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Mohr NM, Young T, Vakkalanka JP, Carter KD, Shane DM, Ullrich F, Schuette AR, Mack LJ, DeJong K, Bell A, Pals M, Camargo CA, Zachrison KS, Boggs KM, Skibbe A, Ward MM. Provider-to-provider telehealth for sepsis patients in a cohort of rural emergency departments. Acad Emerg Med 2024; 31:326-338. [PMID: 38112033 DOI: 10.1111/acem.14857] [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: 11/01/2023] [Revised: 12/11/2023] [Accepted: 12/15/2023] [Indexed: 12/20/2023]
Abstract
BACKGROUND Telehealth has been proposed as one strategy to improve the quality of time-sensitive sepsis care in rural emergency departments (EDs). The purpose of this study was to measure the association between telehealth-supplemented ED (tele-ED) care, health care costs, and clinical outcomes among patients with sepsis in rural EDs. METHODS Cohort study using Medicare fee-for-service claims data for beneficiaries treated for sepsis in rural EDs between February 1, 2017, and September 30, 2019. Our primary hospital-level analysis used multivariable generalized estimating equations to measure the association between treatment in a tele-ED-capable hospital and 30-day total costs of care. In our supporting secondary analysis, we conducted a propensity-matched analysis of patients who used tele-ED with matched controls from non-tele-ED-capable hospitals. Our primary outcome was total health care payments among index hospitalized patients between the index ED visit and 30 days after hospital discharge, and our secondary outcomes included hospital mortality, hospital length of stay, 90-day mortality, 28-day hospital-free days, and 30-day inpatient readmissions. RESULTS In our primary analysis, sepsis patients in tele-ED-capable hospitals had 6.7% higher (95% confidence interval [CI] 2.1%-11.5%) total health care costs compared to those in non-tele-ED-capable hospitals. In our propensity-matched patient-level analysis, total health care costs were 23% higher (95% CI 16.5%-30.4%) in tele-ED cases than matched non-tele-ED controls. Clinical outcomes were similar. CONCLUSIONS Tele-ED capability in a mature rural tele-ED network was not associated with decreased health care costs or improved clinical outcomes. Future work is needed to reduce rural-urban sepsis care disparities and formalize systems of regionalized care.
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Affiliation(s)
- Nicholas M Mohr
- Departments of Emergency Medicine, Anesthesia, and Epidemiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Tracy Young
- Department of Emergency Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - J Priyanka Vakkalanka
- Departments of Emergency Medicine and Epidemiology, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA
| | - Knute D Carter
- Department of Biostatistics, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Dan M Shane
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | - Fred Ullrich
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
| | | | - Luke J Mack
- Department of Family Medicine, University of South Dakota Sanford School of Medicine, Sioux Falls, South Dakota, USA
- Avel eCARE, Sioux Falls, South Dakota, USA
| | | | | | - Mark Pals
- Avel eCARE, Sioux Falls, South Dakota, USA
| | - Carlos A Camargo
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Krislyn M Boggs
- Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Adam Skibbe
- Department of Geography, University of Iowa College of Liberal Arts and Sciences, Iowa City, Iowa, USA
| | - Marcia M Ward
- Department of Health Management and Policy, University of Iowa College of Public Health, Iowa City, Iowa, USA
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Dean K, Chang C, McKenna E, Nott S, Hunter A, Tall JA, Setterfield M, Addis B, Webster E. A retrospective observational study of vCare: a virtual emergency clinical advisory and transfer service in rural and remote Australia. BMC Health Serv Res 2024; 24:100. [PMID: 38238698 PMCID: PMC10797963 DOI: 10.1186/s12913-023-10425-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Accepted: 12/03/2023] [Indexed: 01/22/2024] Open
Abstract
BACKGROUND Provision of critical care in rural areas is challenging due to geographic distance, smaller facilities, generalist skill mix and population characteristics. Internationally, the amalgamation telemedicine and retrieval medicine services are developing to overcome these challenges. Virtual emergency clinical advisory and transfer service (vCare) is one of these novel services based in New South Wales, Australia. We aim to describe patient encounters with vCare from call initiation at the referring site to definitive care at the accepting site. METHODS This retrospective observational study reviewed all patients using vCare in rural and remote Australia for clinical advice and/or inter-hospital transfer for higher level of care between February and March 2021. Data were extracted from electronic medical records and included remoteness of sites, presenting complaint, triage category, camera use, patient characteristics, transfer information, escalation of therapeutic intervention and outcomes. Data were summarised using cross tabulation. RESULTS 1,678 critical care patients were supported by vCare, with children (12.5%), adults (50.6%) and older people (36.9%) evenly split between sexes. Clinicians mainly referred to vCare for trauma (15.1%), cardiac (16.1%) and gastroenterological (14.8%) presentations. A referral to vCare led to an escalation of invasive intervention, skill, and resources for patient care. vCare cameras were used in 19.8% of cases. Overall, 70.5% (n = 1,139) of patients required transfer. Of those, 95.1% were transferred to major regional hospitals and 11.7% required secondary transfer to higher acuity hospitals. Of high-urgency referrals, 42.6% did not receive high priority transport. Imaging most requested included CT and MRI scans (37.2%). Admissions were for physician (33.1%) and surgical care (23.3%). The survival rate was 98.6%. CONCLUSION vCare was used by staff in rural and remote facilities to support decision making and care of patients in a critical condition. Issues were identified including low utilisation of equipment, heavy reliance on regional sites and high rates of secondary transfer. However, these models are addressing a key gap in the health workforce and supporting rural and remote communities to receive care.
