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Nothelle S, Slade E, Zhou J, Magidson PD, Chotrani T, Prichett L, Amjad H, Szanton S, Boyd CM, Wolff JL. Emergency Department Length of Stay for Older Adults With Dementia. Ann Emerg Med 2024; 83:446-456. [PMID: 38069967 PMCID: PMC11032237 DOI: 10.1016/j.annemergmed.2023.09.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2023] [Revised: 09/11/2023] [Accepted: 09/28/2023] [Indexed: 01/11/2024]
Abstract
STUDY OBJECTIVE The emergency department (ED) poses unique challenges and risks to persons living with dementia. A longer ED length of stay is associated with the risk of death, delirium, and medication errors. We sought to determine whether ED length of stay differed by dementia status and trends in ED length of stay for persons living with dementia from 2014 to 2018 and whether persons living with dementia were at a higher risk for prolonged ED length of stay (defined as a length of stay > 90th percentile). METHODS In this observational study, we used data from the Healthcare Cost and Utilization Project State Emergency Department Database from Massachusetts, Arkansas, Arizona, and Florida. We included ED visits resulting in discharge for adults aged ≥65 years from 2014 to 2018. We used inverse probability weighting to create comparable groups of visits on the basis of dementia status. We used generalized linear models to estimate the mean difference in ED length of stay on the basis of dementia status and logistic regression to determine the odds of prolonged ED length of stay. RESULTS We included 1,039,497 ED visits (mean age: 83.5 years; 64% women; 78% White, 12% Hispanic). Compared with visits by persons without dementia, ED length of stay was 3.1 hours longer (95% confidence interval [CI] 3.0 to 3.3 hours) for persons living with dementia. Among the visits resulting in transfer, ED length of stay was on average 4.1 hours longer (95% CI 3.6 to 4.5 hours) for persons living with dementia. Visits by persons living with dementia were more likely to have a prolonged length of stay (risk difference 4.1%, 95% CI 3.9 to 4.4). CONCLUSION ED visits were more than 3 hours longer for persons living with versus without dementia. Initiatives focused on optimizing ED care for persons living with dementia are needed.
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Affiliation(s)
- Stephanie Nothelle
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland.
| | - Eric Slade
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Junyi Zhou
- Biostatistics Epidemiology and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Phillip D Magidson
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Tanya Chotrani
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Laura Prichett
- Biostatistics Epidemiology and Data Management Core, Johns Hopkins University, Baltimore, Maryland
| | - Halima Amjad
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Sarah Szanton
- Johns Hopkins University School of Nursing, Baltimore, Maryland
| | - Cynthia M Boyd
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
| | - Jennifer L Wolff
- Division of Geriatric Medicine and Gerontology, Department of Medicine, Department of Medicne, Johns Hopkins University School of Medicine, Baltimore, Maryland; Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland; Roger C. Lipitz Center for Integrated Health Care, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland
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Sudah S, Menendez M, Jawa A, Levy J, Denard P. Wide Geographic Variation in Resource Utilization after Shoulder Arthroplasty. Orthop Rev (Pavia) 2023; 15:38653. [PMID: 36843859 PMCID: PMC9946799 DOI: 10.52965/001c.38653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/28/2023] Open
Abstract
Background There is growing interest in optimizing cost and resource utilization after shoulder arthroplasty, but little data to guide improvement efforts. Objective The purpose of this study was to evaluate geographic variation in length of stay and home discharge disposition after shoulder arthroplasty across the United States. Methods The Centers for Medicare and Medicaid Services database was used to identify Medicare discharges following shoulder arthroplasties performed from April 2019 through March 2020. National, regional (Northeast, Midwest, South, West), and state-level variation in length of stay and home discharge disposition rates were examined. The degree of variation was assessed using the coefficient of variation, with a value greater than 0.15 being considered as "substantial" variation. Geographic maps were created for visual representation of the data. Results There was substantial state-level variation in home discharge disposition rates (64% in Connecticut to 96% in West Virginia) and length of stay (1.01 days in Delaware to 1.86 days in Kansas). There was wide regional variation in length of stay (1.35 days in the West to 1.50 days in the Northeast) and home discharge disposition rates (73% in the Northeast to 85% in the West). Conclusions There is wide variation in resource utilization after shoulder arthroplasty across the United States. Certain patterns emerge from our data; for instance, the Northeast has the longest hospital stays with the lowest home discharge rates. This study provides important information for the implementation of targeted strategies to effectively reduce geographic variation in healthcare resource utilization.
