1
|
Hong AS, Halm EA. Applying Hospital Readmissions to Oncology: A Square Peg in a Round Hole? JCO Oncol Pract 2022; 18:7-10. [PMID: 34357787 PMCID: PMC8758117 DOI: 10.1200/op.21.00320] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2021] [Accepted: 05/17/2021] [Indexed: 01/03/2023] Open
Affiliation(s)
- Arthur S. Hong
- Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| | - Ethan A. Halm
- Division of General Internal Medicine, Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX
- Department of Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas, TX
| |
Collapse
|
2
|
Klotz AD, Caterino JM, Durham D, Felipe Rico J, Pallin DJ, Grudzen CR, McNaughton C, Marcelin I, Abar B, Adler D, Bastani A, Bernstein SL, Bischof JJ, Coyne CJ, Henning DJ, Hudson MF, Lyman GH, Madsen TE, Reyes‐Gibby CC, Ryan RJ, Shapiro NI, Swor R, Thomas CR, Venkat A, Wilson J, Jim Yeung S, Yilmaz S, Stutman R, Baugh CW. Observation unit use among patients with cancer following emergency department visits: Results of a multicenter prospective cohort from CONCERN. Acad Emerg Med 2021; 29:174-183. [PMID: 34811858 PMCID: PMC10359998 DOI: 10.1111/acem.14392] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/08/2021] [Accepted: 09/19/2021] [Indexed: 11/26/2022]
Abstract
PURPOSE Emergency department (ED) visits by patients with cancer frequently end in hospitalization. As concerns about ED and hospital crowding increase, observation unit care may be an important strategy to deliver safe and efficient treatment for eligible patients. In this investigation, we compared the prevalence and clinical characteristics of cancer patients who received observation unit care with those who were admitted to the hospital from the ED. METHODS We performed a multicenter prospective cohort study of patients with cancer presenting to an ED affiliated with one of 18 hospitals of the Comprehensive Oncologic Emergency Research Network (CONCERN) between March 1, 2016 and January 30, 2017. We compared patient characteristics with the prevalence of observation unit care usage, hospital admission, and length of stay. RESULTS Of 1051 enrolled patients, 596 (56.7%) were admitted as inpatients, and 72 (6.9%) were placed in an observation unit. For patients admitted as inpatients, 23.7% had a length of stay ≤2 days. The conversion rate from observation to inpatient was 17.1% (95% CI 14.6-19.4) among those receiving care in an observation unit. The average observation unit length of stay was 14.7 h. Patient factors associated ED disposition to observation unit care were female gender and low Charlson Comorbidity Index. CONCLUSION In this multicenter prospective cohort study, the discrepancy between observation unit care use and short inpatient hospitalization may represent underutilization of this resource and a target for process change.
Collapse
Affiliation(s)
- Adam D. Klotz
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Jeffrey M. Caterino
- Departments of Emergency Medicine and Internal Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Danielle Durham
- Department of Radiology School of Medicine University of North Carolina at Chapel Hill Chapel Hill North Carolina USA
| | - Juan Felipe Rico
- Department of Pediatrics Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Daniel J. Pallin
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| | - Corita R. Grudzen
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | | | - Isabelle Marcelin
- Ronald O. Perelman Department of Emergency Medicine and Population Health School of Medicine New York University New York New York USA
| | - Beau Abar
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - David Adler
- Department of Emergency Medicine University of Rochester Rochester New York USA
| | - Aveh Bastani
- Department of Emergency Medicine William Beaumont Hospital Troy Michigan USA
| | - Steven L. Bernstein
- Department of Emergency Medicine Yale School of Medicine New Haven Connecticut USA
| | - Jason J. Bischof
- Department of Emergency Medicine Wexner Medical Center The Ohio State University Columbus Ohio USA
| | - Christopher J. Coyne
- Department of Emergency Medicine University of California San Diego San Diego California USA
| | - Daniel J. Henning
- Department of Emergency Medicine University of Washington Seattle Washington USA
| | | | - Gary H Lyman
