Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care

Reliability of a Measure of Admission Intensity for Emergency Physicians

STUDY OBJECTIVE

We assess the stability of a measure of emergency department (ED) admission intensity for value-based care programs designed to reduce variation in ED admission rates. Measure stability is important to accurately assess admission rates across sites and among physicians.

METHODS

We sampled data from 358 EDs in 41 states (January 2018 to December 2021), separate from sites where the measure was derived. The measure is the ED admission rate per 100 ED visits for 16 clinical conditions and 535 included International Classification of Disease 10 diagnosis codes. We used descriptive plots and multilevel linear probability models to assess stability over time across EDs and among physicians.

RESULTS

Across included 3,571 ED-quarters, the average admission rate was 27.6% (95% confidence interval [CI] 26.0% to 28.2%). The between-facility standard deviation was 9.7% (95% CI 9.0% to 10.6%), and the within-facility standard deviation was 3.0% (95% CI 2.95% to 3.10%), with an intraclass correlation coefficient of 0.91. At the physician-quarter level, the average admission rate was 28.3% (95% CI 28.0% to 28.5%) among 7,002 physicians. Relative to their site's mean in each quarter, the between-physician standard deviation was 6.7% (95% CI 6.6% to 6.8%), and the within-physician standard deviation was 5.5% (95% CI 5.5% to 5.6%), with an intraclass correlation coefficient of 0.59. Moreover, 2.9% of physicians were high-admitting in 80%+ of their practice quarters relative to their peers in the same ED and in the same quarter, whereas 3.9% were low-admitting.

CONCLUSION

The measure exhibits stability in characterizing ED-level admission rates and reliably identifies high- and low-admitting physicians.

Reducing Phlebotomy, Length of Stay, Cost: Development of a Blunt Abdominal Trauma Pathway in a Level I, Pediatric Trauma Center

OBJECTIVES

Blunt abdominal trauma (BAT) is a leading cause of morbidity in children with higher hemodynamic stabilities when compared with adults. Pediatric patients with BAT can often be managed without surgical interventions; however, laboratory testing is often recommended. Yet, laboratory testing can be costly, and current literature has not identified appropriate pathways or specific tests necessary to detect intra-abdominal injury after BAT. Therefore, the present study evaluated a proposed laboratory testing pathway to determine if it safely reduced draws of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase and lipase levels orders, emergency department (ED) length of stay, and cost in pediatric BAT patients.

METHODS

A retrospective review of levels I, II, and III BAT pediatric patients (n = 329) was performed from 2015 to 2018 at our level I, pediatric trauma center. Patients were then grouped based on pre-post pathway, and differences were calculated using univariate analyses.

RESULTS

After implementation of the pathway, there was a significant decrease in the number of complete blood counts, coagulation studies, urinalysis, comprehensive metabolic panels, amylase, and lipase levels orders ( P < 0.05). Postpathway patients had lower average ED lengths of stay and testing costs compared with the pre pathway patients ( P < 0.05). There was no increase in rates of return to the ED within 30 days, missed injuries, or readmissions of patients to the ED.

CONCLUSIONS

Results displayed that the adoption of a laboratory testing pathway for BAT patients reduced the number of laboratory tests, ED length of stay, and associated costs pediatric patients without impacting quality care.

Decline in U.S. Emergency Department admission rates driven by critical pathway conditions, 2006-2014

OBJECTIVES

Despite increasing ED visits, evidence suggests overall hospitalization rates have decreased; however, it is unknown what clinical conditions account for these changes. We aim to describe condition-specific trends and hospital-level variation in hospitalization rates after ED visits from 2006 to 2014.

METHODS

Retrospective observational study of adult ED visits to U.S. acute care hospitals using nationally weighted data from the 2006-2014 National Emergency Department Survey. Our primary outcome was ED admission rate, defined as the number of admissions originating in the ED divided by the number of ED visits. We report admission rates overall and for each condition, including changes over time. We used logistic regression to compare the odds of ED admission from 2006 to 2014, adjusting for patient and hospital characteristics. We also measured hospital-level variation by calculating hospital-level median ED admission rates and interquartile ranges.

RESULTS

After adjusting for patient and hospital characteristics, the odds of ED admission for any condition were 0.49 (CI 0.45, 0.52) in 2014 compared to 2006. The conditions with the greatest relative change in ED admission rates were chest pain (21.7 to 7.5%) and syncope (28.9 to 13.8%). The decline in ED admission rates were accompanied by increased variation in hospital-level ED admission rates.

CONCLUSIONS

Recent reductions in ED admissions are largely attributable to decreased admissions for conditions amenable to outpatient critical pathways. Focusing on hospitals with persistently above-average ED admission rates may be a promising approach to improve the value of acute care.

Artificial Intelligence Assesses Clinicians' Adherence to Asthma Guidelines Using Electronic Health Records

BACKGROUND

Clinicians' asthma guideline adherence in asthma care is suboptimal. The effort to improve adherence can be enhanced by assessing and monitoring clinicians' adherence to guidelines reflected in electronic health records (EHRs), which require costly manual chart review because many care elements cannot be identified by structured data.

OBJECTIVE

This study was designed to demonstrate the feasibility of an artificial intelligence tool using natural language processing (NLP) leveraging the free text EHRs of pediatric patients to extract key components of the 2007 National Asthma Education and Prevention Program guidelines.

