California emergency department visit rates for medical conditions increased while visit rates for injuries fell, 2005-11

Trends In Treat-And-Release Emergency Care Visits With High-Intensity Billing In The US, 2006-19

Clinicians' billing practices for professional services in the emergency department (ED) have come under scrutiny as the proportion of expensive high-intensity visits has grown in recent decades. Clinicians respond to payers' criticism by citing the worsening health status of undifferentiated patients alongside increasing expectations of ED care, with few data available to disentangle these phenomena from coding practices. We performed an observational study of US treat-and-release ED visits using data from the Nationwide Emergency Department Sample. In 2006, 4.8 percent of treat-and-release ED visits exhibited high-intensity billing, and this figure rose to 19.2 percent by 2019. The proportion of visits for older patients, those with more comorbidities, and those with nonspecific but potentially serious diagnoses grew. Of the observed growth in high-intensity billing, 47 percent was expected, based on changes in administrative measures for patient case-mix and care services. Any emergency care reimbursement reform must account for growing patient complexity and an evolving role for EDs in the health care system.

Examination of the clinical factors associated with attendance at emergency departments for chronic pain management and the cost of treatment relative to that of other significant medical conditions

ABSTRACT

Little is known about risk factors for emergency department (ED) attendance for chronic pain (CP) management and the relative service burden. We examined ED utilisation in patients with CP, identified risk factors associated with attendance for chronic musculoskeletal pain (CMP), and estimated the comparative cost of treatment. The study cohort comprised a random sample of 3700 adults from the general population in Tayside, Scotland. Linked regional extracts, spanning a 12-month period, were obtained from national registers, providing information on ED attendances, community-dispensed prescribing, and outpatient clinic attendances. The National Health Service Scotland Cost Book was used to ascertain the current average cost of an ED attendance (£130; ∼$167). All-cause ED attendance was higher in those with CP (68.5%; n = 252) than without (29.3%; n = 967). In the entire cohort, more patients attended the ED for the treatment of CMP than for any other medical condition (n = 119; 32.3% of those with CP). Risk factors for ED attendance for CMP were: recent analgesic dose decreases (OR = 4.55); and transitioning from opioid to nonopioid analgesics (OR = 5.08). Characteristics protective of ED attendance for CMP were: being in receipt of strong opioids (OR = 0.21); transitioning from nonopioid to opioid analgesics (OR = 0.25); recent analgesic dose increases (OR = 0.24); and being prescribed tricyclic antidepressants (OR = 0.10), benzodiazepines (OR = 0.46), or hypnotics (OR = 0.45). Chronic musculoskeletal pain was one of the most expensive conditions to treat (£17,680 [∼$22,668] per annum), conferring a substantial burden on ED services. Improved understanding of the risk/protective factors could inform healthcare redesign to reduce avoidable ED attendances for CMP management.

Clinical study on repair of metacarpal bone defects using titanium alloy implantation and autologous bone grafting

Due to various limitations in the use of autologous bone and allogeneic bone in the repair of bone defects, the use of synthetic bone graft substitute has become a hot topic in orthopedic surgery and repair medicine. A total of 53 patients treated for trauma-induced metacarpal bone defects were recruited. These patients were divided into the TiAl₆V₄ titanium alloy implantation group (group A) and the autologous bone graft group (group B). The symptoms of patients in the two groups were closely observed and followed up. The operation time, time to bone fusion, post-surgical pain [visual analog scale (VAS) scores], hand function recovery [total active flexion scale (TAFS) scores] and complications were compared between the two groups. Following surgery, none of the patients had necrosis of fingers or bone non-union. The recovery was rated as excellent and good in up to 91.6% of patients, indicating high clinical efficacy. Compared with the use of autologous bone grafting as the gold standard (group B), there was no significant difference in the excellent and good recovery rate based on TAFS scores at 16 weeks after surgery (91.7 vs. 89.7%, P>0.05), and there was also no significant difference in the incidence of post-operative complications (33.3 vs. 41.3%, P>0.05). The operation time (82.08±6.64 min), time to bone fusion (7.75±1.73 weeks) and VAS scores at 3 days after surgery were all significantly lower in group A than in group B (P<0.05). The values of group B were 104.69±8.63 min, 9.17±2.78 weeks and [5(5, 6)], respectively. However, the hospitalization cost (22,657.8±1,595.4Ұ) was significantly higher than that in group B (14,808.2±2,291.3Ұ; P<0.05). In conclusion, the use of titanium alloy implantation may avoid new injury to the donor site, reduce the operation time and post-operative pain and accelerate bone fusion. Therefore, this method is worthy of popularization for defective bone reconstruction and recovery in the clinic.