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Affiliation(s)
| | | | - Andrew Jawa
- Orthopedic SurgeryNew England Baptist Hospital
| | | | - Patrick Denard
- Orthopedic SurgeryOregon Shoulder Institute at Southern Oregon Orthopedics
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Venkatesh A, Ravi S, Rothenberg C, Kinsman J, Sun J, Goyal P, Augustine J, Epstein SK. Fair Play: Application of Normalized Scoring to Emergency Department Throughput Quality Measures in a National Registry. Ann Emerg Med 2021; 77:501-510. [PMID: 33455841 DOI: 10.1016/j.annemergmed.2020.10.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Revised: 10/23/2020] [Accepted: 10/28/2020] [Indexed: 11/18/2022]
Abstract
STUDY OBJECTIVE The measurement of emergency department (ED) throughput as a patient-centered quality measure is ubiquitous; however, marked heterogeneity exists between EDs, complicating comparisons for payment purposes. We evaluate 4 scoring methodologies for accommodating differences in ED visit volume and heterogeneity among ED groups that staff multiple EDs to improve the validity and "fairness" of ED throughput quality measurement in a national registry, with the goal of developing a volume-adjusted throughput measure that balances variation at the ED group level. METHODS We conducted an ED group-level analysis using the 2017 American College of Emergency Physicians Clinical Emergency Data Registry data set, which included 548 ED groups inclusive of 889 unique EDs. We calculated ED throughput performance scores for each ED group by using 4 scoring approaches: plurality, simple average, weighted average, and a weighted standardized score. For comparison, ED groups (ie, taxpayer identification numbers) were grouped into 3 types: taxpayer identification numbers with only 1 ED; those with multiple EDs, but no ED with greater than 60,000 visits; and those with multiple EDs and at least 1 ED with greater than 60,000 visits. RESULTS We found marked differences in the classification of ED throughput performance between scoring approaches. The weighted standardized score (z score) approach resulted in the least skewed and most uniform distribution across the majority of ED types, with a kurtosis of 12.91 for taxpayer identification numbers composed of 1 ED, 2.58 for those with multiple EDs without any supercenter, and 3.56 for those with multiple EDs with at least 1 supercenter, all lower than comparable scoring methods. The plurality and simple average scoring approaches appeared to disproportionally penalize ED groups that staff a single ED or multiple large-volume EDs. CONCLUSION Application of a weighted standardized (z score) approach to ED throughput measurement resulted in a more balanced variation between different ED group types and reduced distortions in the length-of-stay measurement among ED groups staffing high-volume EDs. This approach may be a more accurate and acceptable method of profiling ED group throughput pay-for-performance programs.
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Affiliation(s)
- Arjun Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT; Department of Emergency Medicine, Yale New Haven Health System, New Haven, CT.
