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Hempel S, Ganz D, Saluja S, Bolshakova M, Kim T, Turvey C, Cordasco K, Basu A, Page T, Mahmood R, Motala A, Barnard J, Wong M, Fu N, Miake-Lye IM. Care coordination across healthcare systems: development of a research agenda, implications for practice, and recommendations for policy based on a modified Delphi panel. BMJ Open 2023; 13:e060232. [PMID: 37197809 DOI: 10.1136/bmjopen-2021-060232] [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: 05/19/2023] Open
Abstract
OBJECTIVE For large, integrated healthcare delivery systems, coordinating patient care across delivery systems with providers external to the system presents challenges. We explored the domains and requirements for care coordination by professionals across healthcare systems and developed an agenda for research, practice and policy. DESIGN The modified Delphi approach convened a 2-day stakeholder panel with moderated virtual discussions, preceded and followed by online surveys. SETTING The work addresses care coordination across healthcare systems. We introduced common care scenarios and differentiated recommendations for a large (main) healthcare organisation and external healthcare professionals that contribute additional care. PARTICIPANTS The panel composition included health service providers, decision makers, patients and care community, and researchers. Discussions were informed by a rapid review of tested approaches to fostering collaboration, facilitating care coordination and improving communication across healthcare systems. OUTCOME MEASURES The study planned to formulate a research agenda, implications for practice and recommendations for policy. RESULTS For research recommendations, we found consensus for developing measures of shared care, exploring healthcare professionals' needs in different care scenarios and evaluating patient experiences. Agreed practice recommendations included educating external professionals about issues specific to the patients in the main healthcare system, educating professionals within the main healthcare system about the roles and responsibilities of all involved parties, and helping patients better understand the pros and cons of within-system and out-of-system care. Policy recommendations included supporting time for professionals with high overlap in patients to engage regularly and sustaining support for care coordination for high-need patients. CONCLUSIONS Recommendations from the stakeholder panel created an agenda to foster further research, practice and policy innovations in cross-system care coordination.
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Affiliation(s)
- Susanne Hempel
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - David Ganz
- Geriatrics Research, Education and Clinical Center, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
| | - Sonali Saluja
- Gehr Family Center for Health Systems Science and Innovation, University of Southern California, Los Angeles, California, USA
| | - Maria Bolshakova
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - Timothy Kim
- Keck School of Medicine, University of Southern California, Los Angeles, California, USA
| | - Carolyn Turvey
- Center for Access and Delivery Research and Evaluation, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
- Department of Psychiatry, Roy J. and Lucille A. Carver College of Medicine at the University of Iowa, Iowa City, Iowa, USA
- Rural Health Resource Center, Iowa City Veterans Affairs Healthcare System, Iowa City, Iowa, USA
| | - Kristina Cordasco
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aashna Basu
- Department of Medicine, David Geffen School of Medicine at the University of California at Los Angeles, Los Angeles, California, USA
- Care in the Community Service, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Tonya Page
- Office of Community, Clinical Integration & Field Support, Veteran Affairs Central Office, Kentucky City, Kentucky, USA
| | - Reshma Mahmood
- Santa Maria and San Luis Obispo Community Outpatient Clinics, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Aneesa Motala
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
| | - Jenny Barnard
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Michelle Wong
- VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
| | - Ning Fu
- Southern California Evidence Review Center, University of Southern California, Los Angeles, California, USA
- School of Public Administration and Emergency Management, Jinan University, Guangzhou, Guangdong, China
| | - Isomi M Miake-Lye
- VA West Los Angeles Evidence-based Synthesis Program, VA Greater Los Angeles Healthcare System, Los Angeles, California, USA
- Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, California, USA
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Turbow SD, Culler SD, Vaughan CP, Rask KJ, Perkins MM, Clevenger CK, Ali MK. Ambulance use and subsequent fragmented hospital readmission among older adults. J Am Geriatr Soc 2023; 71:1416-1428. [PMID: 36573624 PMCID: PMC10175179 DOI: 10.1111/jgs.18210] [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: 08/15/2022] [Revised: 11/11/2022] [Accepted: 11/22/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Interhospital care fragmentation, when a patient is readmitted to a different hospital than they were originally discharged from, occurs in 20%-25% of readmissions. Mode of transport to the hospital, specifically ambulance use, may be a risk factor for fragmented readmissions. Our study seeks to further understand the relationship between ambulance transport and fragmented readmissions in older adults, a population that is at increased risk for poor outcomes following fragmented readmissions. METHODS We analyzed inpatient claims from Medicare beneficiaries in 2018 who had a hospital admission for select Hospital Readmission Reduction Program Conditions (acute myocardial infarction, congestive heart failure, chronic obstructive pulmonary disease, pneumonia) as well as dehydration, syncope, urinary tract infection, or behavioral issues. We evaluated the associations between ambulance transport and a fragmented readmission using logistic regression models adjusted for demographic, clinical, and hospital characteristics. RESULTS The study included 1,186,600 30-day readmissions. Of these, 46.8% (n = 555,847) required ambulance transport. In fully adjusted models, taking an ambulance to the readmission hospital increased the odds of a fragmented readmission by 38% (95% CI 1.32, 1.44). When this association was examined by readmission major diagnostic category (MDC), the strongest associations were seen for Factors Influencing Health Status and Other Contacts with Health Services (i.e., rehabilitation, aftercare) (AOR 3.66, 95% CI 3.11, 4.32), Mental Diseases and Disorders (AOR 2.69, 95% CI 2.44, 2.97), and Multiple Significant Trauma (AOR 2.61, 95% CI 1.56, 4.35). When the model was stratified by patient origin, ambulance use remained associated with fragmented readmissions across all locations. CONCLUSIONS Ambulance use is associated with increased odds of a fragmented readmission, though the strength of the association varies by readmission diagnosis and origin. Patient-, hospital-, and system-level interventions should be developed, implemented, and evaluated to address this modifiable risk factor.