- Fred Hutchinson Cancer Research Center and the Department of Medicine Hutchinson Institute for Cancer Outcomes Research University of Washington School of Medicine Seattle Washington USA
| | - Troy E. Madsen
- Division of Emergency Medicine University of Utah Salt Lake City Utah USA
| | - Cielito C. Reyes‐Gibby
- Department of Emergency Medicine and Biostatistics The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Richard J. Ryan
- Department of Emergency Medicine University of Cincinnati Cincinnati Ohio USA
| | - Nathan I. Shapiro
- Department of Emergency Medicine Beth Israel Deaconess Medical Center Boston Massachusetts USA
| | - Robert Swor
- Department of Emergency Medicine William Beaumont Hospital Royal Oak Michigan USA
| | - Charles R. Thomas
- Department of Radiation Medicine Knight Cancer Institute Oregon Health & Sciences University Portland Oregon USA
| | - Arvind Venkat
- Department of Emergency Medicine Allegheny Health Network Pittsburgh Pennsylvania USA
| | - Jason Wilson
- Department of Emergency Medicine Morsani College of Medicine University of South Florida Tampa Florida USA
| | - Sai‐Ching Jim Yeung
- Department of Emergency Medicine The University of Texas MD Anderson Cancer Center Houston Texas USA
| | - Sule Yilmaz
- Department of Geriatric Oncology University of Rochester Medical center Rochester New York USA
| | - Robin Stutman
- Department of Medicine Memorial Sloan Kettering Cancer Center New York New York USA
| | - Christopher W. Baugh
- Department of Emergency Medicine Brigham and Women’s Hospital Boston Massachusetts USA
| |
Collapse
|
3
|
Ouyang H, Wang J, Sun Z, Lang E. The impact of emergency department crowding on admission decisions and patient outcomes. Am J Emerg Med 2021; 51:163-168. [PMID: 34741995 DOI: 10.1016/j.ajem.2021.10.049] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2021] [Revised: 10/23/2021] [Accepted: 10/27/2021] [Indexed: 10/19/2022] Open
Abstract
OBJECTIVES The objective of this study is to evaluate the impact of emergency department (ED) crowding levels on patient admission decisions and outcomes. METHODS A retrospective study was performed based on 2-year electronic health record data from a tertiary care hospital ED in Alberta, Canada. Using modified Poisson regression models, we studied the association of patient admission decisions and 7-day revisit probability with ED crowding levels measured by: 1) the total number of patients waiting and in treatment (ED census), 2) the number of boarding patients (boarder census), and 3) the average physician workload, calculated by the total number of ED patients divided by the number of physicians on duty (physician workload census). The control variables included age, gender, treatment area, triage level, and chief complaint. A subgroup analysis was performed to evaluate the heterogeneous effects among patients of different acuity levels. RESULTS Our dataset included 141,035 patient visit records after cleaning from August 2013 to July 2015. The patient admission probability was positively correlated with ED census (relative risk [RR] = 1.006, 95% confidence interval [CI] = 1.005 to 1.007) and physician workload census (RR = 1.029, 95% CI = 1.027 to 1.032), but inversely correlated with boarder census (RR = 0.991, 95% CI = 0.989 to 0.993). We further found that the 7-day revisit probability of discharged patients was positively associated with boarder census (RR = 1.009, 95% CI = 1.004 to 1.014). CONCLUSIONS Patient admission probability was found to be directly associated with ED census and physician workload census, but inversely associated with the boarder census. The effects of boarder census and physician workload census were stronger for patients of triage levels 3-5. Our results suggested that (i) insufficient physician staffing may lead to unnecessary patient admissions; (ii) too many boarding patients in ED leads to an increase in unsafe discharges, and as a result, an increase in 7-day revisit probability.
Collapse
Affiliation(s)
- Huiyin Ouyang
- Faculty of Business and Economics, The University of Hong Kong, Hong Kong.
| | - Junyan Wang
- Department of Management Sciences, College of Business, City University of Hong Kong, Hong Kong.
| | - Zhankun Sun
- Department of Management Sciences, College of Business, City University of Hong Kong, Hong Kong.
| | - Eddy Lang
- Alberta Health Services, Alberta, Canada; Department of Emergency Medicine, University of Calgary, Alberta, Canada.
