Indigent health care in emergency medicine: an academic perspective

A Randomized Controlled Trial of a Citywide Emergency Department Care-Coordination Program to Reduce Prescription Opioid-Related Visits: An Economic Evaluation

BACKGROUND

Care provided in the emergency department (ED) can cost up to five times as much as care received for comparable diagnoses in alternative settings. Small groups of patients, many of whom suffer from an opioid use disorder, often account for a large proportion of total ED visits. We recently conducted, and demonstrated the effectiveness of, the first randomized controlled trial of a citywide ED care-coordination program intending to reduce prescription-opioid-related ED visits. All EDs in the metropolitan study area were connected to a Web-based information exchange system.

OBJECTIVE

The objective of this article was to perform an economic evaluation of the 12-month trial from a third-party-payer perspective.

METHODS

We modeled the person-period monthly for the 12-month observation period, and estimated total treatment costs and return on investment (ROI) with regard to cost offsets, over time, for all visits where the patient was admitted to and discharged from the ED.

RESULTS

By the end of month 4, the mean cumulative cost differential was significantly lower for intervention relative to treatment-as-usual participants (-$1370; p = 0.03); this figure climbed to -$3200 (p = 0.02) by the end of month 12. The ROI trended upward throughout the observation period, but failed to reach statistical significance by the end of month 12 (ROI = 3.39, p = 0.07).

CONCLUSION

The intervention produced significant cost offsets by the end of month 4, which continued to accumulate throughout the trial; however, ROI was not significant. Because the per-patient administrative costs of the program are incurred at the time of enrollment, our results highlight the importance of future studies that are able to follow participants for a period beyond 12 months to more accurately estimate the program's ROI.

Individual predictors of frequent emergency department use: a scoping review

BACKGROUND

A small proportion of patients use an excessively large amount of emergency care resources which often results in emergency department (ED) overcrowding, decreased quality of care and efficiency. There is a need to better identify these patients in order to target those who will benefit most from interventions adapted to their specific needs. We aimed to identify the predictive factors of short-term frequent use of ED (over a 1-year period) and chronic frequent use of ED (over a multiple-year period) and to highlight recurring characteristics in patients.

METHODS

A scoping review was performed of all relevant articles found in Medline published between 1979 and 2015 (Ovid). This scoping review included a total of 20 studies, of these, 16 articles focussed on frequent ED users and four others on chronic frequent ED users.

RESULTS

A majority of articles confirm that patients who frequently visit the ED are persons of low socioeconomic status. Both frequent and chronic frequent ED users show high levels of health care use (other than the ED) and suffer from multiple physical and mental conditions.

CONCLUSIONS

This research highlights which individual factors predict frequent emergency department use. Further research is needed to better characterize and understand chronic frequent users as well as the health issues and unmet medical needs that lead to chronic frequent ED use.

Cost-effective: emergency department care coordination with a regional hospital information system

BACKGROUND

Frequent and unnecessary utilization of the emergency department (ED) is often a sign of serious latent patient issues, and the associated costs are shared by many. Helping these patients get the care they need in the appropriate setting is difficult given their complexity, and their tendency to visit multiple EDs.

STUDY OBJECTIVE

We analyzed the cost-effectiveness of a multidisciplinary ED-care-coordination program with a regional hospital information system capable of sharing patients' individualized care plans with cooperating EDs.

METHODS

ED visits, treatment costs, cost per visit, and net income were assessed pre- and postenrollment in the program using nonparametric bootstrapping techniques. Individuals were categorized as frequent (3-11 ED visits in the 365 days preceding enrollment) or extreme (≥12 ED visits) users. Regression to the mean was tested using an adjusted measure of change.

RESULTS

Both frequent and extreme users experienced significant decreases in ED visits (5 and 15, respectively; 95% confidence intervals [CI] 2-5 and 13-17, respectively) and direct-treatment costs ($1285; 95% CI $492-$2364 and $6091; 95% CI $4298-$8998, respectively), leading to significant hospital cost savings and increased net income ($431; 95% CI $112-$878 and $1925; 95% CI $1093-$3159, respectively). The results further indicate that fewer resources were utilized per visit. Regression to the mean did not seem to be an issue.

