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Neef S, Meinel FG, Lorbeer R, Ammermann F, Weber MA, Brunk M, Herlyn P, Beller E. Time trend analysis of Injury Severity score of adult trauma patients with emergent CT examination. Emerg Radiol 2024; 31:507-514. [PMID: 38880828 PMCID: PMC11288995 DOI: 10.1007/s10140-024-02253-x] [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: 05/01/2024] [Accepted: 06/03/2024] [Indexed: 06/18/2024]
Abstract
PURPOSE Controversy exists about whole-body computed tomography (CT) as a primary screening modality for suspected multiple trauma patients. Therefore, the aim of this study was to analyze time trends of CT examinations for trauma patients in relation to the Injury Severity Score (ISS). METHODS We retrospectively analyzed 561 adult trauma patients (mean age = 54 years) who were admitted to the trauma room of our hospital, immediately followed by a CT examination, in 2009, 2013 und 2017. Review of electronic patient charts was performed to determine the cause of injury. ISS was either calculated upon hospital charts and CT imaging reports or documented in the TraumaRegister DGU® for trauma patients with ICU treatment or ISS ≥ 16. RESULTS An increasing number of CT examinations of acute trauma patients were performed at our hospital with 117 patients in 2009 compared to 192 in 2013 and 252 in 2017. Their mean age increased (50 years in 2009, 54 in 2013 and 55 in 2017;p = 0.046), whereas their mean ISS decreased over time (15.2 in 2009 compared to 12.1 in 2013 and 10.6 in 2017;p = 0.001), especially in women (15.1 in 2009, 11.8 in 2013 and 7.4 in 2017;p = 0.001 both), younger age groups (18 to 24 years:15.6 in 2009, 6.5 in 2013 and 8.9 in 2017; p = 0.033 and 25 to 49 years:15.0 in 2009, 11.2 in 2013 and 8.3 in 2017;p = 0.001) as well as motor vehicle collision (MVC) victims (16.2 in 2009, 11.8 in 2013 and 6.1 in 2017; p < 0.001). Trauma patients with a high ISS were especially more likely of older age (OR 1.02,p < 0.001) and with the type of incident being a fall (< 3 m: OR3.84,p < 0.001;>3 m: OR6.22,p < 0.001) compared to MVC. CONCLUSION Previous studies suggesting a benefit of primary whole-body CT for trauma patients might not reflect the current patient population with decreasing ISS. Especially females, younger age groups and MVC patients might benefit from stricter selection criteria for receiving whole-body CT. Our results also emphasize the importance of prevention of fall or tumble for elderly people.
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Affiliation(s)
- Stefanie Neef
- Department of Anesthesiology, Intensive Care Medicine and Pain Management, Helios Weißeritztal- Kliniken, Klinikum Freital, Germany
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Felix G Meinel
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Roberto Lorbeer
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Felix Ammermann
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
- Department of Pedatrics, University Children's Hospital, Klinikum Oldenburg AäR, Rahel-Srauß-Street 10., 26133, Oldenburg, Germany
| | - Marc-André Weber
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany
| | - Manuela Brunk
- Department of Trauma, Hand and Reconstructive Surgery, University Medical Center Rostock, Rostock, Germany
| | - Philipp Herlyn
- Clinic for Trauma, Reconstructive and Hand Surgery, Municipal Clinic Dresden, Dresden, Germany
| | - Ebba Beller
- Institute of Diagnostic and Interventional Radiology, Pediatric Radiology and Neuroradiology, University Medical Centre Rostock, Ernst-Heydemann-Str. 6, 18057, Rostock, Germany.