| |
Collapse
|
4
|
Lines LM. Games People Play: Lessons on Performance Measure Gaming from New Zealand Comment on "Gaming New Zealand's Emergency Department Target: How and Why Did It Vary Over Time and Between Organisations?". Int J Health Policy Manag 2021; 10:225-227. [PMID: 32610791 PMCID: PMC8167274 DOI: 10.34172/ijhpm.2020.41] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2020] [Accepted: 03/05/2020] [Indexed: 11/18/2022] Open
Abstract
For decades, observers have noted that gaming of performance measurement appears to be both endemic and endlessly creative. A recent study by Tenbensel and colleagues provides a detailed look at gaming of a health system performance measure—emergency department (ED) wait times—within four hospitals in New Zealand. Combined, these four hospitals handled more than 25% of the ED visits in the country each year. Tenbensel and colleagues examine whether the New Zealand ED wait time target was set appropriately and whether we can trust any performance measure statistics that are not independently verified or audited. Their thoughtprovoking examination is relevant to anyone working in quality improvement and provides a valuable set of tools for detecting gaming in performance measurement.
Collapse
Affiliation(s)
- Lisa M Lines
- Center for Advanced Methods Development, RTI International, Durham, NC, USA.,Population and Quantitative Health Sciences, University of Massachusetts Medical School, Worcester, MA, USA
| |
Collapse
|
5
|
|
6
|
A Scoping Review of Physicians' Clinical Reasoning in Emergency Departments. Ann Emerg Med 2019; 75:206-217. [PMID: 31474478 DOI: 10.1016/j.annemergmed.2019.06.023] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2019] [Revised: 06/11/2019] [Accepted: 06/18/2019] [Indexed: 11/20/2022]
Abstract
STUDY OBJECTIVE Clinical reasoning is considered a core competency of physicians. Yet there is a paucity of research on clinical reasoning specifically in emergency medicine, as highlighted in the literature. METHODS We conducted a scoping review to examine the state of research on clinical reasoning in this specialty. Our team, composed of content and methodological experts, identified 3,763 articles in the literature, 95 of which were included. RESULTS Most studies were published after 2000. Few studies focused on the cognitive processes involved in decisionmaking (ie, clinical reasoning). Of these, many confirmed findings from the general literature on clinical reasoning; specifically, the role of both intuitive and analytic processes. We categorized factors that influence decisionmaking into contextual, patient, and physician factors. Many studies focused on decisions in regard to investigations and admission. Test ordering is influenced by physicians' experience, fear of litigation, and concerns about malpractice. Fear of litigation and malpractice also increases physicians' propensity to admit patients. Context influences reasoning but findings pertaining to specific factors, such as patient flow and workload, were inconsistent. CONCLUSION Many studies used designs such as descriptive or correlational methods, limiting the strength of findings. Many gray areas persist, in which studies are either scarce or yield conflicting results. The findings of this scoping review should encourage us to intensify research in the field of emergency physicians' clinical reasoning, particularly on the cognitive processes at play and the factors influencing them, using appropriate theoretical frameworks and more robust methods.
Collapse
|
7
|
Hong AS, Sadeghi N, Harvey V, Lee SC, Halm EA. Characteristics of Emergency Department Visits and Select Predictors of Hospitalization for Adults With Newly Diagnosed Cancer in a Safety-Net Health System. J Oncol Pract 2019; 15:e490-e500. [PMID: 30964735 DOI: 10.1200/jop.18.00614] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
PURPOSE There is little description of emergency department (ED) visits and subsequent hospitalizations among a safety-net cancer population. We characterized patterns of ED visits and explored nonclinical predictors of subsequent hospitalization, including time of ED arrival. PATIENTS AND METHODS This was a retrospective cohort study of patients with cancer (excluding leukemia and nonmelanoma skin cancer) between 2012 and 2016 at a large county urban safety-net health system. We identified ED visits occurring within 180 days after a cancer diagnosis, along with subsequent hospitalizations (observation stay or inpatient admission). We used mixed-effects multivariable logistic regression to model hospitalization at ED disposition, accounting for variability across patients and emergency physicians. RESULTS The 9,050 adults with cancer were 77.2% nonwhite and 55.0% female. Nearly one-quarter (24.7%) of patients had advanced-stage cancer at diagnosis, and 9.7% died within 180 days of diagnosis. These patients accrued 11,282 ED visits within 180 days of diagnosis. Most patients had at least one ED visit (57.7%); half (49.9%) occurred during business hours (Monday through Friday, 8:00 am to 4:59 pm), and half (50.4%) resulted in hospitalization. More than half (57.5%) of ED visits were for complaints that included: pain/headache, nausea/vomiting/dehydration, fever, swelling, shortness of breath/cough, and medication refill. Patients were most often discharged home when they arrived between 8:00 am and 11:59 am (adjusted odds ratio for hospitalization, 0.69; 95% CI, 0.56 to 0.84). CONCLUSION ED visits are common among safety-net patients with newly diagnosed cancer, and hospitalizations may be influenced by nonclinical factors. The majority of ED visits made by adults with newly diagnosed cancer in a safety-net health system could potentially be routed to an alternate site of care, such as a cancer urgent care clinic.