| | - Shashank Ravi
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Craig Rothenberg
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Jeremiah Kinsman
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Jean Sun
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Pawan Goyal
- American College of Emergency Physicians, Washington, DC
| | - James Augustine
- National Clinical Governance Board, US Acute Care Solutions, Canton, OH
| | - Stephen K Epstein
- Department of Emergency Medicine, Harvard Medical School, Boston, MA; Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA
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Boulain T, Malet A, Maitre O. Association between long boarding time in the emergency department and hospital mortality: a single-center propensity score-based analysis. Intern Emerg Med 2020; 15:479-489. [PMID: 31728759 DOI: 10.1007/s11739-019-02231-z] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2019] [Accepted: 11/04/2019] [Indexed: 01/25/2023]
Abstract
Once diagnostic work-up and first therapy are completed in patients visiting the emergency department (ED), boarding them within the ED until an in-hospital bed became available is a common practice in busy hospitals. Whether this practice may harm the patients remains a debate. We sought to determine whether an ED boarding time longer than 4 h places the patients at increased risk of in-hospital death. This retrospective, propensity score-matched analysis and propensity score-based inverse probability weighting analysis was conducted in an adult ED in a single, academic, 1136-bed hospital in France. All patients hospitalized via the adult ED from January 1, 2013 to March 31, 2018 were included. Hospital mortality (primary outcome) and hospital length of stay (LOS) were assessed in (1) a matched cohort (1:1 matching of ED visits with or without ED boarding time longer than 4 h but similar propensity score to experience an ED boarding time longer than 4 h); and (2) the whole study cohort. Sensitivity analysis to unmeasured confounding and analyses in pre-specified cohorts of patients were conducted. Among 68,632 included ED visits, 17,271 (25.2%) had an ED boarding time longer than 4 h. Conditional logistic regression performed on a 10,581 pair-matched cohort, and generalized estimating equations with adjustment on confounders and stabilized propensity score-based inverse probability weighting applied on the whole cohort showed a significantly increased risk of hospital death in patients experiencing an ED boarding time longer than 4 h: odds ratio (OR) of 1.13 (95% confidence interval [95% CI] 1.05-1.22), P = 0.001; and OR of 1.12 (95% CI 1.03-1.22), P = 0.007, respectively. Sensitivity analyses showed that these findings might be robust to unmeasured confounding. Hospital LOS was significantly longer in patients exposed to ED boarding time longer than 4 h: median difference 2 days (95% CI 1-2) (P < 0.001) in matched analysis and mean difference 1.15 days (95% CI 1.02-1.28) (P < 0.001) in multivariable unmatched analysis. In this single-center propensity score-based cohort analysis, patients experiencing an ED boarding time longer than 4 h before being transferred to an in-patient bed were at increased risk of hospital death.
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Affiliation(s)
- Thierry Boulain
- Service D'Accueil Des Urgences Adultes, Centre Hospitalier Régional D'Orléans, Orléans, France.
- Service de Médecine Intensive Réanimation, Centre Hospitalier Régional D'Orléans, Orléans, France.
| | - Anne Malet
- Service D'Accueil Des Urgences Adultes, Centre Hospitalier Régional D'Orléans, Orléans, France
| | - Olivier Maitre
- Service D'Accueil Des Urgences Adultes, Centre Hospitalier Régional D'Orléans, Orléans, France
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Menendez ME, Parrish RC, Ring D, Chen NC. Variation in Physician Charges and Medicare Payments for Hand Surgery. J Hand Microsurg 2019; 11:61-70. [PMID: 31413488 PMCID: PMC6692153 DOI: 10.1055/s-0038-1660772] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2018] [Accepted: 04/26/2018] [Indexed: 12/23/2022] Open
Abstract
Purpose To assess national and state-level variation in physician charges (full amounts requested before payments are negotiated) and Medicare payments for common hand procedures. Materials and Methods Using the Medicare Provider Utilization and Payment Data Public Use File for 2012, we evaluated national and state variations in physician charges and Medicare payments for carpal tunnel release, trigger finger release, trigger finger injection, closed treatment of distal radius fracture, and interposition arthroplasty, intercarpal or carpometacarpal joints. We assessed variation, using the coefficient of variation. We also determined the correlation between charges and payments, as well as the association of patient volume with charges and payments. Results There was wide state-level variation in physician charges for carpal tunnel release (11-fold), trigger finger release (9.6-fold), and trigger finger injection (5.5-fold). On a national level, physician charges varied substantially for carpal tunnel release, trigger finger release, trigger finger injection, closed treatment of distal radius fracture, and interposition arthroplasty, intercarpal or carpometacarpal joints. Medicare payments varied to a lesser extent. The correlations between physician charges and Medicare reimbursements were not strong. Weak to no correlations were noted between patient volume and both charges and payments. Conclusion Physician charges for hand surgery vary substantially across states and nationally, and they do not correlate well with Medicare payments and surgeon volume. As the health care market transitions toward more restrictive physician networks and high-deductible plans, protecting uninsured and out-of-network patients from unexpected, high medical bills should be a policy priority. Type of Study/Level of Evidence Economic/Decision Analysis, Level III study.
