primary and secondary outcomes were performed using statistical inferential tests.

RESULTS

A total of 102 patients were analyzed in each group. Patients who received a one-time dose of IV antibiotics in the ED before being discharged on oral antibiotics had an average length of stay of 4.55 hours, as opposed to patients who did not receive a one-time dose of IV antibiotics before being discharged on oral antibiotics who had an average length of stay of 2.82 hours (absolute difference 1.73 hours, P < 0.001). One-time dosing of IV antibiotics in the ED incurred an additional cost of approximately $556 per patient, totaling to more than $56,000 in our study cohort.

CONCLUSION

The use of one-time IV antibiotics in the ED did not confer any additional benefits to patients. The use of one-time doses resulted in statistically significant reduced throughput in the ED and statistically significant increased health care costs.

The effect of increasing emergency department observation volumes on downstream admission rates

Rising length of stay and inpatient boarding in emergency departments have directly affected patient satisfaction and nearly all provider-to-patient care metrics. Prior studies suggest that ED observation has significant clinical and financial benefits including decreasing hospitalization and length of stay. ED observation is one method long employed to shorten ED length of stay and to free up inpatient beds, yet many patients continue to be admitted to the hospital with an average hospital length of stay of only one day. The objectives of this study were to evaluate whether vigorous tracking and provider reviews of one day hospital admits affected the utilization of ED observation and whether this correlated with significant change in rates of admission from observation status. Between September 2020 and May 2021, in a tertiary care hospital with an annual ED volume of 55,0000, chart reviews of 24-h inpatient discharges were initiated by two senior EM faculty to determine perceived suitability for ED observation. Non-punitive email reviews were then initiated with ED attending providers in order to encourage evaluation of whether these patients would have benefitted from being placed into observation. We then analyzed ED observation patient volumes and subsequent admission rates to the hospital from ED observation and compared these numbers to baseline ED observation volume and admission rates between September 2018 and May 2019. A total of 1448 reviews were conducted on 24-h discharges which correlated with an increase in utilization of ED observation from 11.77% (95% CI [11.62, 12.31]) of total ED volume in our control period to 14.21% (95% CI [13.84, 14.58]) during the study period. We found that the overall admission rate from ED observation increased from 20.12% (95% CI [18.97, 21.26]) baseline to 23.80% (95% CI [22.60, 25.00]) during the same time periods. Our data suggest that increasing the total number of patients placed into observation by 21% correlated with a relative increase in admission rates from ED observation by 18%. This would suggest that our efforts to potentially include more patients into our observation program led to a significant increase in subsequent admission rates. There is likely a balance that must be struck between under- and over-utilization of ED observation, and expanding ED observation may be an effective solution to hospital boarding and ED overcrowding.

Emergency department observation implementation guide

Emergency department (ED) crowding poses significant operational challenges to hospitals. One strategy to address these issues is the implementation of an ED observation (EDO) unit. EDO involves placing patients in observation status after their initial evaluation, allowing for continued assessment, treatment, and the determination of a safe disposition. This paper provides a comprehensive guide for ED leaders on the implementation of ED observation in their departments. It includes a checklist summarizing key implementation points, operational and financial considerations, staffing and location planning, patient selection, clinical care protocols, documentation and communication processes, securing buy-in from stakeholders, and outcome measurement. The guide also highlights the updated billing codes based on the 2023 updated Current Procedural Terminology (CPT) guidelines. Successful implementation of an EDO program has shown benefits such as improved patient flow, enhanced revenue generation, reduced costs, and comparable clinical outcomes. This guide aims to equip ED leaders with the necessary knowledge and tools to implement and manage an effective ED observation program in their departments, ultimately improving the overall efficiency of emergency care delivery.

Racial and Ethnic Disparities in Hospital-Based Care Among Dual Eligibles Who Use Health Centers

Introduction

Health center use may reduce hospital-based care among Medicare-Medicaid dual eligibles, but racial and ethnic disparities in this population have not been widely studied. We examined the extent of racial and ethnic disparities in hospital-based care among duals using health centers and the degree to which disparities occur within or between health centers.

Methods

We used 2012-2018 Medicare claims and health center data to model emergency department (ED) visits, observation stays, hospitalizations, and 30-day unplanned returns as a function of race and ethnicity among dual eligibles using health centers.

Results

In rural and urban counties, age-eligible Black individuals had more ED visits (7.9 [4.0, 11.7] and 13.7 [10.0, 17.4] per 100 person-years) and were more likely to experience an unplanned return (1.4 [0.4, 2.4] and 1 [0.4, 1.6] percentage points [pp]) than White individuals, but were less likely to be hospitalized (-3.3 [-3.9, -2.8] and -1.2 [-1.6, -0.9] pp). In urban counties, age-eligible Black individuals were 1.2 [0.9, 1.5] pp more likely than White individuals to have observation stays. Other racial and ethnic groups used the same or less hospital-based care than White individuals. Including state and health center fixed effects eliminated Black versus White disparities in all outcomes, except hospitalization. Results were similar among disability-eligible duals.