Collapse
Affiliation(s)
- Arthur S Hong
- 1 University of Texas Southwestern Medical Center, Dallas, TX
| | - Navid Sadeghi
- 1 University of Texas Southwestern Medical Center, Dallas, TX.,2 Parkland Health & Hospital System, Dallas, TX
| | | | - Simon Craddock Lee
- 1 University of Texas Southwestern Medical Center, Dallas, TX.,3 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| | - Ethan A Halm
- 1 University of Texas Southwestern Medical Center, Dallas, TX.,3 Harold C. Simmons Comprehensive Cancer Center, Dallas, TX
| |
Collapse
|
8
|
Limkakeng Jr AT, Leahy JC, Griffin SM, Lokhnygina Y, Jaffa E, Christenson RH, Newby LK. Provocative biomarker stress test: stress-delta N-terminal pro-B type natriuretic peptide. Open Heart 2018; 5:e000847. [PMID: 30364466 PMCID: PMC6196976 DOI: 10.1136/openhrt-2018-000847] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2018] [Revised: 07/30/2018] [Accepted: 08/31/2018] [Indexed: 11/04/2022] Open
Abstract
Objective Stress testing is commonly performed in emergency department (ED) patients with suspected acute coronary syndrome (ACS). We hypothesised that changes in N-terminal pro-B type natriuretic peptide (NT-proBNP) concentrations from baseline to post-stress testing (stress-delta values) differentiate patients with ischaemic stress tests from controls. Methods We prospectively enrolled 320 adult patients with suspected ACS in an ED-based observation unit who were undergoing exercise stress echocardiography. We measured plasma NT-proBNP concentrations at baseline and at 2 and 4 hours post-stress and compared stress-delta NT-proBNP between patients with abnormal stress tests versus controls using non-parametric statistics (Wilcoxon test) due to skew. We calculated the diagnostic test characteristics of stress-delta NT-proBNP for myocardial ischaemia on imaging. Results Among 320 participants, the median age was 51 (IQR 44-59) years, 147 (45.9%) were men, and 122 (38.1%) were African-American. Twenty-six (8.1%) had myocardial ischaemia. Static and stress-deltas NT-proBNP differed at all time points between groups. The median stress-deltas at 2 hours were 10.4 (IQR 6.0-51.7) ng/L vs 1.7 (IQR -0.4 to 8.7) ng/L, and at 4 hours were 14.8 (IQR 5.0-22.3) ng/L vs 1.0 (-2.0 to 10.3) ng/L for patients with ischaemia versus those without. Areas under the receiver operating curves were 0.716 and 0.719 for 2-hour and 4-hour stress-deltas, respectively. After adjusting for baseline NT-proBNP levels, the 4-hour stress-delta NT-proBNP remained significantly different between the groups (p=0.009). Conclusion Among patients with ischaemic stress tests, static and 4-hour stress-delta NT-proBNP values were significantly higher. Further study is needed to determine if stress-delta NT-proBNP is a useful adjunct to stress testing.