CONCLUSIONS

When examined as a whole, research on the program suggests that expanding it would be an efficient allocation of hospital, and possibly societal, resources.

Triage Ability of Emergency Medical Services Providers and Patient Disposition: A Prospective Study

Study objective:

To determine the ability of emergency medical services (EMS) providers to subjectively triage patients with respect to hospital admission and to determine patient characteristics associated with increased likelihood of admission.

Methods:

A prospective, cross-sectional study of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban, university hospital, Emergency Department. Emergency medical services providers completed a questionnaire asking them to predict admission to the hospital and requested patient demographic information. Predictions were compared to actual patient disposition.

Results:

A total of 887 patients were included in the study, and 315 were admitted to the hospital (36%). With respect to admission, emergency medical services providers had an accuracy rate of 79%, with a sensitivity of 72% and specificity of 83% (kappa = 0.56). Blunt traumatic injury and altered mental status were the most common medical reasons for admission. Variables significantly associated with high admission rates were patients with age > 50 years, chest pain or cardiac complaints, shortness of breath or respiratory complaints, Medicare insurance, and Hispanic ethnicity. The emergency medical services providers most accurately predicted admission for patients presenting with labor (kappa = 1.0), shortness of breath / respiratory complaints (kappa = 0.84), and chest pain (kappa = 0.77).

Conclusion:

Emergency medical services providers can predict final patient disposition with reasonable accuracy, especially for patients presenting with labor, shortness of breath, or chest pain. Certain patient characteristics are associated with a higher rate of actual admission.

The economic role of the Emergency Department in the health care continuum: applying Michael Porter's five forces model to Emergency Medicine

Emergency Medicine plays a vital role in the health care continuum in the United States. Michael Porters' five forces model of industry analysis provides an insight into the economics of emergency care by showing how the forces of supplier power, buyer power, threat of substitution, barriers to entry, and internal rivalry affect Emergency Medicine. Illustrating these relationships provides a view into the complexities of the emergency care industry and offers opportunities for Emergency Departments, groups of physicians, and the individual emergency physician to maximize the relationship with other market players.

How well do paramedics predict admission to the hospital? A prospective study

A study was designed to determine whether paramedics accurately predict which patients will require admission to the hospital, and in those requiring admission, whether they will need a ward bed or intensive care unit (ICU) monitoring. This prospective, cross-sectional study of consecutive Emergency Medical Service (EMS) transport patients was conducted at an urban city hospital. Paramedics were asked to predict if the patient they were transporting would require admission to the hospital, and if so, whether that patient would be admitted to a ward bed or require an ICU bed. Predictions were compared to actual patient disposition. During the study period, 1349 patients were transported to our hospital. Questionnaires were submitted in 985 cases (73%) and complete data were available for 952 (97%) of these patients. Paramedics predicted 202 (22%) patients would be admitted to the hospital, of whom 124 (61%) would go the ward and 78 (39%) would require intensive care. The actual overall admission rate was 21%, although the sensitivity of predicting any admission was 62% with a positive prediction value (PPV) of 59%. Further, the paramedics were able to predict admission to intensive care with a sensitivity of 68% and PPV of 50%. It is concluded that paramedics have very limited ability to predict whether transported patients require admission and the level of required care. In our EMS system, the prehospital diversion policies should not be based solely on paramedic determination.

Access to care: a review of the emergency medicine literature

The authors review the evolution of the emergency medicine literature regarding emergency department (ED) use and access to care over the past 20 years. They discuss the impact of cost containment and the emergence of managed care on prevailing views of ED utilization. In the 1980s, the characterization of "nonurgent ED visits" as "inappropriate" and high ED charges led to the targeting of non-emergency ED care as a potential source of savings. During the 1990s the literature reveals multiple attempts to identify "inappropriate" ED visits and to develop strategies to triage these visits away from the ED. By the late 1990s, demonstration of the risks of denying emergency care and more sophisticated analyses of actual costs led to reconsideration of initiatives to limit access to ED care and renewed focus on the critical role of the ED as a safety net provider. In recent years, "de facto" denials of emergency care due to long ED waiting times and other adverse consequences of ED crowding have begun to dominate the emergency medicine health services literature.