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Affiliation(s)
- Sara D Turbow
- Division of General Internal Medicine, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Steven D Culler
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
| | - Camille P Vaughan
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Veterans Affairs, Birmingham/Atlanta Geriatric Research Education and Clinical Center, Atlanta, Georgia, USA
| | | | - Molly M Perkins
- Division of Geriatrics & Gerontology, Department of Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Carolyn K Clevenger
- Nell Hodgson Woodruff School of Nursing, Emory University, Atlanta, Georgia, USA
| | - Mohammed K Ali
- Department of Family & Preventive Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
- Hubert Department of Global Health, Rollins School of Public Health, Emory University, Atlanta, Georgia, USA
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Tenso K, Pizer S, Palani S. Delivery system emergency department capacity and its effect on nonsystem service utilization. Acad Emerg Med 2023; 30:359-367. [PMID: 36797812 DOI: 10.1111/acem.14694] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2022] [Revised: 01/24/2023] [Accepted: 02/03/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND Emergency department (ED) use is often seen as a source of excess health care spending, prompting managers to limit ED capacity in their health systems. However, if limited ED capacity in a delivery system leads patients to seek emergency care elsewhere, then health care quality and efficient management may be compromised within the system. OBJECTIVE The objective of this study was to explore the effect of the Veterans Health Administration (VHA) in-house ED clinician capacity on VHA community care (CC) ED claims. METHODS We used administrative data from the VHA to identify CC ED claims and Department of Veterans Affairs emergency physician (EP) capacity for 2014-2019. We used quasi-experimental instrumental variables approach with two different instruments: percent weekday federal holidays and VHA EP full-time equivalents (FTEs). We controlled for VHA ED variables such as ED wait times (door to triage, door to doctor, and door to admission) and demand variables such as alternative insurance coverage, driving time to VHA care, and demographic variables (employment, age, household income, race, gender, and VHA priority status). RESULTS After instrumenting for capacity with percent weekday federal holidays, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 61 CC ED claims per 10,000 enrollees. After instrumenting for capacity with EP FTE, we found that one clinic-day capacity (one 8-h ED shift) per 10,000 enrollees increase at the VHA ED will result in a reduction of 48 CC ED claims per 10,000 enrollees. Both of these results are statistically significant at p < 0.001. CONCLUSIONS Our findings imply that offering more in-house ED care, in the form of clinician capacity, can substantially reduce out-of-system ED use. The results may be of interest to integrated health care system managers who prefer their patients to stay within network.