Collapse
Affiliation(s)
| | - J Clancy Leahy
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - S Michelle Griffin
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Yuliya Lokhnygina
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Elias Jaffa
- Division of Emergency Medicine, Duke University School of Medicine, Durham, North Carolina, USA
| | - Robert H Christenson
- Department of Pathology, University of Maryland School of Medicine, Baltimore, USA
| | - L Kristin Newby
- Division of Cardiology, Department of Medicine, Duke Clinical Research Institute, Durham, North Carolina, USA
| |
Collapse
|
9
|
Sabbatini AK, Wright B, Hall MK, Basu A. The cost of observation care for commercially insured patients visiting the emergency department. Am J Emerg Med 2018; 36:1591-1596. [DOI: 10.1016/j.ajem.2018.01.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 01/09/2018] [Accepted: 01/12/2018] [Indexed: 10/18/2022] Open
|
10
|
Wright B, Martin GP, Ahmed A, Banerjee J, Mason S, Roland D. How the Availability of Observation Status Affects Emergency Physician Decisionmaking. Ann Emerg Med 2018; 72:401-409. [PMID: 29880439 DOI: 10.1016/j.annemergmed.2018.04.023] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Revised: 02/17/2018] [Accepted: 04/19/2018] [Indexed: 11/25/2022]
Abstract
STUDY OBJECTIVE This study seeks to understand how emergency physicians decide to use observation services, and how placing a patient under observation influences physicians' subsequent decisionmaking. METHODS We conducted detailed semistructured interviews with 24 emergency physicians, including 10 from a hospital in the US Midwest, and 14 from 2 hospitals in central and northern England. Data were extracted from the interview transcripts with open coding and analyzed with axial coding. RESULTS We found that physicians used a mix of intuitive and analytic thinking in initial decisions to admit, observe, or discharge patients, depending on the physician's individual level of risk aversion. Placing patients under observation made some physicians more systematic, whereas others cautioned against overreliance on observation services in the face of uncertainty. CONCLUSION Emergency physicians routinely make decisions in a highly resource-constrained environment. Observation services can relax these constraints by providing physicians with additional time, but absent clear protocols and metacognitive reflection on physician practice patterns, this may hinder, rather than facilitate, decisionmaking.
Collapse
Affiliation(s)
- Brad Wright
- Department of Health Management and Policy, University of Iowa, Iowa City, IA.
| | - Graham P Martin
- SAPPHIRE Group, Department of Health Sciences, University of Leicester, Leicester, UK
| | - Azeemuddin Ahmed
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, IA
| | - Jay Banerjee
- Emergency Department, University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Suzanne Mason
- School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Damian Roland
- Pediatric Emergency Medicine Academic Group, University Hospitals of Leicester NHS Trust, Leicester, UK
| |
Collapse
|
11
|
Adrion ER, Kocher KE, Nallamothu BK, Ryan AM. Rising Use Of Observation Care Among The Commercially Insured May Lead to Total And Out-Of-Pocket Cost Savings. Health Aff (Millwood) 2017; 36:2102-2109. [PMID: 29200335 DOI: 10.1377/hlthaff.2017.0774] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Proponents of hospital-based observation care argue that it has the potential to reduce health care spending and lengths-of-stay, compared to short-stay inpatient hospitalizations. However, critics have raised concerns about the out-of-pocket spending associated with observation care. Recent reports of high out-of-pocket spending among Medicare beneficiaries have received considerable media attention and have prompted direct policy changes. Despite the potential for changed policies to indirectly affect non-Medicare patients, little is known about the use of, and spending associated with, observation care among commercially insured populations. Using multipayer commercial claims for the period 2009-13, we evaluated utilization and spending among patients admitted for six conditions that are commonly managed with either observation care or short-stay hospitalizations. In our study period, the use of observation care increased relative to that of short-stay hospitalizations. Total and out-of-pocket spending were substantially lower for observation care, though both grew rapidly-and at rates much higher than spending in the inpatient setting-over the study period. Despite this growth, spending on observation care is unlikely to exceed spending for short-stay hospitalizations. As observation care attracts greater attention, policy makers should be aware that Medicare policies that disincentivize observation may have unintended financial impacts on non-Medicare populations, where observation care may be cost saving.
Collapse
Affiliation(s)
- Emily R Adrion
- Emily R. Adrion ( ) is a lecturer in global health policy at the University of Edinburgh, in the United Kingdom, and a sponsored affiliate in the Department of Health Management and Policy at the University of Michigan, in Ann Arbor
| | - Keith E Kocher
- Keith E. Kocher is an assistant professor of emergency medicine at the University of Michigan
| | - Brahmajee K Nallamothu
- Brahmajee K. Nallamothu is a professor in the Department of Internal Medicine, Division of Cardiovascular Medicine, at the University of Michigan Medical School, an investigator in the Center for Clinical Management Research at the Veterans Affairs Ann Arbor Medical Center, and director of the Michigan Integrated Center for Health Analytics and Medical Prediction at the University of Michigan
| | - Andrew M Ryan
- Andrew M. Ryan is an associate professor in the Department of Health Management and Policy and director of the Center for Evaluating Health Reform, both at the University of Michigan
| |
Collapse
|