Severity of Injury and Associated Factors among Injured Patients Who Visited the Emergency Department at Wolaita Sodo Teaching and Referral Hospital, Ethiopia

Background

An injury is a physical damage that occurs when the body is exposed to an excessive amount of energy. Physical agents, radiation, chemical agents, biological agents and physiological needs deprivation can cause injury. The study was aimed at assessing the severity of injury and identifying the factors associated with it among injured patients.

Methods

A cross-sectional study was conducted among patients who visited the emergency department of Wolaita Sodo Teaching and Referral Hospital from January 1, 2012 – January 1, 2017. A total of 320 patient records were included in the study and selected using simple random sampling. Statistical association was done for categorical variables using Chi-square. Rank correlation was done for three ordered options independent variables, Chi-squared test for trend used for two options independent variables, and General Chi-square test of independence used for independent variables with not ordered three and above options. Multivariate multinomial logistic regression was conducted. A P-value <0.05 was taken as a significant association.

Results

The study indicated that the majority (45.3%), 128(40%) and 47(14.7%) had minor, moderate and severe injury, respectively. Residence (AOR 0.462; 95%CI 0.268, 0.798), cause of injury (AOR 3.602; 95%CI 1.336, 9.714), night time injury (AOR 4.895; 95%CI 1.472, 16.277), afternoon time injury (AOR 8.776; 95%CI 2.699, 28.537), and chest injury (AOR 2.391; 95%CI 1.048, 5.454) were significant predictors of moderate injury. Afternoon time of injury (AOR; 4.683; 95%CI 1.137, 19.296) and head, neck and spinal cord injury (AOR; 4.933; 95%CI 1.945, 12.509) were predictors of severe injury.

Trends in Mortality for Medicare Beneficiaries Treated in the Emergency Department From 2009 to 2016

IMPORTANCE

Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date.

OBJECTIVE

To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15 416 385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older.

EXPOSURES

Time (year) as a continuous variable.

MAIN OUTCOMES AND MEASURES

The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined.

RESULTS

The sample included 15 416 385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P < .001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P < .001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P < .001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P < .001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P < .001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P < .001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P < .001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals).

CONCLUSIONS AND RELEVANCE

Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.

Implementation and Development of Emergency Department Pharmacist-Driven Patient-Care Transitional Model: A Discussion of Our Experiences and Processes

Frequent preventable emergency department (ED) visits is an area of great concern among healthcare administrators. Although pharmacist interventions have been shown to reduce re-hospitalizations, studies demonstrating reduction in ED utilizations among the elderly are limited. Additionally, factors influencing readmissions in the ED are multifactorial. Hence, some healthcare systems struggle to reduce readmissions using pharmacy services. This has been a major issue facing care provided to the elderly in the ED. As healthcare care systems develops and implement a collaborative pharmacist and physician/mid-level provider comprehensive transitional model of care in the ED, the quality of care provided to the elderly will be enhanced which will ultimately translate to reduced inappropriate ED visit and re-hospitalization with corresponding reduction in financial burden placed on both the patient, caregiver and the society. Therefore, the objective of this article is to discuss our process with implementing pharmacist-providers transitional model in the ED. The intent is to elucidate some pharmacist-intervention principles and a pharmacist-driven, patient-care transitional model that would provide direction for other healthcare systems to improve ED visits within their locality.

Trends in the utilisation of emergency departments in California, 2005-2015: a retrospective analysis

OBJECTIVE

To examine current trends in the characteristics of patients visiting California emergency departments (EDs) in order to better direct the allocation of acute care resources.

DESIGN

A retrospective study.

SETTING

We analysed ED utilisation trends between 2005 and 2015 in California using non-public patient data from California's Office of Statewide Health Planning and Development.

PARTICIPANTS

We included all ED visits in California from 2005 to 2015.

PRIMARY AND SECONDARY OUTCOME MEASURES

We analysed ED visits and visit rates by age, sex, race/ethnicity, payer and urban/rural trends. We further examined age, sex, race/ethnicity and urban/rural trends within each payer group for a more granular picture of the patient population. Additionally, we looked at the proportion of patients admitted from the ED and distribution of diagnoses.

RESULTS

Between 2005 and 2015, the annual number of ED visits increased from 10.2 to 14.2 million in California. ED visit rates increased by 27.8% (p<0.001), with the greatest increases among patients aged 5-19 (37.4%, p<0.001) and 45-64 years (41.1%, p<0.001), non-Hispanic Black and Hispanic patients (56.8% and 48.8%, p<0.001), the uninsured and Medicaid-insured (36.1%, p=0.002; 28.6%, p<0.001) and urban residents (28.3%, p<0.001). The proportion of ED visits resulting in hospitalisation decreased by 18.3%, with decreases across all payer groups.