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Mazzella AJ, Wood BS, Doad J, Hendrickson MJ, Rosman L, Gehi AK. Interhospital variability in hospital admissions for patients with low-risk syncope presenting to the emergency department. Heart Rhythm O2 2024; 5:435-442. [PMID: 39119025 PMCID: PMC11305874 DOI: 10.1016/j.hroo.2024.06.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2024] Open
Abstract
Background Guidelines and risk scores have sought to standardize the management of syncope in the emergency department (ED), but variation in practice remains. Objective The purpose of this study was to explore factors associated with admission for patients presenting to the ED with low-risk syncope. Methods Our study population included adult patients in the Nationwide Emergency Department Sample between 2006 and 2019 who presented to an ED with a primary diagnosis of syncope. Multivariable hierarchical logistic regression analyses determined the association of patient or hospital factors with admission. Reference effect measures methodology assessed the relative contributions of patient, hospital, and unmeasured hospital factors. Results Of the 3,206,739 qualifying encounters during the study period, 804,398 (25.1%) met low-risk criteria. Of these patients, 20,260 were admitted to the hospital (2.5%). Factors associated with increased odds of admission included increasing age and weekend presentation to the hospital, while female sex, lack of medical insurance, hospital region, teaching status, and higher ED volume decile were associated with lower odds of admission. Reference effect measures methodology demonstrated that unmeasured site variability contributed the widest range of odds for admission (odds ratio [OR] 5th percentile vs 95th percentile 0.23-4.38) compared with the composite patient (OR 0.33-3.68) or hospital (OR 0.65-1.30) factors. Conclusion Admission patterns for low-risk syncope varies widely across institutions. Unmeasured site variation contributes significantly to the variability in admission rates, suggesting which hospital a patient presents to plays a disproportionate role in admission decisions. Further guidance to reduce practice variation in syncope care in the ED is needed.
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Affiliation(s)
- Anthony J. Mazzella
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Brian S. Wood
- The University of North Carolina at Chapel Hill School of Medicine, Chapel Hill, North Carolina
| | - Jagroop Doad
- Campbell University School of Osteopathic Medicine, Lillington, North Carolina
| | - Michael J. Hendrickson
- Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Lindsey Rosman
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
| | - Anil K. Gehi
- Division of Cardiology, Department of Medicine, The University of North Carolina at Chapel Hill, Chapel Hill, North Carolina
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Furlan L, Jacobitti Esposito G, Gianni F, Solbiati M, Mancusi C, Costantino G. Syncope in the Emergency Department: A Practical Approach. J Clin Med 2024; 13:3231. [PMID: 38892942 PMCID: PMC11172976 DOI: 10.3390/jcm13113231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 05/23/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024] Open
Abstract
Syncope is a common condition encountered in the emergency department (ED), accounting for about 0.6-3% of all ED visits. Despite its high frequency, a widely accepted management strategy for patients with syncope in the ED is still missing. Since syncope can be the presenting condition of many diseases, both severe and benign, most research efforts have focused on strategies to obtain a definitive etiologic diagnosis. Nevertheless, in everyday clinical practice, a definitive diagnosis is rarely reached after the first evaluation. It is thus troublesome to aid clinicians' reasoning by simply focusing on differential diagnoses. With the current review, we would like to propose a management strategy that guides clinicians both in the identification of conditions that warrant immediate treatment and in the management of patients for whom a diagnosis is not immediately reached, differentiating those that can be safely discharged from those that should be admitted to the hospital or monitored before a final decision. We propose the mnemonic acronym RED-SOS: Recognize syncope; Exclude life-threatening conditions; Diagnose; Stratify the risk of adverse events; Observe; decide on the Setting of care. Based on this acronym, in the different sections of the review, we discuss all the elements that clinicians should consider when assessing patients with syncope.
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Affiliation(s)
- Ludovico Furlan
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Internal Medicine Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Giulia Jacobitti Esposito
- Emergency Medicine School, Department of Advanced Biomedical Science, University of Naples Federico II, 80138 Naples, Italy; (G.J.E.); (C.M.)
| | - Francesca Gianni
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Monica Solbiati
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
| | - Costantino Mancusi
- Emergency Medicine School, Department of Advanced Biomedical Science, University of Naples Federico II, 80138 Naples, Italy; (G.J.E.); (C.M.)
| | - Giorgio Costantino
- Department of Clinical Sciences and Community Health, University of Milan, 20122 Milan, Italy; (L.F.); (M.S.); (G.C.)