America's Health Care Safety Net: intact or unraveling?

In virtually every community in this nation, the emergency department (ED) is an integral part of the health care safety net, often serving as the only available point of access to the health care system for many vulnerable and disenfranchised individuals. The authors present a brief overview of the March 2000 report released by the Institute of Medicine that described and assessed the current status of the nation's health care safety net. The authors discuss the role of the ED as a safety net provider and as a window onto the status of the rest of the health care system. The authors describe the Andersen behavioral model of health services use and suggest it as a useful theoretical framework for emergency medicine researchers who are interested in studying these issues.

Unsuspected gonorrhea and chlamydia in patients of an urban adult emergency department: a critical population for STD control intervention

BACKGROUND

Urban emergency departments (EDs) providing services to patients at high risk for sexually transmitted infection may be logical sites for intervention.

GOAL

To determine the prevalence of gonorrhea (GC) and chlamydia (CT) in an adult ED patient population, and to assess risk factors for infection.

STUDY DESIGN

Cross-sectional study of patients aged 18 to 44 in an urban ED, seeking care of any medical nature. Main outcome was positive for GC or CT by urine ligase chain reaction assay.

RESULTS

Test results for GC and/or CT were positive in 13.6% of 434 18 to 31 year-olds and in 1.8% of 221 32 to 44 year-olds. Of 63 infected individuals identified by the study, 15 (23.8%) were treated at the ED visit. Age < or =31 detected 88% of infections. Among 18- to 31-year-old patients, predictive risk factors by multivariate analysis included age <25, >1 sex partner in the past 90 days, and a history of sexually transmitted disease.

CONCLUSION

This study identified a high prevalence of GC and CT in patients seeking ED services. Many of these infections were clinically unsuspected. These data demonstrate that the ED is a high-risk setting and may be an appropriate site for routine GC and CT screening in 18- to 31-year-old patients.

Ambulatory STD management in an inner-city emergency department: descriptive epidemiology, care utilization patterns, and patient perceptions of local public STD clinics

BACKGROUND AND OBJECTIVES

In conjunction with a lack of primary and preventive care, many patients are treated in emergency departments (EDs) for sexually transmitted diseases (STDs).

GOAL

To epidemiologically characterize patients accessing an inner-city ED for treatment of STDs.

DESIGN

One hundred patients 17 years or older who were treated for an STD or who had conditions that were given syndromic or presumptive diagnoses of an STD participated in this prospective case series. Cases were identified on the basis of history and physical examination. Patients were interviewed to collect information on demographics, drug and alcohol use, current symptoms, self-medication, and health care access.

RESULTS

A total of 98% of patients who were approached participated. Two thirds of the participants were female. Women were more likely than men to have health insurance, Medical Assistance, and a regular source of health care. Injecting drug use was associated with a 5.3 increase in the odds ratio of delayed treatment seeking (P = 0.038). Effort to self-treat was associated with a 3.2 increase in the odds of delayed treatment seeking (P = 0.015). Being female was associated with a 4.1 increase in the odds of self-treatment (P = 0.009).

CONCLUSION

This study identifies several potential barriers to appropriate health care access and use. The study also identifies the ED as a potential source of intervention for more comprehensive health care and an entry into the health care system for a difficult-to-reach patient population.

Inappropriate use of emergency medical services transport: comparison of provider and patient perspectives

OBJECTIVES

To determine the extent of inappropriate ambulance use from the perspectives of both emergency medical services (EMS) providers and patients utilizing EMS transport, assess level of agreement, and identify variables associated with inappropriate ambulance use.