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Affiliation(s)
- Kimberley Dean
- Orange Health Service, Western NSW Local Health District, 1530 Forest Road, Orange, NSW, 2800, Australia
| | - Cynthia Chang
- Maitland Hospital, Hunter New England Local Health District, 51 Metford Rd, Metford, NSW, 2323, Australia
| | - Erin McKenna
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia
| | - Shannon Nott
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia
- Western NSW Local Health District, 7 Commercial Ave, Dubbo, NSW, 2830, Australia
| | - Amanda Hunter
- vCare Western NSW Local Health District, PO Box 739, Dubbo, NSW, 2830, Australia
| | - Julie A Tall
- Health Intelligence Unit, Western NSW Local Health District, Ward 22, Bloomfield Campus, Locked Bag 6008, Orange, NSW, 2800, Australia
| | - Madeline Setterfield
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia
| | - Bridget Addis
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia
| | - Emma Webster
- School of Rural Health, Faculty of Medicine and Health, University of Sydney, 4 Moran Drive, Dubbo, NSW, 2830, Australia.
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Ofoma UR, Deych E, Mohr NM, Walkey A, Kollef M, Wan F, Joynt Maddox KE. The Relationship Between Hospital Capability and Mortality in Sepsis: Development of a Sepsis-Related Hospital Capability Index. Crit Care Med 2023; 51:1479-1491. [PMID: 37338282 PMCID: PMC10615795 DOI: 10.1097/ccm.0000000000005973] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2023]
Abstract
OBJECTIVES Regionalized sepsis care could improve sepsis outcomes by facilitating the interhospital transfer of patients to higher-capability hospitals. There are no measures of sepsis capability to guide the identification of such hospitals, although hospital case volume of sepsis has been used as a proxy. We evaluated the performance of a novel hospital sepsis-related capability (SRC) index as compared with sepsis case volume. DESIGN Principal component analysis (PCA) and retrospective cohort study. SETTING A total of 182 New York (derivation) and 274 Florida and Massachusetts (validation) nonfederal hospitals, 2018. PATIENTS A total of 89,069 and 139,977 adult patients (≥ 18 yr) with sepsis were directly admitted into the derivation and validation cohort hospitals, respectively. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We derived SRC scores by PCA of six hospital resource use characteristics (bed capacity, annual volumes of sepsis, major diagnostic procedures, renal replacement therapy, mechanical ventilation, and major therapeutic procedures) and classified hospitals into capability score tertiles: high, intermediate, and low. High-capability hospitals were mostly urban teaching hospitals. Compared with sepsis volume, the SRC score explained more variation in hospital-level sepsis mortality in the derivation (unadjusted coefficient of determination [ R2 ]: 0.25 vs 0.12, p < 0.001 for both) and validation (0.18 vs 0.05, p < 0.001 for both) cohorts; and demonstrated stronger correlation with outward transfer rates for sepsis in the derivation (Spearman coefficient [ r ]: 0.60 vs 0.50) and validation (0.51 vs 0.45) cohorts. Compared with low-capability hospitals, patients with sepsis directly admitted into high-capability hospitals had a greater number of acute organ dysfunctions, a higher proportion of surgical hospitalizations, and higher adjusted mortality (odds ratio [OR], 1.55; 95% CI, 1.25-1.92). In stratified analysis, worse mortality associated with higher hospital capability was only evident among patients with three or more organ dysfunctions (OR, 1.88 [1.50-2.34]). CONCLUSIONS The SRC score has face validity for capability-based groupings of hospitals. Sepsis care may already be de facto regionalized at high-capability hospitals. Low-capability hospitals may have become more adept at treating less complicated sepsis.