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Affiliation(s)
- Kertu Tenso
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Massachusetts, Boston, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Steven Pizer
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Massachusetts, Boston, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
| | - Sivagaminathan Palani
- Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Massachusetts, Boston, USA.,Department of Health Law Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA
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Palani S, Garrido MM, Tenso K, Pizer SD. Community care emergency room use and specialty care leakage from Veterans Health Administration hospitals. Acad Emerg Med 2023; 30:379-387. [PMID: 36660799 DOI: 10.1111/acem.14667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Revised: 01/09/2023] [Accepted: 01/13/2023] [Indexed: 01/21/2023]
Abstract
BACKGROUND Care leakage from health systems can affect quality and cost of health care delivery. Identifying modifiable predictors of care leakage may help health systems avoid adverse consequences. Out-of-system emergency department (ED) use may be one modifiable cause of care leakage. Our objective was to investigate the relationship between out-of-system ED use and subsequent specialty care leakage. METHODS We used the Veterans Health Administration's (VA) Corporate Data Warehouse data from January 2021 to July 2021. A total of 330,547 patients who had at least one ED visit (in-house or community care [CC]) in the index period (January 2021-March 2021) were included. Outcomes were the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from the index ED visit. Instrumental-variables regressions, using VA ED physician capacity as an instrument for Veterans' CC ED use, were utilized to estimate the proportions of subsequent specialty care visits in the community. Estimates were adjusted for patient and facility characteristics. RESULTS A CC ED visit was associated with increases in the proportions of specialty care visits in the community within 30, 60, 90, and 120 days from index visit. Within 30 days from index visit, CC ED patients were estimated to have a 45-percentage-point (pp; 95% confidence interval [CI], 43-47 pp) higher proportion of CC specialty care visits than patients with an in-house ED visit (p < 0.001). We observed similar, though slightly attenuated, results over long time periods since the index visit. CONCLUSIONS Veterans who have a CC ED visit have a greater proportion of subsequent specialty care visits in CC hospitals and clinics than Veterans with a VA ED visit. This relationship persists when we examine Veterans whose decision to go to a CC ED is influenced by VA ED physician capacity rather than general preferences for CC.
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Affiliation(s)
- Sivagaminathan Palani
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Melissa M Garrido
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Kertu Tenso
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
| | - Steven D Pizer
- Department of Health Law, Policy and Management, Boston University School of Public Health, Boston, Massachusetts, USA.,Partnered Evidence-Based Policy Resource Center, VA Boston Healthcare System, Boston, Massachusetts, USA
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Carlson LC, Tasi MC, Wasfy JH, Thompson RW, Cafiero-Fonseca ET, Temin ES, Yun BJ. An Analysis of Ambulance Transport and Out-of-Network Emergency Department Utilization in an Accountable Care Organization. Popul Health Manag 2021; 24:576-580. [PMID: 33656386 DOI: 10.1089/pop.2020.0315] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
For hospital-affiliated accountable care organizations (ACOs), emergency care represents a unique challenge for coordination of care and a major source of ACO leakage. The authors analyzed emergency department (ED) visits among ACO members to assess the potential impact of ambulance transport on the use of in-network versus out-of-network EDs. To better understand factors influencing the use of in-network versus out-of-network EDs, 2018 claims data from members of a regional subset of a large ACO in the greater Boston area were analyzed. Within this population, multivariable logistic regression was used to assess the relationship between ambulance transport as well as demographic factors, insurance type, and hospital distance on the use of in-network versus out-of-network EDs. Arrival to an ED via ambulance was found to be significantly associated with reduced odds of presenting to an in-network ED compared to arriving by private transportation (odds ratio 0.70, 95% confidence interval: 0.58-0.85). Age older than 65 years, commercial insurance (relative to Medicare), proximity to an in-network ED, and distance from an out-of-network ED also were significantly associated with use of in-network EDs relative to out-of-network EDs. Given the central role of the ED as a primary source of hospital admissions in the United States, emergency care represents a key potential target for interventions aimed at reducing patient leakage. Future efforts should aim to identify and evaluate new ways that emergency medical services can be leveraged to promote effective care coordination.
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Affiliation(s)
- Lucas C Carlson
- Population Health Management, Mass General Brigham, Somerville, Massachusetts, USA.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA
| | - Michael C Tasi
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts, USA.,Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Jason H Wasfy
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Ryan W Thompson
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Elizabeth T Cafiero-Fonseca
- Performance Analysis and Improvement, Massachusetts General Hospital/Massachusetts General Physicians Organization, Boston, Massachusetts, USA
| | - Elizabeth S Temin
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Brian J Yun
- Harvard Medical School, Boston, Massachusetts, USA.,Department of Emergency Medicine, Massachusetts General Hospital, Boston, Massachusetts, USA
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Song Z, Johnson W, Kennedy K, Biniek JF, Wallace J. Out-Of-Network Spending Mostly Declined In Privately Insured Populations With A Few Notable Exceptions From 2008 To 2016. Health Aff (Millwood) 2020; 39:1032-1041. [PMID: 32479236 PMCID: PMC8299541 DOI: 10.1377/hlthaff.2019.01776] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
While out-of-network or potential "surprise" billing has garnered increasing attention, particularly in emergency department and inpatient settings, few national studies have examined out-of-network care overall or in other settings. We examined out-of-network spending and use among two large nationwide populations with employer-sponsored insurance. In a primary sample of 27,883,040 people in data for 2008-16 from the Truven MarketScan Commercial Claims and Encounters Database, we found that the unadjusted share of total spending that occurred out of network decreased from 7.0 percent in 2008-10 to 6.1 percent in 2014-16, an adjusted average decline of 0.10 percentage points per year. Using a secondary sample of 13,093,209 people in the Health Care Cost Institute database provided qualitatively similar results, including when provider charges (upper bound for balance billing) were used in place of observed out-of-network prices. In subgroup analyses of the primary sample, the share of out-of-network spending was stable or declined among all segments of care except hospitalist services, pathologist services, and laboratory tests across the study period. Out-of-network use demonstrated comparable patterns. Prices were higher out of network than in network. Policy makers should focus their efforts on protecting consumers from balance billing or potential surprise billing in clinical scenarios where patients often have little choice over their provider.