METHODS

This is a retrospective cross-sectional study using a birth cohort with a diagnosis of asthma at Mayo Clinic between 2003 and 2016. We used 1,039 clinical notes with an asthma diagnosis from a random sample of 300 patients. Rule-based NLP algorithms were developed to identify asthma guideline-congruent elements by examining care description in EHR free text.

RESULTS

Natural language processing algorithms demonstrated a sensitivity (0.82-1.0), specificity (0.95-1.0), positive predictive value (0.86-1.0), and negative predictive value (0.92-1.0) against manual chart review for asthma guideline-congruent elements. Assessing medication compliance and inhaler technique assessment were the most challenging elements to assess because of the complexity and wide variety of descriptions.

CONCLUSIONS

Natural language processing technologies may enable the automated assessment of clinicians' documentation in EHRs regarding adherence to asthma guidelines and can be a useful population management and research tool to assess and monitor asthma care quality. Multisite studies with a larger sample size are needed to assess the generalizability of these NLP algorithms.

Medicare Two-Midnight Rule Accelerated Shift To Observation Stays

During the past two decades several policies have attempted to replace inappropriate hospital inpatient stays with observation hospital stays, where patients receive hospital care but are classified as outpatients. The Two-Midnight rule, adopted in October 2013 by the Centers for Medicare and Medicaid Services, states that more highly reimbursed inpatient payment is appropriate if care is expected to last at least two midnights; otherwise, observation stays should be used. For hospitals, the administrative burden associated with making these status determinations is substantial. We found that after the Two-Midnight rule was implemented, potentially inappropriate short inpatient stays decreased immediately by 2.0 stays per 1,000 beneficiaries and potentially more appropriate short outpatient stays increased immediately by 1.8 stays per 1,000 beneficiaries, hastening a preexisting trend in this direction. However, after this initial improvement, the rate of change slowed to a new steady state. Given the steady state and ongoing administrative resources needed, it is time to reconsider the value of status determination required by the Two-Midnight rule.

Hospital Occupancy and its Effect on Emergency Department Evaluation

STUDY OBJECTIVE

To examine whether hospital occupancy was associated with increased testing and treatment during emergency department (ED) evaluations, resulting in reduced admissions.

METHODS

We analyzed the electronic health records of an urban academic ED. We linked data from all ED visits from October 1, 2010, to May 29, 2015, with daily hospital occupancy (inpatients/total staffed beds). Outcome measures included the frequency of laboratory testing, advanced imaging, medication administration, and hospitalizations. We modeled each outcome using multivariable negative binomial or logistic regression, as appropriate, and examined their association with daily hospital occupancy quartiles, controlling for patient and visit characteristics. We calculated the adjusted outcome rates and relative changes at each daily hospital occupancy quartile using marginal estimating methods.

RESULTS

We included 270,434 ED visits with a mean patient age of 48.1 (standard deviation 19.8) years; 40.1% were female, 22.8% were non-Hispanic Black, and 51.5% were commercially insured. Hospital occupancy was not associated with differences in laboratory testing, advanced imaging, or medication administration. Compared with the first quartile, the third and fourth quartiles of daily hospital occupancy were associated with decreases of 1.5% (95% confidence interval [CI] -2.9 to -0.2; absolute change -0.6 percentage points [95% CI -1.2 to -0.1]) and 4.6% (95% CI -6.0 to -3.2; absolute change -1.9 percentage points [95% CI -2.5 to -1.3]) in hospitalizations, respectively.

CONCLUSION

The lack of association between hospital occupancy and laboratory testing, advanced imaging, and medication administration suggest that changes in ED testing or treatment did not facilitate the decrease in admissions during periods of high hospital occupancy.

Regional variation in outcomes and healthcare resources utilization in, emergency department visits for syncope

BACKGROUND

Management of patients with syncope lacks standardization. We sought to assess regional variation in hospitalization rates and resource utilization of patients with syncope.

METHODS

We identified adults with syncope using the Nationwide Emergency Department Sample from years 2006 to 2014. Demographics and comorbidity characteristics were compared across geographic regions in the US. Multiple regression was conducted to compare outcomes.

RESULTS

9,132,176 adults presented with syncope. Syncope in the Northeast (n = 1,831,889) accounted for 20.1% of visits; 22.6% in the Midwest (n = 2,060,940), 38.5% in the South (n = 3,527,814) and 18.7% in the West (n = 1,711,533). Mean age was 56 years with 57.7% being female. The Northeast had the highest risk-adjusted hospitalization rate (24.5%) followed by the South (18.6%, ORadj 0.58; 95% CI 0.52-0.65, p < 0.001), the Midwest (17.2%, ORadj 0.51; 95% CI 0.46-0.58, p < 0.001) and West (15.8%, ORadj 0.45; 95% CI 0.39-0.51, p < 0.001). Risk-adjusted rates of syncope hospitalizations significantly declined from 25.8% (95% CI 24.8%-26.7%) in 2006 to 11.7% (95% CI 11.0%-12.5%) in 2014 (Ptrend < 0.001). The Northeast had the lowest risk-adjusted ED (Emergency Department) service charges per visit ($3320) followed by the Midwest ($4675, IRRadj 1.41; 95% CI 1.30-1.52, p < 0.001), the West ($4814, IRRadj 1.45; 95% CI 1.31-1.60, p < 0.001) and South ($4969, IRRadj 1.50; 95% CI 1.38-1.62, p < 0.001). Service charges increased from $3047/visit (95% CI $2912-$3182) in 2006 to $6267/visit (95% CI $5947-$6586) in 2014 (Ptrend < 0.001).