METHODS

A prospective cross-sectional study was done of a consecutive sample of patients arriving by ambulance during the month of February 1997 at an urban university hospital ED. EMS providers and patients completed a survey with questions regarding their perceptions of whether the need for ambulance transport was an emergency or a nonemergency. Patient demographic information and availability of alternate means of transportation to the hospital were also evaluated.

RESULTS

Eight hundred eighty-seven patients were included in the study. EMS providers thought that 501 patient transports were appropriate and represented true emergencies, whereas 689 patients believed their medical problems were true emergencies. A significant number of patients (n=415, 47%) had access to alternative transportation to the hospital. Blunt traumatic injury and altered mental status were the most common reasons for EMS transport. Patient characteristics significantly associated with EMS provider perception of a true emergency were male gender, age >51 years, higher education, chest pain/cardiac complaints, shortness of breath/respiratory complaints, and Medicare insurance. Characteristics significantly associated with patients who perceived themselves to have true emergencies were black ethnicity, higher education, shortness of breath/respiratory complaints, and Medicare insurance. There was 75% agreement between EMS providers and patients on appropriateness of ambulance transport (kappa=0.84).

CONCLUSION

Inappropriate ambulance use is a significant problem from both EMS provider and patient perspectives. Certain patient characteristics are associated with a higher probability of appropriate and inappropriate uses of EMS transport. A large number of patients transported by ambulance have alternative means of transportation but elect not to use them.

Use of the ED as a regular source of care: associated factors beyond lack of health insurance

STUDY OBJECTIVE

To determine the characteristics and health care experiences of patients who identify the ED as their usual source of care.

METHODS

We conducted a cross-sectional survey in a Level I trauma center ED at an urban teaching hospital. Our population comprised 892 adults who presented to the ED over the course of 30 days. We asked participants about their regular source of health care, previous health care experiences, and perceptions of the use of the ED.

RESULTS

Patients who reported the ED as their regular source of care were three times more likely to have used the ED more than once in the preceding year. Among the regular ED users, 68% desired a physician as their regular source of care, and 46% of these subjects said they had tried unsuccessfully to get one in the preceding year. Five variables were associated with self-report of the ED as the regular source of health care: annual income less than $30,000, having been refused care in an office or clinic in the past, perception that an ED visit costs less than an office visit, absence of chronic illness, and unwillingness to use the ED if a $25 copayment were in effect.

CONCLUSION

Low income, perceived mistreatment by health care providers, and misperception about charges contribute to use of the ED as a regular site for health care. These factors suggest the difficulty of altering health care use patterns in this group.

"Inappropriate" emergency department use: a comparison of three methodologies for identification

OBJECTIVE

To determine the level of agreement between the rates of "inappropriate" ED visits assigned to a cohort of ambulatory patients based on three methods of defining ED use appropriateness.

METHODS

Ambulatory adult patients seen at one urban, university-based teaching hospital ED between 8 AM and midnight during select days from April to June 1994 were assessed regarding the appropriateness of their ED visits. Patients triaged to acute resuscitation rooms in the ED were excluded. Eligible patients were asked to complete a 90-question survey including demographics and health service use (response rate 81%). The appropriateness of ED use was assessed for consenting respondents by 1) application of a list of 51 non-emergent complaints that have been used by managed care providers and previously published (TRIAGE), 2) use of ten explicit criteria (e.g., need for parenteral medication) from prior publications (EXPLICIT), and 3) the consensus of two emergency physicians (EPs) reviewing the records of ED patients (PHYS). All three methods were applied at the time of retrospective chart review. The agreement between methods was evaluated using kappa scores.