CONCLUSIONS

Our findings reveal an increasing demand for emergency care and may reflect current limitations in accessing care in other parts of the healthcare system. Policymakers may need to recognise the increasingly vital role that EDs are playing in the provision of care and consider ways to incorporate this changing reality into the delivery of health services.

Strategies to Identify and Reduce Opioid Misuse Among Patients with Gastrointestinal Disorders: A Systematic Scoping Review

BACKGROUND

Scoping reviews are preliminary assessments intended to characterize the extent and nature of emerging research evidence, identify literature gaps, and offer directions for future research. We conducted a systematic scoping review to describe published scientific literature on strategies to identify and reduce opioid misuse among patients with gastrointestinal (GI) symptoms and disorders.

METHODS

We performed structured keyword searches to identify manuscripts published through June 2016 in the PubMed MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases to extract original research articles that described healthcare practices, tools, or interventions to identify and reduce opioid misuse among GI patients. The Chronic Care Model (CCM) was used to classify the strategies presented.

RESULTS

Twelve articles met the inclusion criteria. A majority of studies used quasi-experimental or retrospective cohort study designs. Most studies addressed the CCM's clinical information systems element. Seven studies involved identification of opioid misuse through prescription drug monitoring and opioid misuse screening tools. Four studies discussed reductions in opioid use by harnessing drug monitoring data and individual care plans, and implementing self-management and opioid detoxification interventions. One study described drug monitoring and an audit-and-feedback intervention to both identify and reduce opioid misuse. Greatest reductions in opioid misuse were observed when drug monitoring, self-management, or audit-and-feedback interventions were used.

CONCLUSION

Prescription drug monitoring and self-management interventions may be promising strategies to identify and reduce opioid misuse in GI care. Rigorous, empirical research is needed to evaluate the longer-term impact of these strategies.

Trends in diagnostic patterns and mortality in emergency ambulance service patients in 2007-2014: a population-based cohort study from the North Denmark Region

OBJECTIVE

Demand for ambulances is growing. Nevertheless, knowledge is limited regarding diagnoses and outcomes in patients receiving emergency ambulances. This study aims to examine time trends in diagnoses and mortality among patients transported with emergency ambulance to hospital.

DESIGN

Population-based cohort study with linkage of Danish national registries.

SETTING

The North Denmark Region in 2007-2014.

PARTICIPANTS

Cohort of 148 757 patients transported to hospital by ambulance after calling emergency services.

MAIN OUTCOME MEASURES

The number of emergency ambulance service patients, distribution of their age, sex, hospital diagnoses, comorbidity, and 1-day and 30-day mortality were assessed by calendar year. Poisson regression with robust variance estimation was used to estimate both age-and sex-adjusted relative risk of death and prevalence ratios for Charlson Comorbidity Index (CCI) to allow comparison by year, with 2007 as reference year.

RESULTS

The annual number of emergency ambulance service patients increased from 24.3 in 2007 to 40.2 in 2014 per 1000 inhabitants. The proportions of women increased from 43.1% to 46.4% and of patients aged 60+ years from 39.9% to 48.6%, respectively. The proportion of injuries gradually declined, non-specific diagnoses increased, especially the last year. Proportion of patients with high comorbidity (CCI≥3) increased from 6.4% in 2007 to 9.4% in 2014, corresponding to an age- and sex-adjusted prevalence ratio of 1.27 (95% CI 1.16 to 1.39). The 1-day and 30 day mortality decreased from 2.40% to 1.21% and from 5.01% to 4.36%, respectively, from 2007 to 2014, corresponding to age-adjusted and sex-adjusted relative risk of 0.43 (95% CI 0.37 to 0.50) and 0.72 (95% CI 0.66 to 0.79), respectively.

CONCLUSION

During the 8-year period, the incidence of emergency ambulance service patients, the proportion of women, elderly, and non-specific diagnoses increased. The level of comorbidity increased substantially, whereas the 1-day and 30-day mortality decreased.

Emergency Department Use across 88 Small Areas after Affordable Care Act Implementation in Illinois

Introduction

This study analyzes changes in hospital emergency department (ED) visit rates before and after the 2014 Affordable Care Act (ACA) insurance expansions in Illinois. We compare the association between population insurance status change and ED visit rate change between a 24-month (2012–2013) pre-ACA period and a 24-month post-ACA (2014–2015) period across 88 socioeconomically diverse areas of Illinois.