CONCLUSIONS

Significant regional variability in hospitalization rates and ED service charges exist among patients with syncope. Standardizing practices may be needed to reduce variability.

Practical alternative to hospitalization for emergency department patients (PATH): A feasibility study

OBJECTIVE

We sought to determine the feasibility of the Practical Alternative to Hospitalization (PATH) program, an intervention that offers ED clinicians an outpatient care pathway for patients initially designated for inpatient admission or observation.

METHODS

We evaluated a novel care delivery model that was piloted at a tertiary academic medical center in December 2019. An advanced practice provider screened patients designated for inpatient admission or observation and identified eligible participants. Outpatient services were customized for each patient but primarily included care coordination and monitoring through telemedicine and home health services. The primary feasibility outcome was the proportion of eligible patients who were enrolled in the program, as well as patient outcomes after discharge including return ED visits and averted ED boarding time.

RESULTS

A total of 199 patients were designated for inpatient admission or observation during PATH program hours. Of 52 eligible patients, 30 (58%) were enrolled. The mean participant age was 62.5 years (SD 17.5), and 25 (83%) had non-Hispanic Black race/ethnicity. The most common disease conditions were chest pain, heart failure, and hyperglycemia. 4 (13%) enrolled patients returned to an ED within 30 days. We estimate that ED boarding time was reduced by 8.2 h (SD 8.1) per patient.

CONCLUSION

Emergency physicians and patients were willing to use a novel service that provided an alternative disposition to hospitalization.

IMPLICATIONS

alternative payment models that seek to reduce hospital utilization and cost may consider strengthening systems to monitor and coordinate care for patients after ED discharge.

Towards a New System for the Assessment of the Quality in Care Pathways: An Overview of Systematic Reviews

Clinical or care pathways are developed by a multidisciplinary team of healthcare practitioners, based on clinical evidence, and standardized processes. The evaluation of their framework/content quality is unclear. The aim of this study was to describe which tools and domains are able to critically evaluate the quality of clinical/care pathways. An overview of systematic reviews was conducted, according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses, using Medline, Embase, Science Citation Index, PsychInfo, CINAHL, and Cochrane Library, from 2015 to 2020, and with snowballing methods. The quality of the reviews was assessed with Assessment the Methodology of Systematic Review (AMSTAR-2) and categorized with The Leuven Clinical Pathway Compass for the definition of the five domains: processes, service, clinical, team, and financial. We found nine reviews. Three achieved a high level of quality with AMSTAR-2. The areas classified according to The Leuven Clinical Pathway Compass were: 9.7% team multidisciplinary involvement, 13.2% clinical (morbidity/mortality), 44.3% process (continuity-clinical integration, transitional), 5.6% financial (length of stay), and 27.0% service (patient-/family-centered care). Overall, none of the 300 instruments retrieved could be considered a gold standard mainly because they did not cover all the critical pathway domains outlined by Leuven and Health Technology Assessment. This overview shows important insights for the definition of a multiprinciple framework of core domains for assessing the quality of pathways. The core domains should consider general critical aspects common to all pathways, but it is necessary to define specific domains for specific diseases, fast pathways, and adapting the tool to the cultural and organizational characteristics of the health system of each country.

Advanced imaging and trends in hospitalizations from the emergency department

Objective

The proportion of US emergency department (ED) visits that lead to hospitalization has declined over time. The degree to which advanced imaging use contributed to this trend is unknown. Our objective was to examine the association between advanced imaging use during ED visits and changes in ED hospitalization rates between 2007–2008 and 2015–2016.

Methods

We analyzed data from the National Hospital Ambulatory Medical Care Survey. The primary outcome was ED hospitalization, including admission to inpatient and observation units and outside transfers. The primary exposure was advanced imaging during the ED visit, including computed tomography, magnetic resonance imaging, and ultrasound. We constructed a survey-weighted multivariable logistic regression with binary outcome of ED hospitalization to examine changes in adjusted hospitalization rates from 2007–2008 to 2015–2016, comparing ED visits with and without advanced imaging.

Results

ED patients who received advanced imaging (versus those who did not) were more likely to be 65 years or older (25.3% vs 13.0%), non-Hispanic white (65.3% vs 58.5%), female (58.4% vs 54.1%), and have Medicare (26.5% vs 16.0%). Among ED visits with advanced imaging, adjusted annual hospitalization rate declined from 22.5% in 2007–2008 to 17.3% (adjusted risk ratio [aRR] 0.77; 95% CI 0.68, 0.86) in 2015–2016. In the same periods, among ED visits without advanced imaging, adjusted annual hospitalization rate declined from 14.3% to 11.6% (aRR 0.81; 95% CI 0.73, 0.90). The aRRs between ED visits with and without advanced imaging were not significantly different.

Conclusion

From 2007–2016, ED visits with advanced imaging did not have a greater reduction in admission rate compared to those without advanced imaging. Our results suggest that increasing advanced imaging use likely had a limited role in the general decline in hospital admissions from EDs. Future research is needed to further validate this finding.