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Affiliation(s)
- Mariano E. Menendez
- Department of Orthopaedic Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts, United States
| | - Raymond C. Parrish
- Department of Surgery and Perioperative Care, Dell Medical School at the University of Texas at Austin, Texas, United States
| | - David Ring
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
| | - Neal C. Chen
- Department of Orthopaedic Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, United States
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Ioannides KL, Baehr A, Karp DN, Wiebe DJ, Carr BG, Holena DN, Delgado MK. Measuring Emergency Care Survival: The Implications of Risk Adjusting for Race and Poverty. Acad Emerg Med 2018; 25:856-869. [PMID: 29851207 PMCID: PMC6274627 DOI: 10.1111/acem.13485] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/30/2018] [Accepted: 05/25/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES We determined the impact of including race, ethnicity, and poverty in risk adjustment models for emergency care-sensitive conditions mortality that could be used for hospital pay-for-performance initiatives. We hypothesized that adjusting for race, ethnicity, and poverty would bolster rankings for hospitals that cared for a disproportionate share of nonwhite, Hispanic, or poor patients. METHODS We performed a cross-sectional analysis of patients admitted from the emergency department to 157 hospitals in Pennsylvania with trauma, sepsis, stroke, cardiac arrest, and ST-elevation myocardial infarction. We used multivariable logistic regression models to predict in-hospital mortality. We determined the predictive accuracy of adding patient race and ethnicity (dichotomized as non-Hispanic white vs. all other Hispanic or nonwhite patients) and poverty (uninsured, on Medicaid, or lowest income quartile zip code vs. all others) to other patient-level covariates. We then ranked each hospital on observed-to-expected mortality, with and without race, ethnicity, and poverty in the model, and examined characteristics of hospitals with large changes between models. RESULTS The overall mortality rate among 170,750 inpatients was 6.9%. Mortality was significantly higher for nonwhite and Hispanic patients (adjusted odds ratio [aOR] = 1.27, 95% confidence interval [CI] = 1.19-1.36) and poor patients (aOR = 1.21, 95% CI = 1.12-1.31). Adding race, ethnicity, and poverty to the risk adjustment model resulted in a small increase in C-statistic (0.8260 to 0.8265, p = 0.002). No hospitals moved into or out of the highest-performing decile when adjustment for race, ethnicity, and poverty was added, but the three hospitals that moved out of the lowest-performing decile, relative to other hospitals, had significantly more nonwhite and Hispanic patients (68% vs. 11%, p < 0.001) and poor patients (56% vs. 10%, p < 0.001). CONCLUSIONS Sociodemographic risk adjustment of emergency care-sensitive mortality improves apparent performance of some hospitals treating a large number of nonwhite, Hispanic, or poor patients. This may help these hospitals avoid financial penalties in pay-for-performance programs.