RESULTS

Of the 892 eligible respondents, 64% were white, 54% were employed, 50% were female, and 29% were uninsured. Of the respondents, 26% had no regular source of ambulatory care and 25% considered the ED their regular source of care. The assigned rates of "inappropriate" visits using the three definitions were TRIAGE, 58%; PHYS, 47%; and EXPLICIT, 42%. Of those deemed "inappropriate" by the EXPLICIT criteria, 81% also were judged as "inappropriate" by the TRIAGE criteria, and 72%, by the PHYS criteria. Of those patients deemed "inappropriate" by the TRIAGE criteria, 59% also were judged as "inappropriate" by the EXPLICIT criteria, and 66%, by the PHYS criteria. Levels of agreement (kappas) were TRIAGE/EXPLICIT, 0.39; TRIAGE/PHYS, 0.42; and EXPLICIT/PHYS, 0.42.

CONCLUSION

There is only moderate agreement between different methods of determining appropriateness of ED use. Until further refinement is made in triage assessment, managed care organizations and EPs should remain cautious when implementing a protocol that defines and restricts "inappropriate" ED visits.

The potential impact of health care reform on emergency department utilization

How will emergency department utilization and costs be affected by universal coverage provisions? Proponents of health care reform predict that the number of ED visits will decline when currently uninsured Americans become eligible for primary physicians' care. However, economic concepts indicate the contrary: that ED volume and costs will actually escalate upon implementation of health care reform initiatives. These basic concepts include: 1) the insulation of most consumers from the true cost of health care, fostering higher demands for that care; 2) the financial benefits afforded physicians and health maintenance organizations by ED's ability, and legal responsibility, to assess and treat any patient at any time; and 3) access to ED personnel and material by individuals with urgent and nonurgent conditions, which generates fixed costs, regardless of patient volume. These effects of health care reform on EDs must be anticipated by hospital administrators to avoid compromise of patient care quality and consumer satisfaction.

Health care reform and emergency medicine

The twin goals of health care reform--providing universal coverage and limiting health care costs--will require increased primary care access and reductions in the overuse of inappropriate subspecialty interventions. The emergency department provides acute care access for all patients and nonemergency care for those patients unable to find other sources of care. Implementation of marketplace reforms may direct patients away from EDs to other primary care sites and reallocate residency positions now available for training of emergency physicians to other primary care specialties. These two effects may endanger the viability of the ED as the safety net of the health care system. The impact of health care reform on the emergency care system of the nation requires careful analysis to protect the important role of the ED in providing acute care and in guaranteeing access to care.

Refusing care to emergency department of patients: evaluation of published triage guidelines

STUDY OBJECTIVE

To determine whether a set of published triage guidelines identifies patients who can safely be refused emergency department care.

DESIGN

Historical cohort study.

SETTING

A public hospital ED.

TYPE OF PARTICIPANTS

All patients triaged during a one-week period who were not in the most acute triage category.

MEASUREMENTS

Two ED nurses, blinded to the study hypothesis, reviewed each triage sheet to determine whether the case met the published guidelines for refusing care. In addition, each ED record was reviewed for appropriateness; a visit was considered appropriate only if predetermined, explicit criteria were met and an emergency physician agreed that a 24-hour delay in care might have worsened the patient's outcome.

MAIN RESULTS

Of the 106 patients who would have been refused care according to the triage guidelines, 35 (33%) had appropriate visits. Four were hospitalized.

CONCLUSION

When tested in our patient population, the triage guidelines were not sufficiently sensitive to identify patients who needed ED care. Broad application of these guidelines may jeopardize the health of some patients.

Patients who leave emergency departments without being seen by a physician: magnitude of the problem in Los Angeles County

STUDY OBJECTIVES

To determine the hospital characteristics associated with patients leaving emergency departments prior to physician evaluation.

DESIGN

Cross-sectional design with data collection by mail and telephone survey.

SETTING

Los Angeles County, California.

TYPE OF PARTICIPANTS

Convenience sample of four public and 26 private hospital EDs with a combined monthly volume of 92,570.

INTERVENTIONS

None.