Changes in Emergency Department Care Intensity from 2007-16: Analysis of the National Hospital Ambulatory Medical Care Survey

INTRODUCTION

Emergency departments (ED) in the United States (US) have increasingly taken the central role for the expedited diagnosis and treatment of acute episodic illnesses and exacerbations of chronic diseases, allowing outpatient management to be possible for many conditions that traditionally required hospitalization and inpatient care. The goal of this analysis was to examine the changes in ED care intensity in this context through the changes in ED patient population and ED care provided.

METHODS

We analyzed the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2007-2016. Incorporating survey design and weight, we calculated the changes in ED patient characteristics and ED care provided between 2007 and 2016. We also calculated changes in the proportion of visits with low-severity illnesses that may be safely managed at alternative settings. Lastly, we compared ED care received and final ED dispositions by calculating adjusted relative risk (aRR) comparing ED visits in 2007 to 2016, using survey weighted multivariable logistic regression.

RESULTS

NHAMCS included 35,490 visits in 2007 and 19,467 visits in 2016, representing 117 million and 146 million ED visits, respectively. Between 2007 and 2016, there was an increase in the proportion of ED patients aged 45-64 (21.0% to 23.6%) and 65-74 (5.9% to 7.5%), while visits with low-severity illnesses decreased from 37.3% to 30.4%. There was a substantial increase in the proportion of Medicaid patients (22.2% to 34.0%) with corresponding decline in the privately insured (36.2% to 28.3%) and the uninsured (15.4% to 8.6%) patients. After adjusting for patient and visit characteristics, there was an increase in the utilization of advanced imaging (aRR 1.29; 95% confidence interval [CI], 1.17-1.41), blood tests (aRR 1.16; 95% CI, 1.10-1.22), urinalysis (aRR 1.22; 95% CI, 1.13-1.31), and visits where the patient received four or more medications (aRR 2.17; 95% CI, 1.88-2.46). Lastly, adjusted hospitalization rates declined (aRR 0.74; 95% CI, 0.64-0.84) while adjusted discharge rates increased (aRR 1.06; 95%CI 1.03-1.08).

CONCLUSION

From 2007 to 2016, ED care intensity appears to have increased modestly, including aging of patient population, increased illness severity, and increased resources utilization. The role of increased care intensity in the decline of ED hospitalization rate requires further study.

Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy

OBJECTIVES

To describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered "low-value", and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations.

METHODS

We analyzed 2002-2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression.

RESULTS

From 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: -3.1%; 95%CI -4.7, -1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: -2.2%; 95%CI -3.0, -1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: -0.6%; 95%CI -2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI -1.9, 2.0]; -0.9% [95%CI -3.1, 1.3]; and -1.2% [95%CI -5.3, 2.9], respectively).

CONCLUSIONS

Before and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.

Capturing Emergency Department Discharge Quality With the Care Transitions Measure: A Pilot Study

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.

Michigan Emergency Department Leader Attitudes Toward and Experiences With Clinical Pathways to Guide Admission Decisions: A Mixed-methods Study

OBJECTIVES

The objective was to characterize emergency department (ED) leader's attitudes toward potentially avoidable admissions and experiences with the use of clinical pathways to guide admission decisions, including the challenges and successes with implementation of these pathways.

METHODS

A mixed-methods study of Michigan ED leaders was conducted. First, a cross-sectional Web-based survey was distributed via e-mail to all 135 hospital-based EDs in the state. Descriptive statistics were calculated. Survey participants who provided contact information were considered eligible for follow-up. Semistructured interviews were conducted by telephone until thematic saturation was reached. Interviews were recorded, transcribed verbatim, reviewed for accuracy, and thematically coded. Representative quotes were extracted for reporting.

RESULTS

Survey responses were received from 64 ED leaders (48% eligible response rate). Semistructured interviews were conducted with a purposeful sample of 11 of the 29 representatives willing to be contacted. Eight sites implemented clinical care pathways as a strategy to reduce avoidable admissions. Pathways were developed for high-frequency conditions. Many pathways were multidisciplinary, incorporating case managers and outpatient care providers, which was thought to improve acceptability. Five models of care emerged 1) standardized care, 2) observation medicine, 3) enhanced follow-up, 4) care coordination, and 5) comprehensive programs. We identified barriers to and facilitators of discharging a patient from the ED when an admission otherwise could be avoided. Barriers included limited access to follow-up, lack of care coordination, and lack of trust in patient's ability to provide self-care or navigate the system. Facilitators included strong relationships with outpatient providers, care coordination, and shared decision making.

CONCLUSIONS

Potential solutions to help avoid hospitalization from the ED include multidisciplinary clinical care pathways. Successful pathways emerged from bringing stakeholders from the ED, hospital, and health care community together. Additionally, emergency providers need systems and supports in place to help their patients navigate follow-up care in a timely fashion.