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Affiliation(s)
- Kimon L.H. Ioannides
- Department of Emergency Medicine, Temple University Hospital, Philadelphia, PA,Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Avi Baehr
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Emergency Medicine, Denver Health and Hospital Authority, Denver, CO
| | - David N. Karp
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA
| | - Douglas J. Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
| | - Brendan G. Carr
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA
| | - Daniel N. Holena
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Department of Surgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M. Kit Delgado
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania,
Philadelphia, PA,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA,Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine,
University of Pennsylvania, Philadelphia, PA
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Keogh B, Culliford D, Guerrero-Ludueña R, Monks T. Exploring emergency department 4-hour target performance and cancelled elective operations: a regression analysis of routinely collected and openly reported NHS trust data. BMJ Open 2018; 8:e020296. [PMID: 29794093 PMCID: PMC5988090 DOI: 10.1136/bmjopen-2017-020296] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Revised: 03/15/2018] [Accepted: 04/10/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To quantify the effect of intrahospital patient flow on emergency department (ED) performance targets and indicate if the expectations set by the National Health Service (NHS) England 5-year forward review are realistic in returning emergency services to previous performance levels. DESIGN Linear regression analysis of routinely reported trust activity and performance data using a series of cross-sectional studies. SETTING NHS trusts in England submitting routine nationally reported measures to NHS England. PARTICIPANTS 142 acute non-specialist trusts operating in England between 2012 and 2016. MAIN OUTCOME MEASURES The primary outcome measures were proportion of 4-hour waiting time breaches and cancelled elective operations. METHODS Univariate and multivariate linear regression models were used to show relationships between the outcome measures and various measures of trust activity including empty day beds, empty night beds, day bed to night bed ratio, ED conversion ratio and delayed transfers of care. RESULTS Univariate regression results using the outcome of 4-hour breaches showed clear relationships with empty night beds and ED conversion ratio between 2012 and 2016. The day bed to night bed ratio showed an increasing ability to explain variation in performance between 2015 and 2016. Delayed transfers of care showed little evidence of an association. Multivariate model results indicated that the ability of patient flow variables to explain 4-hour target performance had reduced between 2012 and 2016 (19% to 12%), and had increased in explaining cancelled elective operations (7% to 17%). CONCLUSIONS The flow of patients through trusts is shown to influence ED performance; however, performance has become less explainable by intratrust patient flow between 2012 and 2016. Some commonly stated explanatory factors such as delayed transfers of care showed limited evidence of being related. The results indicate some of the measures proposed by NHS England to reduce pressure on EDs may not have the desired impact on returning services to previous performance levels.
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Affiliation(s)
- Brad Keogh
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | - David Culliford
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
| | | | - Thomas Monks
- NIHR CLAHRC Wessex, University of Southampton, Southampton, UK
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Chang AM, Cohen DJ, Lin A, Augustine J, Handel DA, Howell E, Kim H, Pines JM, Schuur JD, McConnell KJ, Sun BC. Hospital Strategies for Reducing Emergency Department Crowding: A Mixed-Methods Study. Ann Emerg Med 2017; 71:497-505.e4. [PMID: 28844764 DOI: 10.1016/j.annemergmed.2017.07.022] [Citation(s) in RCA: 62] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2017] [Revised: 06/30/2017] [Accepted: 07/13/2017] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE Emergency department (ED) crowding and patient boarding are associated with increased mortality and decreased patient satisfaction. This study uses a positive deviance methodology to identify strategies among high-performing, low-performing, and high-performance improving hospitals to reduce ED crowding. METHODS In this mixed-methods comparative case study, we purposively selected and recruited hospitals that were within the top and bottom 5% of Centers for Medicare & Medicaid Services case-mix-adjusted ED length of stay and boarding times for admitted patients for 2012. We also recruited hospitals that showed the highest performance improvement in metrics between 2012 and 2013. Interviews were conducted with 60 key leaders (physicians, nurses, quality improvement specialists, and administrators). RESULTS We engaged 4 high-performing, 4 low-performing, and 4 high-performing improving hospitals, matched on hospital characteristics including geographic designation (urban versus rural), region, hospital occupancy, and ED volume. Across all hospitals, ED crowding was recognized as a hospitalwide issue. The strategies for addressing ED crowding varied widely. No specific interventions were associated with performance in length-of-stay metrics. The presence of 4 organizational domains was associated with hospital performance: executive leadership involvement, hospitalwide coordinated strategies, data-driven management, and performance accountability. CONCLUSION There are organizational characteristics associated with ED decreased length of stay. Specific interventions targeted to reduce ED crowding were more likely to be successfully executed at hospitals with these characteristics. These organizational domains represent identifiable and actionable changes that other hospitals may incorporate to build awareness of ED crowding.
