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Sabbatini AK, Gallahue F, Newson J, White S, Gallagher TH. Capturing Emergency Department Discharge Quality With the Care Transitions Measure: A Pilot Study. Acad Emerg Med 2019; 26:605-609. [PMID: 30256486 DOI: 10.1111/acem.13623] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2018] [Revised: 09/05/2018] [Accepted: 09/11/2018] [Indexed: 11/28/2022]
Abstract
BACKGROUND Recent attention has been given to developing measures to capture the quality of ED transitions of care. We examined the utility of a patient-reported measure of transitional care, the Care Transitions Measure-3 (CTM-3), in the ED setting and its association with outcomes of care after ED discharge. METHODS A telephone survey was conducted of a convenience sample of patients 14 days after discharge from two emergency departments (EDs) in an academic health system. Patients responded to three statements using a four-point agreement scale (strongly disagree, disagree, agree, strongly agree): 1) "The hospital staff took my preferences and those of my family or caregiver into account when deciding what my health care needs would be"; 2) " When I left the ER, I had a good understanding of the things I was responsible for in managing my health"; and 3) "When I left the hospital, I clearly understood the purpose for taking each of my medications." Patients were also queried about outcomes after ED discharge that are known to be related to ED care transitions including medication adherence, completion of recommended follow-up, and return visits to the ED. Multivariable logistic regression was used to determine the association between the CTM-3 score (on a 100-point scale) and outcomes of interest. RESULTS Among 1,832 patients called, 576 were reached by phone, and 410 consented and completed our survey, representing a 22.4% response rate of patients we attempted to call. A 10-point increase in the CTM-3 score (better care experiences) was associated with a 12% decrease in the odds of having an ED return visit (adjusted odds ratio [AOR] = 0.88, 95% confidence interval [CI] = 0.77-1.00) and a 45% increase in the odds of taking prescribed medications as recommended (AOR = 1.45, 95% CI = 1.12-1.87). There was no association between CTM-3 score and completion of follow-up. CONCLUSIONS The CTM-3 is associated with outcomes of care after an ED visit, including ED return visits and medication adherence, and may have utility as a patient-reported measure of ED transitions of care.
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Affiliation(s)
- Amber K Sabbatini
- Department of Emergency Medicine, University of Washington, Seattle, WA.,Center for Scholarship in Patient Care Quality and Safety, University of Washington, Seattle, WA
| | - Fiona Gallahue
- Department of Emergency Medicine, University of Washington, Seattle, WA
| | - Joshua Newson
- School of Medicine, University of Washington, Seattle, WA
| | | | - Thomas H Gallagher
- Department of Medicine, University of Washington, Seattle, WA.,Center for Scholarship in Patient Care Quality and Safety, University of Washington, Seattle, WA
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Greenwood-Ericksen MB, Macy ML, Ham J, Nypaver MM, Zochowski M, Kocher KE. Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations? West J Emerg Med 2019; 20:477-484. [PMID: 31123549 PMCID: PMC6526889 DOI: 10.5811/westjem.2019.2.42057] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 02/11/2019] [Accepted: 02/16/2019] [Indexed: 01/14/2023] Open
Abstract
INTRODUCTION Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions. METHODS A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins. RESULTS Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality. CONCLUSION While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations.