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Affiliation(s)
- Zirui Song
- Zirui Song is an assistant professor of health care policy and medicine at Harvard Medical School, a general internist at Massachusetts General Hospital, and faculty member in the Center for Primary Care at Harvard Medical School, in Boston, Massachusetts
| | - William Johnson
- William Johnson is a senior researcher at the Health Care Cost Institute, in Washington, D.C
| | - Kevin Kennedy
- Kevin Kennedy is a researcher at the Health Care Cost Institute
| | | | - Jacob Wallace
- Jacob Wallace is an assistant professor of Public Health in the Department of Health Policy and Management, Yale School of Public Health, in New Haven, Connecticut
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Brown JF, Raven MC, Tangherlini NL, Kennedy Hall M. Frequent Users of 9-1-1 Emergency Medical Services: Sign of Success or Symptom of Impending Failure? PREHOSP EMERG CARE 2018; 23:1-3. [PMID: 30130427 DOI: 10.1080/10903127.2018.1475531] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 04/30/2018] [Accepted: 05/08/2018] [Indexed: 10/28/2022]
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Cambon J, Cordier T, Munnich EL, Renda A, Kapur B, Hoxhaj S, Williams M. Effects of Educational Messaging on Urgent and Emergent Care-Seeking Behaviors Among Publicly Insured Populations. AMERICAN HEALTH & DRUG BENEFITS 2018; 11:86-94. [PMID: 29915641 PMCID: PMC5973246] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Received: 06/28/2017] [Accepted: 11/02/2017] [Indexed: 06/08/2023]
Abstract
BACKGROUND The impact of messaging campaigns on influencing urgent care- and emergent care-seeking behaviors, including the use of in-network providers, is not well-understood. Although out-of-network healthcare utilization can have negative financial consequences for patients in narrow network Affordable Care Act plans, individuals with time-sensitive medical conditions, and especially patients visiting the emergency department, may not think about out-of-network issues. Inappropriate or avoidable emergency department visits can also create unnecessary costs for patients. OBJECTIVE To evaluate the impact of 5 messaging strategies to educate individuals about the use of in-network providers and when care should be sought in the emergency department, urgent care center, or other sites of care. METHODS Using a retrospective analysis, individuals aged ≥18 years who were enrolled in an individually purchased Affordable Care Act-compliant Humana plan as of July 1, 2015, were randomized to 1 of 5 messaging arms (e-mail, magnet mailer with or without e-mail, and key-tag mailer with or without e-mail) or to a control group. The outreach was implemented and evaluated in 2 distinct, geographically defined populations of Orlando, Palm Beach, and Tampa, Florida (Population 1); and Atlanta, Georgia, and San Antonio and Austin, Texas (Population 2). The relative number of each emergency department, urgent care, and out-of-network visits during follow-up was modeled using negative binomial regression. Cox proportional hazard models were used to calculate the risk for ≥1 of each visit type (assessed separately) and high emergency department utilization (defined as ≥3 visits during follow-up) relative to the control, while accounting for variable follow-up time. RESULTS The relative numbers of each visit type assessed were not significantly different for any message group compared with the control in either population. The risk for an emergency department visit was 4% lower in the e-mail arm of Population 2 (hazard ratio [HR], 0.96; 95% confidence interval [CI], 0.94-0.99; P = .005) and 7% lower in the e-mail/key-tag arm of Population 1 (HR, 0.93; 95% CI, 0.89-0.97; P = .001). The risk for high emergency department utilization was significantly reduced by the key-tag, magnet, and e-mail/key-tag strategies in Population 1, but no impact was found in Population 2. CONCLUSION Despite the mixed results, the study provides new insights into how different messaging strategies could be used to educate patients and influence healthcare utilization decisions by people with health insurance.
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Affiliation(s)
- Jesse Cambon
- Analytics Consultant with Humana, Louisville, KY, during this study
| | | | | | | | - Bobby Kapur
- Chief of Emergency Medicine, Jackson Memorial Hospital, Miami, FL
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