Conclusion

Racial and ethnic disparities in hospital-based care among dual eligibles are less common within than between health centers. If health centers are to play a more central role in eliminating racial and ethnic health disparities, these differences across health centers must be understood and addressed.

Health center use and hospital-based care among individuals dually enrolled in Medicare and Medicaid, 2012-2018

OBJECTIVE

To examine the relationship between federally qualified health center (FQHC) use and hospital-based care among individuals dually enrolled in Medicare and Medicaid.

DATA SOURCES

Data were obtained from 2012 to 2018 Medicare claims.

STUDY DESIGN

We modeled hospital-based care as a function of FQHC use, person-level factors, a Medicare prospective payment system (PPS) indicator, and ZIP code fixed effects. Outcomes included emergency department (ED) visits (overall and nonemergent), observation stays, hospitalizations (overall and for ambulatory care sensitive conditions), and 30-day unplanned returns. We stratified all models on the basis of eligibility and rurality.

DATA EXTRACTION METHODS

Our sample included individuals dually enrolled in Medicare and Medicaid for at least two full consecutive years, residing in a primary care service area with an FQHC. We excluded individuals without primary care visits, who died, or had end-stage renal disease.

PRINCIPAL FINDINGS

After the Medicare PPS was introduced, FQHC use in rural counties was associated with fewer ED and nonemergent ED visits per 100 person-years among both age-eligible (-14.8 [-17.5, -12.1]; -6.6 [-7.5, -5.6]) and disability-eligible duals (-11.3 [-14.4, -8.3]; -6 [-7.4, -4.6]) as well as a lower probability of observation stays (-0.8 pp age-eligible; -0.4 pp disability-eligible) and unplanned returns (-2.1 pp age-eligible; -1.9 pp disability-eligible). In urban counties, FQHC use was associated with more ED and nonemergent ED visits per 100 person-years (10.6 [8.4, 12.8]; 4.0 [2.6, 5.4]) among disability-eligible duals (a decrease of more than 60% compared with the pre-PPS period) and increases in the probability of hospitalization (1.1 pp age-eligible; 0.8 pp disability-eligible) and ACS hospitalization (0.5 pp age-eligible; 0.3 pp disability-eligible) (a decrease of roughly 50% compared with the pre-PPS period).

CONCLUSIONS

FQHC use is associated with reductions in hospital-based care among dual enrollees after introduction of the Medicare PPS. Further research is needed to understand how FQHCs can tailor care to best serve this complex population.

The Value Proposition of Observation Medicine in Managing Acute Oncologic Pain

PURPOSE OF REVIEW

Despite recommended best practice guidelines, pain remains an ongoing but undertreated symptom in patients with cancer, many of whom require emergency department evaluation for acute oncologic pain. A significant proportion of these patients are hospitalized for pain management, which increases healthcare costs and exposes patients to the risks of hospitalization. We reviewed the literature on observation medicine: an emerging mode of healthcare delivery which can offer patients with acute pain access to a hospital's pain management solutions and specialists without an inpatient hospitalization. Specifically, we appraised the role of observation medicine in acute pain management and its financial implications in order to consider its potential impact on the management of acute oncologic pain.

RECENT FINDINGS

Recent evidence shows that observation medicine has the potential to decrease short-stay hospitalizations in cancer patients presenting with various concerns, including pain. Observation medicine is reported to be successful in providing comprehensive and cost-effective care for non-cancer patients with acute pain, making it a promising alternative to short-stay hospitalizations for cancer patients with acute oncologic pain.

Trends and Variation in the Use of Observation Stays at Children's Hospitals

BACKGROUND

Observation status could improve efficiency of healthcare resource use but also might shift financial burdens to patients and hospitals. Although the use of observation stays has increased for adult patient populations, the trends are unknown among hospitalized children.

OBJECTIVE

The goal of this study was to describe recent trends in observation stays for pediatric populations at children's hospitals.

DESIGN, SETTING, AND PARTICIPANTS

Both observation and inpatient stays for all conditions were retrospectively studied using the Pediatric Health Information System database (2010 to 2019).

EXPOSURE, MAIN OUTCOMES, AND MEASURES

Patient type was classified as inpatient or observation status. Main outcomes included annual percentage of observation stays, annual percentage of observation stays having prolonged length of stay (>2 days), and growth rates of observation stays for the 20 most common conditions. Risk adjusted hospital-level use of observation stays was estimated using generalized linear mixed-effects models.