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Affiliation(s)
- Anna Marie Chang
- Department of Emergency Medicine, Thomas Jefferson University, Philadelphia, PA.
| | - Deborah J Cohen
- Department of Family Medicine, Oregon Health & Science University, Portland, OR
| | - Amber Lin
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
| | - James Augustine
- Department of Emergency Medicine, Wright State Physicians, Dayton, OH
| | - Daniel A Handel
- Division of Emergency Medicine, Medical University of South Carolina, Charleston, SC
| | - Eric Howell
- Department of Medicine, Johns Hopkins University, Baltimore, MD
| | - Hyunjee Kim
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR; Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
| | - Jesse M Pines
- Departments of Emergency Medicine and Health Policy and Management, George Washington University, Washington, DC
| | - Jeremiah D Schuur
- Department of Emergency Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA
| | - K John McConnell
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR; Center for Health Systems Effectiveness, Oregon Health & Science University, Portland, OR
| | - Benjamin C Sun
- Department of Emergency Medicine, Oregon Health & Science University, Portland, OR
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9
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Chang AM, Lin A, Fu R, McConnell KJ, Sun B. Associations of Emergency Department Length of Stay With Publicly Reported Quality-of-care Measures. Acad Emerg Med 2017; 24:246-250. [PMID: 27640877 DOI: 10.1111/acem.13102] [Citation(s) in RCA: 57] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2016] [Revised: 08/25/2016] [Accepted: 09/02/2016] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The Institute of Medicine identified emergency department (ED) crowding as a critical threat to patient safety. We assess the association between changes in publicly reported ED length of stay (LOS) and changes in quality-of-care measures in a national cohort of hospitals. METHODS Longitudinal analysis of 2012 and 2013 data from the American Hospital Association (AHA) Survey, Center for Medicare and Medicaid Services (CMS) Cost Reports, and CMS Hospital Compare. We included hospitals reporting Hospital Compare timeliness measure of LOS for admitted patients. We used AHA and CMS data to incorporate hospital predictors of interest. We used the method of first differences to test for relationships in the change over time between timeliness measures and six hospital-level measures. RESULTS The cohort consisted of 2,619 hospitals. Each additional hour of ED LOS was associated with a 0.7% decrease in proportion of patients giving a top satisfaction rating, a 0.7% decrease in proportion of patients who would "definitely recommend" the hospital, and a 6-minute increase in time to pain management for long bone fracture (p < 0.01 for all). A 1-hour increase in ED LOS is associated with a 44% increase in the odds of having an increase in left without being seen (95% confidence interval = 25% to 68%). ED LOS was not associated with hospital readmissions (p = 0.14) or time to percutaneous coronary intervention (p = 0.14). CONCLUSION In this longitudinal study of hospitals across the United States, improvements in ED timeliness measures are associated with improvements in the patient experience.
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Affiliation(s)
- Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA
| | - Amber Lin
- Center for Policy Research–Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland OR
- School of Public Health Oregon Health & Science University Portland OR
| | - Rongwei Fu
- Center for Policy Research–Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland OR
- School of Public Health Oregon Health & Science University Portland OR
| | - K. John McConnell
- Center for Policy Research–Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland OR
- Center for Health Systems Effectiveness Oregon Health & Science University Portland OR
| | - Benjamin Sun
- Center for Policy Research–Emergency Medicine Department of Emergency Medicine Oregon Health & Science University Portland OR
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