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Affiliation(s)
| | - Michelle L. Macy
- Ann & Robert H. Lurie Children’s Hospital of Chicago and Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Jason Ham
- University of Michigan, Department of Internal Medicine, Ann Arbor, Michigan
| | - Michele M. Nypaver
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
- University of Michigan, Department of Pediatrics, University of Michigan, Ann Arbor, Michigan
| | - Melissa Zochowski
- University of Michigan, College of Engineering, XTRM Labs, Ann Arbor, Michigan
| | - Keith E. Kocher
- University of Michigan, Department of Emergency Medicine, Ann Arbor, Michigan
- University of Michigan, Institute for Healthcare Policy and Innovation, Ann Arbor, Michigan
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Chan CL, Lin W, Yang NP, Lai KR, Huang HT. Pre-emergency-department care-seeking patterns are associated with the severity of presenting condition for emergency department visit and subsequent adverse events: a timeframe episode analysis. PLoS One 2015; 10:e0127793. [PMID: 26030278 PMCID: PMC4452693 DOI: 10.1371/journal.pone.0127793] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2014] [Accepted: 04/19/2015] [Indexed: 11/18/2022] Open
Abstract
Background Many patients treated in Emergency Department (ED) visits can be treated at primary or urgent care sectors, despite the fact that a number of ED visitors seek other forms of care prior to an ED visit. However, little is known regarding how the pre-ED activity episodes affect ED visits. Objectives We investigated whether care-seeking patterns involve the use of health care services of various types prior to ED visits and examined the associations of these patterns with the severity of the presenting condition for the ED visit (EDVS) and subsequent events. Methods This retrospective observational study used administrative data on beneficiaries of the universal health care insurance program in Taiwan. The service type, treatment capacity, and relative diagnosis were used to classify pre-ED visits into 8 care types. Frequent pattern analysis was used to identify sequential care-seeking patterns and to classify 667,183 eligible pre-ED episodes into patterns. Generalized linear models were developed using generalized estimating equations to examine the associations of these patterns with EDVS and subsequent events. Results The results revealed 17 care-seeking patterns. The EDVS and likelihood of subsequent events significantly differed among patterns. The ED severity index of patterns differ from patterns seeking directly ED care (coefficients ranged from -0.05 to 0.13), and the odds-ratios for the likelihood of subsequent ED visits and hospitalization ranged from 1.18 to 1.86 and 1.16 to 2.84, respectively. Conclusions The pre-ED care-seeking patterns differ in severity of presenting condition and subsequent events that may represent different causes of ED visit. Future health policy maker may adopt different intervention strategies for targeted population to reduce unnecessary ED visit effectively.
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Affiliation(s)
- Chien-Lung Chan
- Department of Information Management and Innovation Center for Big Data and Digital Convergence, Yuan Ze University, Chung-Li, Taiwan
| | - Wender Lin
- Department of Health Care Administration, Chang Jung Christian University, Tainan, Taiwan
| | - Nan-Ping Yang
- Community Health Research Center & Institute of Public Health, National Yang-Ming University, Taipei, Taiwan
- Keelung Hospital, Ministry of Health and Welfare, Keelung, Taiwan
| | - K. Robert Lai
- Department of Computer Science and Engineering, and Innovation Center for Big Data and Digital Convergence, Yuan Ze University, Chung-Li, Taiwan
| | - Hsin-Tsung Huang
- Department of Information Management and Innovation Center for Big Data and Digital Convergence, Yuan Ze University, Chung-Li, Taiwan
- Medical Affairs Division, National Health Insurance Administration, Ministry of Health and Welfare, Taipei, Taiwan
- * E-mail:
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Hefner JL, Wexler R, McAlearney AS. Primary care access barriers as reported by nonurgent emergency department users: implications for the US primary care infrastructure. Am J Med Qual 2014; 30:135-40. [PMID: 24500644 DOI: 10.1177/1062860614521278] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The objective was to explore variation by insurance status in patient-reported barriers to accessing primary care. The authors fielded a brief, anonymous, voluntary survey of nonurgent emergency department (ED) visits at a large academic medical center and conducted descriptive analysis and thematic coding of 349 open-ended survey responses. The privately insured predominantly reported primary care infrastructure barriers-wait time in clinic and for an appointment, constraints related to conventional business hours, and difficulty finding a primary care provider (because of geography or lack of new patient openings). Half of those insured by Medicaid and/or Medicare also reported these infrastructure barriers. In contrast, the uninsured predominantly reported insurance, income, and transportation barriers. Given that insured nonurgent ED users frequently report infrastructure barriers, these should be the focus of patient-level interventions to reduce nonurgent ED use and of health system-level policies to enhance the capacity of the US primary care infrastructure.