RESULTS

The percentage of observation stays increased from 23.6% in 2010 to 34.3% in 2019 (P < .001), and the percentage of observation stays with prolonged length of stay rose from 1.1% to 4.6% (P < .001). Observation status was expanded among a diverse group of clinical conditions; diabetes mellitus and surgical procedures showed the highest growth rates. Adjusted hospital-level use ranged from 0% to 67% in 2019, indicating considerable variation among hospitals.

CONCLUSION

Based on the increase in observation stays, future studies should explore the appropriateness of observation care related to efficient use of healthcare resources and financial implications for hospitals and patients.

Racial and ethnic disparities in hospital observation in Maryland

OBJECTIVES

Hospital observation is a key disposition option from the emergency department (ED) and encompasses up to one third of patients requiring post-ED care. Observation has been associated with higher incidence of catastrophic financial costs and has downstream effects on post-discharge clinical services. Yet little is known about the non-clinical determinants of observation assignment. We sought to evaluate the impact of patient-level demographic factors on observation designation among Maryland patients.

METHODS

We conducted a retrospective analysis of all ED encounters in Maryland between July 2012 and January 2017 for four priority diagnoses (heart failure, chronic obstructive pulmonary disease [COPD], pneumonia, and acute chest pain) using multilevel logistic models allowing for heterogeneity of the effects across hospitals. The primary exposure was self-reported race and ethnicity. The primary outcome was the initial status assignment from the ED: hospital observation versus inpatient admission.

RESULTS

Across 46 Maryland hospitals, 259,788 patient encounters resulted in a disposition of inpatient admission (65%) or observation designation (35%). Black (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 1.16-1.23) and Hispanic (aOR: 1.11; 95% CI: 1.01-1.21) patients were significantly more likely to be placed in observation than white, non-Hispanic patients. These differences were consistent across the majority of acute-care hospitals in Maryland (27/46).

CONCLUSION

Black and Hispanic patients in Maryland are more likely to be treated under the observation designation than white, non-Hispanic patients independent of clinical presentation. Race agnostic, time-based status assignments may be key in eliminating these disparities.

Emergent neuroimaging for seizures in epilepsy: A population study

We determined how often patients with epilepsy presented to the emergency department (ED) for seizure and the frequency and predictors for undergoing emergent neuroimaging during those visits. We conducted a retrospective population-based cohort study using administrative claims' data from 2007 to 2015. Adults with epilepsy were identified based on a diagnosis of epilepsy and an outpatient prescription for an antiepileptic medication. The Bonferroni corrected significance level was 0.0018. We identified 381,362 patients with a mean follow-up period of 1.99 years, of whom 35,015 (9.2%) patients presented to the ED for seizure at least once. Patients with at least one ED visit were younger, more likely to be male, had fewer comorbidities, and had longer follow-up as compared with those with no ED visit (all p < 0.001). Among the 35,015 patients presenting to the ED, 13.6% had neuroimaging, mostly commonly head computed tomography (CT; 95.5%). Patients undergoing neuroimaging were younger (46 versus 48 years) and with higher rates of psychosis (17.4% versus 13.8%) and depression (16.1% versus 12.2%; p < 0.001). This helps to quantify the burden of ED and emergent neuroimaging utilization for patients with epilepsy and can help inform efforts to curtail unnecessary neuroimaging.

Multiyear Rehospitalization Rates and Hospital Outcomes in an Integrated Health Care System

IMPORTANCE

Since the introduction of the rehospitalization rate as a quality measure, multiple changes have taken place in the US health care delivery system. Interpreting rehospitalization rates without taking a global view of these changes and new data elements from comprehensive electronic medical records yields a limited assessment of the quality of care.

OBJECTIVE

To examine hospitalization outcomes from a broad perspective, including the implications of numerator and denominator definitions, all adult patients with all diagnoses, and detailed clinical data.

DESIGN, SETTING, AND PARTICIPANTS

This cohort study obtained data from 21 hospitals in Kaiser Permanente Northern California (KPNC), an integrated health care delivery system that serves patients with Medicare Advantage plans, Medicaid, and/or Kaiser Foundation Health Plan. The KPNC electronic medical record system was used to capture hospitalization data for adult patients who were 18 years of age or older; discharged from June 1, 2010, through December 31, 2017; and hospitalized for reasons other than childbirth. Hospital stays for transferred patients were linked using public and internal sources.

EXPOSURES

Hospitalization type (inpatient, for observation only), comorbidity burden, acute physiology score, and care directives.