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Affiliation(s)
- Uchenna R. Ofoma
- Division of Critical Care Medicine, Department of Anesthesiology, Washington University in St. Louis, St. Louis MO, USA
| | - Elena Deych
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia, and Epidemiology, University of Iowa Carver College of Medicine, Iowa City IA, USA
| | - Allan Walkey
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, The Pulmonary Center, Boston University School of Medicine, Boston, MA
- Evans Center for Implementation and Improvement Sciences, Department of Medicine, Boston University School of Medicine, Boston, MA
| | - Marin Kollef
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
| | - Fei Wan
- Division of Public Health Sciences, Department of Surgery, Washington University in St. Louis, St. Louis MO, USA
| | - Karen E Joynt Maddox
- Division of Cardiology, Department of Medicine, Washington University in St. Louis, St. Louis MO, USA
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Walton NT, Mohr NM. Concept review of regionalized systems of acute care: Is regionalization the next frontier in sepsis care? J Am Coll Emerg Physicians Open 2022; 3:e12631. [PMID: 35024689 PMCID: PMC8733842 DOI: 10.1002/emp2.12631] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Revised: 11/21/2021] [Accepted: 11/23/2021] [Indexed: 11/10/2022] Open
Abstract
Regionalization has become a buzzword in US health care policy. Regionalization, however, has varied meanings, and definitions have lacked contextual information important to understanding its role in improving care. This concept review is a comprehensive primer and summation of 8 common core components of the national models of regionalization informed by text-based analysis of the writing of involved organizations (professional, regulatory, and research) guided by semistructured interviews with organizational leaders. Further, this generalized model of regionalized care is applied to sepsis care, a novel discussion, drawing on existing small-scale applications. This discussion highlights the fit of regionalization principles to the sepsis care model and the actualized and perceived potential benefits. The principal aim of this concept review is to outline regionalization in the United States and provide a roadmap and novel discussion of regionalized care integration for sepsis care.
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Affiliation(s)
| | - Nicholas M. Mohr
- Departments of Emergency Medicine, Anesthesia‐Critical Care Medicine, and EpidemiologyUniversity of Iowa–Carver College of MedicineIowa CityIowaUSA
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Kim YJ, Hong JS, Hong SI, Kim JS, Seo DW, Ahn R, Jeong J, Lee SW, Moon S, Kim WY. The Prevalence and Emergency Department Utilization of Patients Who Underwent Single and Double Inter-hospital Transfers in the Emergency Department: a Nationwide Population-based Study in Korea, 2016-2018. J Korean Med Sci 2021; 36:e172. [PMID: 34184436 PMCID: PMC8239427 DOI: 10.3346/jkms.2021.36.e172] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/31/2021] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Inter-hospital transfer (IHT) for emergency department (ED) admission is a burden to high-level EDs. This study aimed to evaluate the prevalence and ED utilization patterns of patients who underwent single and double IHTs at high-level EDs in South Korea. METHODS This nationwide cross-sectional study analyzed data from the National Emergency Department Information System for the period of 2016-2018. All the patients who underwent IHT at Level I and II emergency centers during this time period were included. The patients were categorized into the single-transfer and double-transfer groups. The clinical characteristics and ED utilization patterns were compared between the two groups. RESULTS We found that 2.1% of the patients in the ED (n = 265,046) underwent IHTs; 18.1% of the pediatric patients (n = 3,556), and 24.2% of the adult patients (n = 59,498) underwent double transfers. Both pediatric (median, 141.0 vs. 208.0 minutes, P < 0.001) and adult (median, 189.0 vs. 308.0 minutes, P < 0.001) patients in the double-transfer group had longer duration of stay in the EDs. Patient's request was the reason for transfer in 41.9% of all IHTs (111,076 of 265,046). Unavailability of medical resources was the reason for transfer in 30.0% of the double transfers (18,920 of 64,054). CONCLUSION The incidence of double-transfer of patients is increasing. The main reasons for double transfers were patient's request and unavailability of medical resources at the first-transfer hospitals. Emergency physicians and policymakers should focus on lowering the number of preventable double transfers.
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Affiliation(s)
- Youn Jung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jung Seok Hong
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Seok In Hong
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - June Sung Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Woo Seo
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ryeok Ahn
- Department of Emergency Medicine, Ulsan University Hospital, University of Ulsan College of Medicine, Ulsan, Korea
| | - Jinwoo Jeong
- Department of Emergency Medicine, Dong-A University College of Medicine, Busan, Korea
| | - Sung Woo Lee
- Department of Emergency Medicine, Korea University Anam Hospital, Korea University College of Medicine, Seoul, Korea
| | - Sungwoo Moon
- National Emergency Medical Center, National Medical Center, Seoul, Korea
- Department of Emergency Medicine, Korea University Ansan Hospital, Korea University College of Medicine, Ansan, Korea
| | - Won Young Kim
- Department of Emergency Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.
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