Methods

We used annual American Community Survey estimates for 2012–2015 to obtain insurance status changes for uninsured, private, Medicaid, and Medicare (disability) populations of 88 Illinois Public Use Micro Areas (PUMAs), areas with a mean of about 90,000 age 18–64 residents. Over 12 million ED visits to 201 non-federal Illinois hospitals were used to calculate visit rates by residents of each PUMA, using population-based mapping weights to allocate visits from zip codes to PUMAs. We then estimated n=88 correlations between population insurance-status changes and changes in ED visit rates per 1,000 residents comparing the two years before and after ACA implementation.

Results

The baseline PUMA uninsurance rate ranged from 6.7% to 41.1% and there was 4.6-fold variation in baseline PUMA ED visit rates. The top quartile of PUMAs had >21,000 reductions in uninsured residents; 16 PUMAs had at least a 15,000 person increase in Medicaid enrollment. Compared to 2012–2013, 2014–2015 average monthly ED visits by the uninsured dropped 42%, but increased 42% for Medicaid and 10% for the privately insured. Areas with the largest increases in Medicaid enrollment experienced the largest growth in ED use; change in Medicaid enrollment was the only significant correlate of area change in total ED visits and explained a third of variation across the 88 PUMAs.

Conclusion

ACA implementation in Illinois accelerated existing trends towards greater use of hospital ED care. It remains to be seen whether providing better access to primary and preventive care to the formerly uninsured will reduce ED use over time, or whether ACA insurance expansion is a part of continued, long-term growth. Monitoring ED use at the local level is critical to the success of new home- and community-based care coordination initiatives.

When high pressure, system constraints, and a social justice mission collide: A socio-structural analysis of emergency department social work services

The emergency department (ED) can be a critical intervention point for many patients with multifaceted needs. Social workers have long been part of interdisciplinary ED teams. This study aimed to contribute to the limited understanding of social worker-patient interactions and factors influencing social work services in this setting. This paper reports a qualitative content analysis of social work medical record notes (N = 1509) of services provided to trauma patients in an urban, public, level 1 trauma center and an in-depth analysis of semi-structured interviews with ED social workers (N = 10). Eight major social work roles were identified: investigator, gatekeeper, resource broker, care coordinator, problem solver, crisis manager, advocate, discharge planner. Analyses revealed a complex interplay between ED social work services and multi-layered contexts. Using a social-ecological framework, we identified the interactions between micro or individual level factors, mezzo or local system level factors and macro environmental and systemic factors that play a role in ED interactions and patient services. Macro-level contextual influences were socio-structural forces including socioeconomic barriers to health, social hierarchies that reflected power differentials between providers and patients, and distrust or bias. Mezzo-level forces were limited resources, lack of healthcare system coordination, a challenging hierarchy within the medical model and the pressure to discharge patients quickly. Micro-level factors included characteristics of patients and social workers, complexity of patient stressors, empathic strain, lack of closure and compassion. All of these forces were at play in patient-social worker interactions and impacted service provision. Social workers were at times able to successfully navigate these forces, yet at other times these challenges were insurmountable. A conceptual model of ED social work and the influences on the patient-social worker interactions was developed to assist in guiding innovative research and practice models to improve services and outcomes in the complex, fast-paced ED.

Relationship of Affordable Care Act Implementation to Emergency Department Utilization Among Young Adults

STUDY OBJECTIVE

The 2010 provision of the Patient Protection and Affordable Care Act (ACA) extended eligibility for health insurance for young adults aged 19 to 25 years. It is unclear, however, how expanded coverage changes health care behavior and promotes efficient use of emergency department (ED) services. Our objective was to use population-level emergency department data to characterize any changes in diagnoses seen in ED among young adults since the implementation of the ACA dependent coverage expansion.

METHODS

We performed a difference-in-differences analysis of 2009 to 2011 ED visits from California, Florida, and New York, using all-capture administrative data to determine how the use of ED services changed for clinical categories after the ACA provision among young adults aged 19 to 25 years compared with slightly older adults unaffected by the provision, aged 26 to 31 years.

RESULTS

We analyzed a total of 10,158,254 ED visits made by 4,734,409 patients. After the implementation of the 2010 ACA provision, young adults had a relative decrease of 0.5% ED visits per 1,000 people compared with the older group. For the majority of diagnostic categories, young adults' rates and risk of visit did not change relative to that of slightly older adults after the implementation of the ACA. However, although young adults' ED visits significantly increased for mental illnesses (2.6%) and diseases of the circulatory system (eg, nonspecific chest pain) (4.8%), visits decreased for pregnancy-related diagnoses and diseases of the skin (eg, cellulitis, abscess) compared with that of the older group (3.7% and 3.1%, respectively).

CONCLUSION

Our results indicate that increased coverage has kept young adults out of the ED for specific conditions that can be cared for through access to other channels. As EDs face capacity challenges, these results are encouraging and offer insight into what could be expected under further insurance expansions from health care reform.