A Quality Framework for Emergency Department Treatment of Opioid Use Disorder

Emergency clinicians are on the front lines of responding to the opioid epidemic and are leading innovations to reduce opioid overdose deaths through safer prescribing, harm reduction, and improved linkage to outpatient treatment. Currently, there are no nationally recognized quality measures or best practices to guide emergency department quality improvement efforts, implementation science researchers, or policymakers seeking to reduce opioid-associated morbidity and mortality. To address this gap, in May 2017, the National Institute on Drug Abuse's Center for the Clinical Trials Network convened experts in quality measurement from the American College of Emergency Physicians' (ACEP's) Clinical Emergency Data Registry, researchers in emergency and addiction medicine, and representatives from federal agencies, including the National Institute on Drug Abuse and the Centers for Medicare & Medicaid Services. Drawing from discussions at this meeting and with experts in opioid use disorder treatment and quality measure development, we developed a multistakeholder quality improvement framework with specific structural, process, and outcome measures to guide an emergency medicine agenda for opioid use disorder policy, research, and clinical quality improvement.

Big-data analysis: A clinical pathway on endoscopic retrograde cholangiopancreatography for common bile duct stones

BACKGROUND

A clinical pathway (CP) is a standardized approach for disease management. However, big data-based evidence is rarely involved in CP for related common bile duct (CBD) stones, let alone outcome comparisons before and after CP implementation.

AIM

To investigate the value of CP implementation in patients with CBD stones undergoing endoscopic retrograde cholangiopancreatography (ERCP).

METHODS

This retrospective study was conducted at Nanjing Drum Tower Hospital in patients with CBD stones undergoing ERCP from January 2007 to December 2017. The data and outcomes were compared by using univariate and multivariable regression/linear models between the patients who received conventional care (non-pathway group, n = 467) and CP care (pathway group, n = 2196).

RESULTS

At baseline, the main differences observed between the two groups were the percentage of patients with multiple stones (P < 0.001) and incidence of cholangitis complication (P < 0.05). The percentage of antibiotic use and complications in the CP group were significantly less than those in the non-pathway group [adjusted odds ratio (OR) = 0.72, 95% confidence interval (CI): 0.55-0.93, P = 0.012, adjusted OR = 0.44, 95%CI: 0.33-0.59, P < 0.001, respectively]. Patients spent lower costs on hospitalization, operation, nursing, medication, and medical consumable materials (P < 0.001 for all), and even experienced shorter length of hospital stay (LOHS) (P < 0.001) after the CP implementation. No significant differences in clinical outcomes, readmission rate, or secondary surgery rate were presented between the patients in the non-pathway and CP groups.

CONCLUSION

Implementing a CP for patients with CBD stones is a safe mode to reduce the LOHS, hospital costs, antibiotic use, and complication rate.

Impact of a brief intervention on reducing alcohol use and increasing alcohol treatment services utilization among alcohol- and drug-using adult emergency department patients

Most previous brief intervention (BI) studies have focused on alcohol or drug use, instead of both substances. Our primary aim was to determine if an alcohol- and drug-use BI reduced alcohol use and increased alcohol treatment services utilization among adult emergency department (ED) patients who drink alcohol and require an intervention for their drug use. Our secondary aims were to assess when the greatest relative reductions in alcohol use occurred, and which patients (stratified by need for an alcohol use intervention) reduced their alcohol use the most. In this secondary analysis, we studied a sub-sample of participants from the Brief Intervention for Drug Misuse in the Emergency Department (BIDMED) randomized, controlled trial of a BI vs. no BI, whose responses to the Alcohol, Smoking and Substance Involvement Screening Test (ASSIST) indicated a need for a BI for any drug use, and who also reported alcohol use. Participants were stratified by their ASSIST alcohol subscore: 1) no BI needed, 2) a BI needed, or 3) an intensive intervention needed for alcohol use. Alcohol use and alcohol treatment services utilization were measured every 3 months for 12 months post-enrollment. Of these 833 participants, median age was 29 years-old, 46% were female; 55% were white/non-Hispanic, 27% black/non-Hispanic, and 15% Hispanic. Although any alcohol use, alcohol use frequency, days of alcohol use, typical drinks consumed/day, and most drinks consumed/day decreased in both the BI and no BI arms, there were no differences between study arms. Few patients sought alcohol use treatment services in follow-up, and utilization also did not differ by study arm. Compared to baseline, alcohol use reduced the most during the first 3 months after enrollment, yet reduced little afterward. Participants whose ASSIST alcohol subscores indicated a need for an intensive intervention generally had the greatest relative decreases in alcohol use. These results indicate that the BI was not efficacious in reducing alcohol use among alcohol- and drug-using adult ED patients than the self-assessments alone, but suggest that self-assessments with or without a BI may confer reductions in alcohol use.

Observation Status or Inpatient Admission: Impact of Patient Disposition on Outcomes and Utilization Among Emergency Department Patients With Chest Pain

OBJECTIVES

to compare healthcare utilization including coronary angiography, percutaneous coronary intervention (PCI), rehospitalization, and rate of subsequent acute myocardial infarction (AMI) within 30 days, among patients presenting to the emergency department (ED) with chest pain admitted as short-term inpatient (≤2 days) versus observation (in-ED observation units combined with in-hospital observation).

METHODS

We identified adults diagnosed with acute chest pain in the ED from 2010 to 2014 using administrative claims from privately insured and Medicare Advantage. Patients having AMI during the index visit were excluded. One-to-one propensity-score matching and logistic regression were used. Odds ratios (ORs) with 95% confidence intervals (CIs) were reported.