- Emergency Department, IRCCS Cà Granda Ospedale Maggiore Policlinico, 20122 Milan, Italy
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Lo AX, Rundle AG. Everyone eventually goes to ground: Distinguishing true syncope from mimics for emergency department studies on syncope in older persons. J Am Coll Emerg Physicians Open 2022; 3:e12841. [PMID: 36311341 PMCID: PMC9597094 DOI: 10.1002/emp2.12841] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 10/06/2022] [Accepted: 10/07/2022] [Indexed: 11/06/2022] Open
Affiliation(s)
- Alexander X. Lo
- Department of Emergency MedicineNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA,Center for Health Services & Outcomes ResearchNorthwestern University Feinberg School of MedicineChicagoIllinoisUSA
| | - Andrew G. Rundle
- Department of EpidemiologyColumbia University Mailman School of Public HealthNew YorkNew YorkUSA
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Almulhim KN. The Characteristics of Syncope-Related Emergency Department Visits: Resource Utilization and Admission Rate Patterns in Emergency Departments. Cureus 2022; 14:e22039. [PMID: 35340474 PMCID: PMC8913182 DOI: 10.7759/cureus.22039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/07/2022] [Indexed: 11/05/2022] Open
Abstract
Background and objective Decision-making about syncope patients presenting to the emergency department (ED) is challenging since physicians must balance the minimal risks of life-threatening conditions with the unessential use of expensive imaging or unnecessary hospitalizations. This study aimed to determine the characteristics of ED visits, resource utilization, and admission rate patterns related to syncope in the United States (US) during the period 2005-2015. Methods Data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) on ED visits during the 11-year period from 2005 to 2015 were retrieved. ED visits for syncope were identified and compared against non-syncope ED visits. The demographic and clinical characteristics of patients, as well data on resource allocation and admission trends were captured and described for the syncope and the non-syncope groups. Results Syncope accounted for 1.11% of the total ED visits during the study period from 2005 to 2015. The incidence of syncope-related ED visits was higher among elderly females, whites, and non-Hispanics. The trend of admission rates showed a decline from about 30% in 2005-2010 to less than 20% in 2014 and 2015. Advanced imaging (CT or MRI) was ordered for 34% of syncope patients. Conclusion The percentage of syncope-related ED visits remained stable during the study period, but the admission rates declined while the use of advanced imaging in syncope-related ED visits remained substantially high despite the advances in research and availability of clinical guidelines. Future research is needed to rationalize healthcare utilization in syncope-related ED visits and precisely identify the high-risk population.
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Courtney DM, Lang E. GRACE-recurrent low-risk chest pain: A user's guide. Acad Emerg Med 2021; 28:826-828. [PMID: 34228840 DOI: 10.1111/acem.14310] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2021] [Revised: 05/26/2021] [Accepted: 05/26/2021] [Indexed: 11/29/2022]
Affiliation(s)
- D. Mark Courtney
- Department of Emergency Medicine UT Southwestern Medical Center Dallas Texas USA
| | - Eddy Lang
- Department of Emergency Medicine Cumming School of Medicine University of CalgaryAlberta Health Services Calgary Alberta Canada
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Li J, Smyth SS, Clouser JM, McMullen CA, Gupta V, Williams MV. Planning Implementation Success of Syncope Clinical Practice Guidelines in the Emergency Department Using CFIR Framework. MEDICINA (KAUNAS, LITHUANIA) 2021; 57:570. [PMID: 34204986 PMCID: PMC8228757 DOI: 10.3390/medicina57060570] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 05/25/2021] [Accepted: 06/01/2021] [Indexed: 11/16/2022]
Abstract
Background and Objectives: Overuse and inappropriate use of testing and hospital admission are common in syncope evaluation and management. Though guidelines are available to optimize syncope care, research indicates that current clinical guidelines have not significantly impacted resource utilization surrounding emergency department (ED) evaluation of syncope. Matching implementation strategies to barriers and facilitators and tailoring strategies to local context hold significant promise for a successful implementation of clinical practice guidelines (CPG). Our team applied implementation science principles to develop a stakeholder-based implementation strategy. Methods and Materials: We partnered with patients, family caregivers, frontline clinicians and staff, and health system administrators at four health systems to conduct quantitative surveys and qualitative interviews for context assessment. The identification of implementation strategies was done by applying