MAIN OUTCOMES AND MEASURES

Mortality (inpatient, 30-day, and 30-day postdischarge), nonelective rehospitalization, and discharge disposition (home, home with home health assistance, regular skilled nursing facility, or custodial skilled nursing facility).

RESULTS

In total, 1 384 025 hospitalizations were identified, of which 1 155 034 (83.5%) were inpatient and 228 991 (16.5%) were for observation only. These hospitalizations involved 679 831 patients (mean [SD] age, 61.4 [18.1] years; 362 582 female [53.3%]). The number of for-observation-only hospitalizations increased from 16 497 (9.4%) in the first year of the study to 120 215 (20.5%) in the last period of the study, whereas inpatient hospitalizations with length of stay less than 24 hours decreased by 33% (from 12 008 [6.9%] to 27 108 [4.6%]). Illness burden measured using administrative data or acute physiology score increased significantly. The proportion of patients with a Comorbidity Point Score of 65 or higher increased from 20.5% (range across hospitals, 18.4%-26.4%) to 28.8% (range, 22.3%-33.0%), as did the proportion with a Charlson Comorbidity Index score of 4 or higher, which increased from 28.8% (range, 24.6%-35.0%) to 38.4% (range, 31.9%-43.4%). The proportion of patients at or near critical illness (Laboratory-based Acute Physiology Score [LAPS2] ≥110) increased by 21.4% (10.3% [range across hospitals, 7.4%-14.7%] to 12.5% [range across hospitals, 8.3%-16.6%]; P < .001), reflecting a steady increase of 0.07 (95% CI, 0.04-0.10) LAPS2 points per month. Unadjusted inpatient mortality in the first year of the study was 2.78% and in the last year was 2.71%; the corresponding numbers for 30-day mortality were 5.88% and 6.15%, for 30-day postdischarge mortality were 3.94% and 4.22%, and for nonelective rehospitalization were 12.00% and 12.81%, respectively. All outcomes improved after risk adjustment. Compared with the first month, the final observed to expected ratio was 0.79 (95% CI, 0.73-0.84) for inpatient mortality, 0.86 (95% CI, 0.82-0.89) for 30-day mortality, 0.90 (95% CI, 0.85-0.95) for 30-day nonelective rehospitalization, and 0.87 (95% CI, 0.83-0.92) for 30-day postdischarge mortality. The proportion of nonelective rehospitalizations meeting public reporting criteria decreased substantially over the study period (from 58.0% in 2010-2011 to 45.2% in 2017); most of this decrease was associated with the exclusion of observation stays.

CONCLUSIONS AND RELEVANCE

This study found that in this integrated system, the hospitalization rate decreased and risk-adjusted hospital outcomes improved steadily over the 7.5-year study period despite worsening case mix. The comprehensive results suggest that future assessments of care quality should consider the implications of numerator and denominator definitions, display multiple metrics concurrently, and include all hospitalization types and detailed data.

Postdischarge Unplanned Care Events Among Commercially Insured Patients With an Observation Stay Versus Short Inpatient Admission

STUDY OBJECTIVE

Observation stays are composing an increasing proportion of unscheduled hospitalizations in the United States, with unclear consequences for the quality of care. This study used a nationally representative data set of commercially insured patients hospitalized from the emergency department (ED) to compare 30-day postdischarge unplanned care events after an observation stay versus a short inpatient admission.

METHODS

This was a retrospective analysis of ED hospitalizations using the 2015 Truven MarketScan Commercial Claims and Encounters data set. Adult observation stays and short inpatient hospitalizations of 2 days or less were identified and followed for 30 days from hospital discharge to identify unplanned care events, defined as a subsequent inpatient admission, observation stay, or return ED visit. A propensity score analysis was used to compare rates of unplanned events after each type of index hospitalization.

RESULTS

Among the propensity-weighted cohorts, patients with an index observation stay were 28% more likely to experience any unplanned care event within 30 days of discharge compared with those with a short inpatient admission (20.4% versus 15.9%; risk ratio 1.28; 95% confidence interval [CI] 1.21 to 1.34). Specifically, patients in the observation stay group had substantially higher rates of postdischarge observation stays (4.8% versus 1.9%; odds ratio 2.60; 95% CI 2.15 to 3.16) and ED revisits with discharge (11.1% versus 8.8%; odds ratio 1.26; 95% CI 1.21 to 1.44) compared with those in the inpatient group, but were less likely to be readmitted as inpatients (6.4% versus 7.2%; odds ratio 0.90; 95% CI 0.83 to 0.96).

CONCLUSION

Commercially insured patients with an observation stay from the ED have a higher risk of postdischarge acute care events compared with similar patients with a short inpatient admission. Additional research is necessary to determine the extent to which quality of care, including care transitions, may differ between these 2 groups.