RESULTS

A total of 774,017 chest pain visits were included. After matching, healthcare utilization was lower among observation versus short inpatient, with 10.9% versus 24.4% (OR = 0.38, 95% CI = 0.36 to 0.39) undergoing cardiac catheterization and 1.8% versus 7.6% (OR = 0.23, 95% CI = 0.21 to 0.24) having PCI. The incidence of subsequent AMI within the following 30 days was similar in patients admitted as observation versus short inpatient (0.23% vs. 0.21%; OR = 1.09, 95% CI = 0.84 to 1.42).

CONCLUSIONS

There were higher rates of cardiac catheterization and PCI among those admitted as a short inpatient compared to observation, while the incidence of subsequent AMI within 30 days was similar.

Analysis of Clinical Variations in Asthma Care Documented in Electronic Health Records Between Staff and Resident Physicians

Clinical documentation using free text to describe a patient's medical status is an essential component of electronic health records (EHRs), and the quality of information in documents plays a critical role in clinical practice and translational research. Physicians are the primary creators of EHRs, but their clinical practices vary substantially, resulting in variations in clinical documentation. These variations can represent a source for potential bias in clinical outcomes and downstream applications using EHRs. Asthma is one example, presenting an inconsistent ascertainment process and criteria. A recent study revealed that resident physicians' knowledge of asthma diagnosis and management is relatively limited. In this study, we examined clinical documentation variations in asthma care between staff and resident physicians using individual words, topics, and asthma-related concepts in EHR clinical narratives. Additionally, we discuss potential biases in building an informatics model and further compare asthma diagnosis and outcomes between two physician groups.

Reducing variation in hospital admissions from the emergency department for low-mortality conditions may produce savings

The emergency department (ED) is now the primary source for hospitalizations in the United States, and admission rates for all causes differ widely between EDs. In this study we used a national sample of ED visits to examine variation in risk-standardized hospital admission rates from EDs and the relationship of this variation to inpatient mortality for the fifteen most commonly admitted medical and surgical conditions. We then estimated the impact of variation on national health expenditures under different utilization scenarios. Risk-standardized admission rates differed substantially across EDs, ranging from 1.03-fold for sepsis to 6.55-fold for chest pain between the twenty-fifth and seventy-fifth percentiles of the visits. Conditions such as chest pain, soft tissue infection, asthma, chronic obstructive pulmonary disease, and urinary tract infection were low-mortality conditions that showed the greatest variation. This suggests that some of these admissions might not be necessary, thus representing opportunities to improve efficiency and reduce health spending. Our data indicate that there may be sizeable savings to US payers if differences in ED hospitalization practices could be narrowed among a few of these high-variation, low-mortality conditions.

Randomized Controlled Trial of Electronic Care Plan Alerts and Resource Utilization by High Frequency Emergency Department Users with Opioid Use Disorder

Introduction

There is a paucity of literature supporting the use of electronic alerts for patients with high frequency emergency department (ED) use. We sought to measure changes in opioid prescribing and administration practices, total charges and other resource utilization using electronic alerts to notify providers of an opioid-use care plan for high frequency ED patients.

Methods

This was a randomized, non-blinded, two-group parallel design study of patients who had 1) opioid use disorder and 2) high frequency ED use. Three affiliated hospitals with identical electronic health records participated. Patients were randomized into “Care Plan” versus “Usual Care groups”. Between the years before and after randomization, we compared as primary outcomes the following: 1) opioids (morphine mg equivalents) prescribed to patients upon discharge and administered to ED and inpatients; 2) total medical charges, and the numbers of; 3) ED visits, 4) ED visits with advanced radiologic imaging (computed tomography [CT] or magnetic resonance imaging [MRI]) studies, and 5) inpatient admissions.

Results

A total of 40 patients were enrolled. For ED and inpatients in the “Usual Care” group, the proportion of morphine mg equivalents received in the post-period compared with the pre-period was 15.7%, while in the “Care Plan” group the proportion received in the post-period compared with the pre-period was 4.5% (ratio=0.29, 95% CI [0.07–1.12]; p=0.07). For discharged patients in the “Usual Care” group, the proportion of morphine mg equivalents prescribed in the post-period compared with the pre-period was 25.7% while in the “Care Plan” group, the proportion prescribed in the post-period compared to the pre-period was 2.9%. The “Care Plan” group showed an 89% greater proportional change over the periods compared with the “Usual Care” group (ratio=0.11, 95% CI [0.01–0.092]; p=0.04). Care plans did not change the total charges, or, the numbers of ED visits, ED visits with CT or MRI or inpatient admissions.

Conclusion

Electronic care plans were associated with an incremental decrease in opioids (in morphine mg equivalents) prescribed to patients with opioid use disorder and high frequency ED use.

Factors Influencing Hospital Admission of Non-critically Ill Patients Presenting to the Emergency Department: a Cross-sectional Study

BACKGROUND

Little is known about the factors that influence physicians' admission decisions, especially among lower acuity patients. For the purpose of our study, non-medical refers to all of the factors-other than the patient's clinical condition-that could potentially influence admission decisions.

OBJECTIVE

To describe the influence of non-medical factors on physicians' decisions to admit non-critically ill patients presenting to the ED.

DESIGN

Cross-sectional study of hospital admissions at a single academic medical center.

PARTICIPANTS

Non-critically ill adult patients admitted to the hospital (n = 297) and the admitting emergency medicine physicians (n = 34).