RESULTS

Questionnaires were returned from 83% of EDs surveyed. During 1990, 4.2% of patients at these EDs left without being seen by a physician. In all, 7.3% of public hospital patients left without being seen, and 2.4% of private hospital patients left without being seen (P < .001). The percentage of patients who left without being seen was significantly higher at EDs with longer waiting times, higher fraction of uninsured patients, and at hospitals with accredited residency training programs (P < .001 for each comparison). A logistic regression model, used to simultaneously evaluate the effects of multiple correlated factors, revealed that waiting time, fraction of patients uninsured, and teaching status had independent positive associations with patients who left without being seen.

CONCLUSION

More than 4% of patients who seek care at EDs in Los Angeles County leave without being seen by a physician. A greater proportion of patients leave without medical evaluation from EDs with long waiting times for ambulatory patients and from those that serve uninsured populations. These findings should be interpreted in light of existing data on the health consequences faced by patients who leave hospital EDs without treatment.

Proposals for health care reform: how do we evaluate them?

The Society for Academic Emergency Medicine suggests a systematic approach to evaluating proposals for reform of the medical care system. Described are the three components of the problem--access, cost, and quality. Then, goals are proposed for health care reform. With this background, we describe the major questions that reform proposals must address and the potential impact of reform on emergency medicine. Emergency physicians must actively support health reform legislation that is in the over-all best interest or our patients and our specialty, and work with the new federal administration to evaluate proposed changes.

The emergent problem of ambulance misuse

STUDY OBJECTIVE

The primary objective was to determine whether rates of ambulance misuse varied systematically by type of health insurance. The secondary objective was to determine whether the level of service provided in the ambulance varied by ambulance company ownership.

DESIGN

Survey.

SETTING

A 175-bed community hospital in central Connecticut.

PARTICIPANTS

One hundred forty-five records were selected randomly for study from the records of the 488 patients presenting to the hospital emergency department within a 45-day period.

OUTCOME MEASURES

The urgency of presenting complaint and the use of life support measures within the ambulance were obtained from each ambulance run form. Type of health insurance, clinical data, and disposition were obtained from ED records. Ambulance use was deemed unnecessary if the patient's presenting complaint was nonurgent, the patient was ambulatory, and the patient was not ultimately hospitalized. Advanced life support measures were deemed unnecessary if they were applied to patients with nonurgent complaints.

RESULTS

Patients with private insurance made appropriate use of ambulances in 77.8% of cases, patients with Medicare did so in 65.8% of cases, and patients with Medicaid did so in 14.7% of cases. These results were statistically significant at P < .001. Among patients with Medicare, ambulance misuse was more common among nursing home residents. Approximately 20% of the observed misuse was related to alcohol intoxication. Although it did not reach statistical significance, we noted a higher frequency of inappropriate use of advanced life support measures in patients brought to the ED by a private ambulance service than for those brought by a municipal service.

CONCLUSION

Ambulance misuse is common in the studied community and may be related to the broader problem of the provision of care to the poor or otherwise underserved. Our results raise several interesting questions for further research.

Universal access: its potential impact on emergency medicine

The nation's current economic conditions, the first time in 60 years that a recession has adversely affected the middle class, might well be the actual trigger mechanism in the passage of a US universal access plan. When enacted, it would provide emergency medicine and other basic physician and hospital benefits to the currently uninsured patients now seen in hospital EDs, in doctors' offices, and as inpatients. It will, thereby, enhance current physician-patient relationships and enable many of the working poor and their dependents to receive medical care. Conventional widsom suggests that such a social insurance plan could significantly reduce the number of routine visits to hospital EDs, assuming that additional, accessible, and high-quality alternative primary-care services are developed. In any case, a universal access plan should improve the percentage of billed charges collected by emergency physicians. The nation's 1,500 third-party payers, with their managed care strategy, will have difficulty (for the reasons outlined) in micromanaging such external pressures as ensuring high-quality patient care, more benefits (including tertiary services), and less cost to the private and public sectors. As there is more micromanaging by third-party payers to reduce expenditures, it will be increasingly difficult for emergency physicians to find specialists willing to accept previously uninsured patients, except at public or teaching environments where the delivery of services to uncompensated patients has been the pattern for several decades.(ABSTRACT TRUNCATED AT 250 WORDS)