the CFIR-ERIC Implementation Strategy Matching Tool and soliciting stakeholders' inputs. We then co-designed with patients and frontline teams, and developed and tested specific strategies. Results: A total of 114 clinicians completed surveys and 32 clinicians and stakeholders participated in interviews. Results from the surveys and interviews indicated low awareness of syncope guidelines, communication challenges with patients, lack of CPG protocol integration into ED workflows, and organizational process to change as major barriers to CPG implementation. Thirty-one patients and their family caregivers participated in interviews and expressed their expectations: clarity regarding their diagnosis, context surrounding care plan and diagnostic testing, and a desire to feel cared about. Identifying change methods to address the clinician barriers and patients and family caregivers expectations informed development of the multilevel, multicomponent implementation strategy, MISSION, which includes patient educational materials, mentored implementation, academic detailing, Syncope Optimal Care Pathway and a corresponding mobile app, and Lean quality improvement methods. The pilot of MISSION demonstrated feasibility, acceptability and initial success on appropriate testing. Conclusions: Effective multifaceted implementation strategies that target individuals, teams, and healthcare systems can be employed to plan successful implementation and promote adherence to syncope CPGs.
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Affiliation(s)
- Jing Li
- Center for Health Services Research, University of Kentucky, Waller Health Care Annex, 304A, Lexington, KY 40536, USA; (J.M.C.); (M.V.W.)
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, 900 S. Limestone St., CTW320, Lexington, KY 40536, USA; (S.S.S.); (C.A.M.); (V.G.)
| | - Susan S. Smyth
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, 900 S. Limestone St., CTW320, Lexington, KY 40536, USA; (S.S.S.); (C.A.M.); (V.G.)
| | - Jessica M. Clouser
- Center for Health Services Research, University of Kentucky, Waller Health Care Annex, 304A, Lexington, KY 40536, USA; (J.M.C.); (M.V.W.)
| | - Colleen A. McMullen
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, 900 S. Limestone St., CTW320, Lexington, KY 40536, USA; (S.S.S.); (C.A.M.); (V.G.)
| | - Vedant Gupta
- Department of Cardiovascular Medicine, Gill Heart & Vascular Institute, University of Kentucky, 900 S. Limestone St., CTW320, Lexington, KY 40536, USA; (S.S.S.); (C.A.M.); (V.G.)
| | - Mark V. Williams
- Center for Health Services Research, University of Kentucky, Waller Health Care Annex, 304A, Lexington, KY 40536, USA; (J.M.C.); (M.V.W.)
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Khaliq W, Aboabdo M, Harris CM, Bazerbashi N, Moughames E, Al Jalbout N, Hajjar K, Beydoun HA, Beydoun MA, Eid SM. Regional variation in outcomes and healthcare resources utilization in, emergency department visits for syncope. Am J Emerg Med 2021; 44:62-67. [PMID: 33581602 PMCID: PMC11290478 DOI: 10.1016/j.ajem.2021.01.042] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2020] [Revised: 01/03/2021] [Accepted: 01/16/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Management of patients with syncope lacks standardization. We sought to assess regional variation in hospitalization rates and resource utilization of patients with syncope. METHODS We identified adults with syncope using the Nationwide Emergency Department Sample from years 2006 to 2014. Demographics and comorbidity characteristics were compared across geographic regions in the US. Multiple regression was conducted to compare outcomes. RESULTS 9,132,176 adults presented with syncope. Syncope in the Northeast (n = 1,831,889) accounted for 20.1% of visits; 22.6% in the Midwest (n = 2,060,940), 38.5% in the South (n = 3,527,814) and 18.7% in the West (n = 1,711,533). Mean age was 56 years with 57.7% being female. The Northeast had the highest risk-adjusted hospitalization rate (24.5%) followed by the South (18.6%, ORadj 0.58; 95% CI 0.52-0.65, p < 0.001), the Midwest (17.2%, ORadj 0.51; 95% CI 0.46-0.58, p < 0.001) and West (15.8%, ORadj 0.45; 95% CI 0.39-0.51, p < 0.001). Risk-adjusted rates of syncope hospitalizations significantly declined from 25.8% (95% CI 24.8%-26.7%) in 2006 to 11.7% (95% CI 11.0%-12.5%) in 2014 (Ptrend < 0.001). The Northeast had the lowest risk-adjusted ED (Emergency Department) service charges per visit ($3320) followed by the Midwest ($4675, IRRadj 1.41; 95% CI 1.30-1.52, p < 0.001), the West ($4814, IRRadj 1.45; 95% CI 1.31-1.60, p < 0.001) and South ($4969, IRRadj 1.50; 95% CI 1.38-1.62, p < 0.001). Service charges increased from $3047/visit (95% CI $2912-$3182) in 2006 to $6267/visit (95% CI $5947-$6586) in 2014 (Ptrend < 0.001). CONCLUSIONS Significant regional variability in hospitalization rates and ED service charges exist among patients with syncope. Standardizing practices may be needed to reduce variability.