MAIN MEASURES

A patient survey assessed non-medical factors, including primary care access and utilization. A physician survey assessed clinical and non-medical factors influencing the decision to admit. Based on physician responses, admissions were characterized as "strongly acuity-driven," "moderately acuity-driven," or "weakly acuity-driven." Among these admission types, we compared length of stay, cost, and readmission within 30 days to the hospital or ED.

KEY RESULTS

Based on the admitting physician's assessment, we categorized the motivation for admission as strongly acuity-driven in 185 (62 %) admissions, moderately acuity-driven in 92 (31 %), and weakly acuity-driven in 20 (7 %). Per the physician surveys, 51 % of hospitalizations were strongly or moderately influenced by one or more non-medical factors, including lack of information about baseline conditions (23 %); inadequate access to outpatient specialty care (14 %); need for a diagnostic testing or procedure (12 %); a recent ED visit (11 %); and inadequate access to primary care (10 %). Compared with strongly-acuity driven admissions, admissions that were moderately or weakly acuity-driven were shorter and less costly but were associated with similar rates of ED (35 %) and hospital (27 %) readmission.

CONCLUSIONS

Non-medical factors are influential in the admission decisions for many patients presenting to the emergency department. Moderately and weakly acuity-driven admissions may represent a feasible target for alternative care pathways.

Exploring the Potential of Predictive Analytics and Big Data in Emergency Care

Clinical research often focuses on resource-intensive causal inference, whereas the potential of predictive analytics with constantly increasing big data sources remains largely unexplored. Basic prediction, divorced from causal inference, is much easier with big data. Emergency care may benefit from this simpler application of big data. Historically, predictive analytics have played an important role in emergency care as simple heuristics for risk stratification. These tools generally follow a standard approach: parsimonious criteria, easy computability, and independent validation with distinct populations. Simplicity in a prediction tool is valuable, but technological advances make it no longer a necessity. Emergency care could benefit from clinical predictions built using data science tools with abundant potential input variables available in electronic medical records. Patients' risks could be stratified more precisely with large pools of data and lower resource requirements for comparing each clinical encounter to those that came before it, benefiting clinical decisionmaking and health systems operations. The largest value of predictive analytics comes early in the clinical encounter, in which diagnostic and prognostic uncertainty are high and resource-committing decisions need to be made. We propose an agenda for widening the application of predictive analytics in emergency care. Throughout, we express cautious optimism because there are myriad challenges related to database infrastructure, practitioner uptake, and patient acceptance. The quality of routinely compiled clinical data will remain an important limitation. Complementing big data sources with prospective data may be necessary if predictive analytics are to achieve their full potential to improve care quality in the emergency department.

Costs associated with ambulatory care sensitive conditions across hospital-based settings

OBJECTIVES

Ambulatory care sensitive conditions (ACSCs) are acute care diagnoses that could potentially be prevented through improved primary care. This study investigated how payments and charges for these ACSC visits differ by three hospital-based settings (outpatient, emergency department [ED], and inpatient) and examined differences in payments and charges by their physician and facility components.

METHODS

This was a secondary analysis of data (2005 through 2010) from the Medical Expenditure Panel Survey. Multiple linear regression models were used to assess differences in the mean-adjusted payments and charges for ACSC visits by clinical setting and further divided payments and charges into physician and facility components.

RESULTS

Of all ACSC visits from 2005 through 2010, 41% were outpatient visits, 36% were ED visits, and 23% were hospital admissions. After adjusting for patient demographics and comorbid conditions, charges for an inpatient ACSC visit were four times higher ($11,414 vs. $2,563) and payments were five times higher ($4,325 vs. $859) when compared to an ED visit. By comparison, charges for an ACSC ED visit were two times higher ($2,563 vs. $1,084) and payments 2.5 times higher ($859 vs. $341) relative to an ACSC visit managed in an outpatient hospital-based clinic. Across all clinical settings, hospital facility fees account for 77% to 94% of the charge differences and 81% to 93% of the payment differences.

CONCLUSIONS

For hospital-based ACSC visits, inpatient hospitalizations are by far the most expensive. Finding ways to expand outpatient resources and improve the health management of the chronically ill may avoid conditions that lead to more expensive hospital-based encounters. Across all hospital-based settings, facility fees are the major contributor of expense.

The Affordable Care Act and emergency care

The Affordable Care Act (ACA) will have far-reaching effects on the way health care is designed and delivered. Several elements of the ACA will directly affect both demand for ED care and expectations for its role in providing coordinated care. Hospitals will need to employ strategies to reduce ED crowding as the ACA expands insurance coverage. Discussions between EDs and primary care physicians about their respective roles providing acute unscheduled care would promote the goals of the ACA.

Variation in resource utilization across a national sample of pediatric emergency departments

OBJECTIVE

To describe variations in emergency department (ED) quality measures and determine the association between ED costs and outcomes for 3 pediatric conditions: asthma, gastroenteritis, and simple febrile seizure.

STUDY DESIGN

This cross-sectional analysis of ED visits used the Pediatric Health Information System database. Children aged ≤ 18 years who were evaluated in an ED between July 2009 and June 2011 and had a discharge diagnosis of asthma, gastroenteritis, or simple febrile seizure were included. Two quality of care metrics were evaluated for each target condition, and Spearman correlation was applied to evaluate the relationship between ED costs (reflecting overall resource utilization) and admission and revisit rates among institutions.