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Becker NV, Friedman AB. ED, heal thyself. Am J Emerg Med 2013; 32:175-7. [PMID: 24332901 DOI: 10.1016/j.ajem.2013.11.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2013] [Revised: 11/01/2013] [Accepted: 11/01/2013] [Indexed: 11/18/2022] Open
Abstract
Emergency department (ED) wait times have continued to worsen despite receiving considerable attention for more than 2 decades and despite the availability of a variety of methods to restructure care in a more streamlined fashion. This article offers an economic framework that abstracts away from the details of operations research to understand the fundamental disincentives to improving wait times. Hospitals that reduce wait times are financially penalized if they must provide more uncompensated care as a result. Pending changes under the Patient Protection and Affordable Care Act are considered. We find that the likely effect of the Patient Protection and Affordable Care Act's insurance expansion is to reduce this penalty for improving ED wait times. Consequently, mandating adoption of solutions to ED crowding may be unnecessary and counterproductive. If the insurance expansion is insufficient to fully solve the problem, the hospital value-based purchasing initiative should adopt wait times as a goal in its next iteration.
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Affiliation(s)
- Nora V Becker
- Department of Health Care Management, Wharton School of Business, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ari B Friedman
- Department of Health Care Management, Wharton School of Business, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
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Quest TE, Asplin BR, Cairns CB, Hwang U, Pines JM. Research priorities for palliative and end-of-life care in the emergency setting. Acad Emerg Med 2011; 18:e70-6. [PMID: 21676052 PMCID: PMC3368013 DOI: 10.1111/j.1553-2712.2011.01088.x] [Citation(s) in RCA: 74] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Palliative care focuses on the physical, spiritual, psychological, and social care from diagnosis to cure or death of a potentially life-threatening illness. When cure is not attainable and end of life approaches, the intensity of palliative care is enhanced to deliver the highest quality care experience. The emergency department (ED) frequently cares for patients and families during the end-of-life phase of the palliative care continuum. The intersection between palliative care and emergency care continues to be more clearly defined. Currently, there is a mounting body of evidence to guide the most effective strategies for improving palliative and end-of-life care in the ED. In a workgroup session at the 2009 Agency for Healthcare Research and Quality (AHRQ)/American College of Emergency Physicians (ACEP) conference "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach," four key research questions arose: 1) which patients are in greatest need of palliative care services in the ED, 2) what is the optimal role of emergency clinicians in caring for patients along a chronic trajectory of illness, 3) how does the integration and initiation of palliative care training and services in the ED setting affect health care utilization, and 4) what are the educational priorities for emergency clinical providers in the domain of palliative care? Workgroup leaders suggest that these four key questions may be answered by strengthening the evidence using six categories of inquiry: descriptive, attitudinal, screening, outcomes, resource allocation, and education of clinicians.
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Pines JM, Asplin BR. Conference proceedings-improving the quality and efficiency of emergency care across the continuum: a systems approach. Acad Emerg Med 2011; 18:655-61. [PMID: 21676065 DOI: 10.1111/j.1553-2712.2011.01085.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
In October 2009, the American College of Emergency Physicians (ACEP) convened a conference held in Boston, Massachusetts, to outline critical issues in emergency care quality and efficiency and to develop a series of research agendas and projects aimed at addressing important questions about how to improve acute, episodic care. The aim of the conference was to describe how hospital-based emergency department (ED) systems could provide solutions for broader delivery problems in the U.S. health care system. The conference featured keynote speakers Drs. Carolyn Clancy (Director, Agency for Healthcare Research and Quality) and Elliott Fisher (Director, Center for Health Policy Research at Dartmouth Medical School). Panels focused on: 1) systems and workflow redesign to improve health care and 2) improving coordination of care for high-cost patients. Additional sessions were conducted to develop five research agendas on the following topics: 1) health information technology; 2) demand for acute care services; 3) frequent, high-cost users of emergency care; 4) critical pathways for post-emergency care diagnosis and treatment; and 5) end-of-life and palliative care in the ED.
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Affiliation(s)
- Jesse M Pines
- Department of Emergency Medicine and Health Policy, George Washington University, Washington, DC, USA.
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