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Affiliation(s)
- Waseem Khaliq
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Moeen Aboabdo
- Johns Hopkins University School of Public Health, Baltimore, MD, United States
| | - Che Matthew Harris
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - Noor Bazerbashi
- Houston Methodist Medical Center, Houston, TX, United States
| | - Eric Moughames
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Nour Al Jalbout
- Department of Emergency Medicine, American University of Beirut Medical Center, Lebanon
| | - Karim Hajjar
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Hind A Beydoun
- Department of Research Programs, Fort Belvoir Community Hospital, Fort Belvoir, VA, United States
| | - May A Beydoun
- Laboratory of Epidemiology and Population Sciences, National Institute on Aging, NIA/NIH/IRP, Baltimore, MD, United States
| | - Shaker M Eid
- Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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Advanced imaging and trends in hospitalizations from the emergency department. PLoS One 2020; 15:e0239059. [PMID: 32936833 PMCID: PMC7494122 DOI: 10.1371/journal.pone.0239059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/28/2020] [Indexed: 12/05/2022] Open
Abstract
Objective The proportion of US emergency department (ED) visits that lead to hospitalization has declined over time. The degree to which advanced imaging use contributed to this trend is unknown. Our objective was to examine the association between advanced imaging use during ED visits and changes in ED hospitalization rates between 2007–2008 and 2015–2016. Methods We analyzed data from the National Hospital Ambulatory Medical Care Survey. The primary outcome was ED hospitalization, including admission to inpatient and observation units and outside transfers. The primary exposure was advanced imaging during the ED visit, including computed tomography, magnetic resonance imaging, and ultrasound. We constructed a survey-weighted multivariable logistic regression with binary outcome of ED hospitalization to examine changes in adjusted hospitalization rates from 2007–2008 to 2015–2016, comparing ED visits with and without advanced imaging. Results ED patients who received advanced imaging (versus those who did not) were more likely to be 65 years or older (25.3% vs 13.0%), non-Hispanic white (65.3% vs 58.5%), female (58.4% vs 54.1%), and have Medicare (26.5% vs 16.0%). Among ED visits with advanced imaging, adjusted annual hospitalization rate declined from 22.5% in 2007–2008 to 17.3% (adjusted risk ratio [aRR] 0.77; 95% CI 0.68, 0.86) in 2015–2016. In the same periods, among ED visits without advanced imaging, adjusted annual hospitalization rate declined from 14.3% to 11.6% (aRR 0.81; 95% CI 0.73, 0.90). The aRRs between ED visits with and without advanced imaging were not significantly different. Conclusion From 2007–2016, ED visits with advanced imaging did not have a greater reduction in admission rate compared to those without advanced imaging. Our results suggest that increasing advanced imaging use likely had a limited role in the general decline in hospital admissions from EDs. Future research is needed to further validate this finding.