RESULTS

More than 250,000 ED visits at 21 member hospitals were analyzed. Among children with asthma, the median rate of chest radiography utilization was 35.1% (IQR, 31.3%-41.7%), and that of corticosteroid administration was 82.6% (IQR, 78.5%-86.5%). For children with gastroenteritis, the median rate of ondansetron administration was 52% (IQR, 43.2%-57.0%), and that of intravenous fluid administration was 18.1% (IQR, 15.3%-21.3%). Among children with febrile seizures, the median rate of computed tomography utilization was 3.1% (IQR, 2.7%-4.3%), and that of lumbar puncture was 4.0% (IQR, 2.3%-5.6%). Increased costs were not associated with lower admission rate or 3-day ED revisit rate for the 3 conditions.

CONCLUSION

We observed variation in quality measures for patients presenting to pediatric EDs with common conditions. Higher costs were not associated with lower hospitalization or ED revisit rates.

Demography is destiny: an agenda for geriatric emergency medicine in Australasia

The present paper presents an agenda for geriatric emergency medicine research, education and policy development. Herein we will argue: Population ageing is the definitive health policy challenge in Australasia, and the greatest stressor for emergency medicine posed by population ageing is the disproportionate contribution of older people to hospital occupancy. ED practices and models of care may on occasions contribute to rather than reduce high hospital occupancy in older people, benefitting neither individual patients nor the community at large. Geriatric emergency medicine priorities can be conceptualised using a simple framework, and this process will facilitate a research and policy focus on how to achieve equivalent or improved care for older people with less hospital occupancy.

Making greater use of dedicated hospital observation units for many short-stay patients could save $3.1 billion a year

Using observation units in hospitals to provide care to certain patients can be more efficient than admitting them to the hospital and can result in shorter lengths-of-stay and lower costs. However, such units are present in only about one-third of US hospitals. We estimated national cost savings that would result from increasing the prevalence and use of observation units for patients whose stay there would be shorter than twenty-four hours. Using a systematic literature review, national survey data, and a simulation model, we estimated that if hospitals without observation units had them in place, the average cost savings per patient would be $1,572, annual hospital savings would be $4.6 million, and national cost savings would be $3.1 billion. Future policies intended to increase the cost-efficiency of hospital care should include support for observation unit care as an alternative to short-stay inpatient admission.

The chest pain choice decision aid: a randomized trial

BACKGROUND

Cardiac stress testing in patients at low risk for acute coronary syndrome is associated with increased false-positive test results, unnecessary downstream procedures, and increased cost. We judged it unlikely that patient preferences were driving the decision to obtain stress testing.

METHODS AND RESULTS

The Chest Pain Choice trial was a prospective randomized evaluation involving 204 patients who were randomized to a decision aid or usual care and were followed for 30 days. The decision aid included a 100-person pictograph depicting the pretest probability of acute coronary syndrome and available management options (observation unit admission and stress testing or 24-72 hours outpatient follow-up). The primary outcome was patient knowledge measured by an immediate postvisit survey. Additional outcomes included patient engagement in decision making and the proportion of patients who decided to undergo observation unit admission and cardiac stress testing. Compared with usual care patients (n=103), decision aid patients (n=101) had significantly greater knowledge (3.6 versus 3.0 questions correct; mean difference, 0.67; 95% CI, 0.34-1.0), were more engaged in decision making as indicated by higher OPTION (observing patient involvement) scores (26.6 versus 7.0; mean difference, 19.6; 95% CI, 1.6-21.6), and decided less frequently to be admitted to the observation unit for stress testing (58% versus 77%; absolute difference, 19%; 95% CI, 6%-31%). There were no major adverse cardiac events after discharge in either group.

CONCLUSIONS

Use of a decision aid in patients with chest pain increased knowledge and engagement in decision making and decreased the rate of observation unit admission for stress testing.

Research priorities for palliative and end-of-life care in the emergency setting

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.

Conference proceedings-improving the quality and efficiency of emergency care across the continuum: a systems approach

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.

Enhancing systems to improve the management of acute, unscheduled care

For acutely ill patients, health care services are available in many different settings, including hospital-based emergency departments (EDs), retail clinics, federally qualified health centers, and outpatient clinics. Certain conditions are the sole domain of particular settings: stabilization of critically ill patients can typically only be provided in EDs. By contrast, many conditions that do not require hospital resources, such as advanced radiography, admission, and same-day consultation can often be managed in clinic settings. Because clinics are generally not open nights, and often not on weekends or holidays, the ED remains the only option for face-to-face medical care during these times. For patients who can be managed in either setting, there are many open research questions about which is the best setting, because these venues differ in terms of access, costs of care, and potentially, quality. Consideration of these patients must be risk-adjusted, as patients may self-select a venue for care based upon perceived acuity. We present a research agenda for acute, unscheduled care in the United States developed in conjunction with an Agency for Healthcare Research and Quality-funded conference hosted by the American College of Emergency Physicians in October 2009, titled "Improving the Quality and Efficiency of Emergency Care Across the Continuum: A Systems Approach." Given the possible increase in ED utilization over the next several years as more people become insured, understanding differences in cost, quality, and access for conditions that may be treated in EDs or clinic settings will be vital in guiding national health policy.