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Pozo-Rosich P, Layos-Romero A, Martin-Delgado J, Pascual J, Bailón C, Tentor A, Santiago A, Ignacio E, Torrés A, Mira JJ. Low-value care practice in headache: a Spanish mixed methods research study. J Headache Pain 2020; 21:74. [PMID: 32522142 PMCID: PMC7288523 DOI: 10.1186/s10194-020-01147-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 06/04/2020] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Headache is one of the most prevalent diseases. The Global Burden of Disease Study ranks it as the seventh most common disease overall and the second largest neurological cause of disability in the world. The "Do Not Do" recommendations are a strategy for increasing the quality of care and reducing the cost of care for headache. This study aimed to identify specific low-value practices in headache care, determine their frequency, and estimate the cost overrun that they represent, in order to establish "Do not Do" recommendations specifically for headache by consensus and according to scientific evidence. METHODS This was a mixed methods research study that combined qualitative consensus-building techniques, involving a multidisciplinary panel of experts to define the "Do Not Do" recommendations in headache care, and a retrospective observational study with review of a randomized set of patient records from the past 6 months in four hospitals, to quantify the frequency of these "Do Not Do" practices. We calculated the sum of direct costs of medical consultations, medicines, and unnecessary diagnostic tests. RESULTS Seven "Do Not Do" recommendations were established for headache. In total, 3507 medical records were randomly reviewed. Low-value practices had a highly variable occurrence, depending on the hospital and type of headache. Overall, 34.1% of low-value practices were related to treatment, 21% were related to overuse of imaging in consultation, and 19% were related to emergency care. The estimated cost of low-value practices in the four hospitals was 203,520.47 euros per 1000 patients. CONCLUSIONS This study identified low-value headache practices that need to be eradicated and provided data on their frequency and cost overruns.
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Affiliation(s)
- Patricia Pozo-Rosich
- Headache Unit, Neurology Department, Vall d'Hebron Hospital, Barcelona, Spain
- Headache and Neurological Pain Research Group, VHIR, Universitat Autonoma of Barcelona, Barcelona, Spain
| | | | - Jimmy Martin-Delgado
- ATENEA research group, Foundation for the Promotion of Health and Biomedical Research, Sant Joan d'Alacant, Spain.
| | - Julio Pascual
- University Hospital Marqués de Valdecilla, Santander, Spain
- University of Cantabria and IDIVAL, Santander, Spain
| | | | - Ana Tentor
- Barrio del Pilar Health Center, Madrid, Spain
| | | | | | - Antonio Torrés
- Patient Safety Observatory, Andalusian Healthcare Quality Agency, Seville, Spain
| | - José Joaquín Mira
- Health Department Sant Joan d'Alicante, Alicante, Spain
- Miguel Hernández University of Elche, Elche, Spain
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11
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Li J, Gupta V, Smyth SS, Cowley A, Du G, Sirrine M, Stearley S, Chadha R, Bhalla V, Williams MV. Value-based syncope evaluation and management: Perspectives of health care professionals on readiness, barriers and enablers. Am J Emerg Med 2020; 38:1867-1874. [PMID: 32739858 DOI: 10.1016/j.ajem.2020.05.029] [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: 03/18/2020] [Revised: 05/05/2020] [Accepted: 05/10/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND Syncope is a common condition seen in the emergency department. Given the multitude of etiologies, research exists on the evaluation and management of syncope. Yet, physicians' approach to patients with syncope is variable and often not value based. The 2017 ACC/AHA/HRS Guideline for the Evaluation and Management of Patients with Syncope includes a focus on unnecessary medical testing. However, little research assesses implementation of the guidelines. METHODS Mixed methods approach was applied. The targeted provider specialties include emergency medicine, hospital medicine and cardiology. The Evidence-based Practice Attitude Scale-36 and the Organizational Readiness to Change Assessment surveys were distributed to four different hospital sites. We then conducted focus groups and key informant interviews to obtain more information about clinicians' perceptions to guideline-based practice and barriers/facilitators to implementation. Descriptive statistics and bivariate analyses were used for survey analysis. Two-stage coding was used to identify themes with NVivo. RESULTS Analysis of surveys revealed that overall attitude toward evidence-based practices was moderate and implementation of new guidelines were seen as a burden, potentially decreasing compliance. There were differences across hospital settings. Five common themes emerged from interviews: uncertainty of a syncope diagnosis, rise of consumerism in health care, communication challenge with patient, provider differences in standardized care, and organizational processes to change. CONCLUSIONS Despite recommendations for the use of syncope guidelines, adherence is suboptimal. Overcoming barriers to use will require a paradigm shift. A multifaceted approach and collaborative relationships are needed to adhere to the Guidelines to improve patient care and operational efficiency.
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Affiliation(s)
- Jing Li
- Center for Health Services Research, Department of Medicine, University of Kentucky, Lexington, KY, USA; Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Lexington, KY, USA.
| | - Vedant Gupta
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Susan S Smyth
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Amy Cowley
- Center for Health Services Research, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Gaixin Du
- Center for Health Services Research, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Matthew Sirrine
- Center for Health Services Research, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Seth Stearley
- Division of Emergency Medicine, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Romil Chadha
- Division of Hospital Medicine, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Vikas Bhalla
- Division of Cardiovascular Medicine, Department of Medicine, University of Kentucky, Lexington, KY, USA
| | - Mark V Williams
- Center for Health Services Research, Department of Medicine, University of Kentucky, Lexington, KY, USA; Division of Hospital Medicine, Department of Medicine, University of Kentucky, Lexington, KY, USA
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Chou SC, Baker O, Schuur JD. Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey. West J Emerg Med 2020; 21:209-216. [PMID: 32191178 PMCID: PMC7081865 DOI: 10.5811/westjem.2019.10.43497] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2019] [Accepted: 10/17/2019] [Indexed: 11/11/2022] Open
Abstract
INTRODUCTION Emergency departments (ED) in the United States (US) have increasingly taken the central role for the expedited diagnosis and treatment of acute episodic illnesses and exacerbations of chronic diseases, allowing outpatient management to be possible for many conditions that traditionally required hospitalization and inpatient care. The goal of this analysis was to examine the changes in ED care intensity in this context through the changes in ED patient population and ED care provided. METHODS We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007-2016. Incorporating survey design and weight, we calculated the changes in ED patient characteristics and ED care provided between 2007 and 2016. We also calculated changes in the proportion of visits with low-severity illnesses that may be safely managed at alternative settings. Lastly, we compared ED care received and final ED dispositions by calculating adjusted relative risk (aRR) comparing ED visits in 2007 to 2016, using survey weighted multivariable logistic regression. RESULTS NHAMCS included 35,490 visits in 2007 and 19,467 visits in 2016, representing 117 million and 146 million ED visits, respectively. Between 2007 and 2016, there was an increase in the proportion of ED patients aged 45-64 (21.0% to 23.6%) and 65-74 (5.9% to 7.5%), while visits with low-severity illnesses decreased from 37.3% to 30.4%. There was a substantial increase in the proportion of Medicaid patients (22.2% to 34.0%) with corresponding decline in the privately insured (36.2% to 28.3%) and the uninsured (15.4% to 8.6%) patients. After adjusting for patient and visit characteristics, there was an increase in the utilization of advanced imaging (aRR 1.29; 95% confidence interval [CI], 1.17-1.41), blood tests (aRR 1.16; 95% CI, 1.10-1.22), urinalysis (aRR 1.22; 95% CI, 1.13-1.31), and visits where the patient received four or more medications (aRR 2.17; 95% CI, 1.88-2.46). Lastly, adjusted hospitalization rates declined (aRR 0.74; 95% CI, 0.64-0.84) while adjusted discharge rates increased (aRR 1.06; 95%CI 1.03-1.08). CONCLUSION From 2007 to 2016, ED care intensity appears to have increased modestly, including aging of patient population, increased illness severity, and increased resources utilization. The role of increased care intensity in the decline of ED hospitalization rate requires further study.
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Affiliation(s)
- Shih-Chuan Chou
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Olesya Baker
- Brigham and Women's Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Jeremiah D Schuur
- The Warren Alpert Medical School of Brown University, Department of Emergency Medicine, Providence, Rhode Island
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