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Harrison J, McDermott G, Dixon EL, Mehta M, Haider A, Rareshide C, Southwick L, Agarwal AK, Merchant RM, Kilaru AS. Eligibility of emergency department patients for public benefit programs. Acad Emerg Med 2024. [PMID: 38528799 DOI: 10.1111/acem.14870] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 12/29/2023] [Accepted: 01/05/2024] [Indexed: 03/27/2024]
Affiliation(s)
- Joseph Harrison
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Department of Clinical Psychology, Philadelphia College of Osteopathic Medicine, School of Professional and Applied Psychology, Philadelphia, Pennsylvania, USA
| | - Grace McDermott
- Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
| | - Erica L Dixon
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Michael Mehta
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Aliza Haider
- Center for Healthcare Transformation and Innovation, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Charles Rareshide
- Center for Health Incentives and Behavioral Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Lauren Southwick
- Center for Healthcare Transformation and Innovation, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Anish K Agarwal
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Healthcare Transformation and Innovation, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Raina M Merchant
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Healthcare Transformation and Innovation, Penn Medicine, Philadelphia, Pennsylvania, USA
| | - Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
- Center for Healthcare Transformation and Innovation, Penn Medicine, Philadelphia, Pennsylvania, USA
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Kilaru AS, Scheulen JJ, Harbertson CA, Gonzales R, Mondal A, Agarwal AK. Boarding in US Academic Emergency Departments During the COVID-19 Pandemic. Ann Emerg Med 2023; 82:247-254. [PMID: 36681622 PMCID: PMC9851166 DOI: 10.1016/j.annemergmed.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Revised: 11/15/2022] [Accepted: 12/01/2022] [Indexed: 01/20/2023]
Abstract
STUDY OBJECTIVE The first 2 years of the COVID-19 pandemic brought substantial and dynamic changes to emergency department volumes and throughput. The objective of this study was to describe changes in ED boarding among US academic EDs across the duration of the COVID-19 pandemic. METHODS We conducted a retrospective analysis of monthly data collected from a convenience sample of academic departments of emergency medicine. The study period was from January 2019 to December 2021. The primary outcome was total boarding hours, and secondary outcomes included patient volume stratified by ED disposition. We used multivariable linear panel regression models with fixed effects for individual EDs to estimate adjusted means for 3-month quarters. RESULTS Of the 73 academic departments of emergency medicine contacted, 34 (46.6%) participated, comprising 43 individual EDs in 25 states. The adjusted mean total boarding hours per month significantly decreased during the second quarter of 2020 (4,449 hours; 95% confidence interval [CI] 3,189 to 5,710) compared to the first quarter of 2019 (8,521 hours; 95% CI 7,845 to 9,197). Beginning in the second quarter of 2021, total boarding hours significantly increased beyond pre-pandemic levels, peaking during the fourth quarter of 2021 (12,127 hours; 95% CI 10,925 to 13,328). CONCLUSIONS A sustained and considerable increase in boarding observed in selected US academic EDs during later phases of the COVID-19 pandemic may reflect ongoing stresses to the health care system, with potential consequences for patient outcomes as well as clinician well-being.
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Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania.
| | - James J Scheulen
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Cathi A Harbertson
- Department of Emergency Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Rachel Gonzales
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Angira Mondal
- Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania
| | - Anish K Agarwal
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, Wharton School, University of Pennsylvania
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Kilaru AS, Friedman AB, Delgado MK. Considering the Whole Person in Hospital Admission Decisions for Older Adults in the Emergency Department. JAMA Intern Med 2023; 183:793-794. [PMID: 37307011 DOI: 10.1001/jamainternmed.2023.2155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ari B Friedman
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Mucio Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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Thakrar AP, Faude S, Perrone J, Milone MC, Lowenstein M, Snider CK, Spadaro A, Delgado MK, Nelson LS, Kilaru AS. Association of Urine Fentanyl Concentration With Severity of Opioid Withdrawal Among Patients Presenting to the Emergency Department. J Addict Med 2023; 17:447-453. [PMID: 37579106 PMCID: PMC10440418 DOI: 10.1097/adm.0000000000001155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/08/2023]
Abstract
BACKGROUND AND AIMS Fentanyl is involved in most US drug overdose deaths and its use can complicate opioid withdrawal management. Clinical applications of quantitative urine fentanyl testing have not been demonstrated previously. The aim of this study was to determine whether urine fentanyl concentration is associated with severity of opioid withdrawal. DESIGN This is a retrospective cross-sectional study. SETTING This study was conducted in 3 emergency departments in an urban, academic health system from January 1, 2020, to December 31, 2021. PARTICIPANTS This study included patients with opioid use disorder, detectable urine fentanyl or norfentanyl, and Clinical Opiate Withdrawal Scale (COWS) recorded within 6 hours of urine drug testing. MEASUREMENTS The primary exposure was urine fentanyl concentration stratified as high (>400 ng/mL), medium (40-399 ng/mL), or low (<40 ng/mL). The primary outcome was opioid withdrawal severity measured with COWS within 6 hours before or after urine specimen collection. We used a generalized linear model with γ distribution and log-link function to estimate the adjusted association between COWS and the exposures. FINDINGS For the 1127 patients in our sample, the mean age (SD) was 40.0 (10.7), 384 (34.1%) identified as female, 332 (29.5%) reported their race/ethnicity as non-Hispanic Black, and 658 (58.4%) reported their race/ethnicity as non-Hispanic White. For patients with high urine fentanyl concentrations, the adjusted mean COWS (95% confidence interval) was 4.4 (3.9-4.8) compared with 5.5 (5.1-6.0) among those with medium and 7.7 (6.8-8.7) among those with low fentanyl concentrations. CONCLUSIONS Lower urine fentanyl concentration was associated with more severe opioid withdrawal, suggesting potential clinical applications for quantitative urine measurements in evolving approaches to fentanyl withdrawal management.
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Affiliation(s)
- Ashish P. Thakrar
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- National Clinician Scholars Program, University of Pennsylvania
| | - Sophia Faude
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Emergency Medicine, Grossman School of Medicine, New York University Langone Health
| | - Jeanmarie Perrone
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Michael C. Milone
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Pathology and Laboratory Medicine, University of Pennsylvania
| | - Margaret Lowenstein
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Christopher K. Snider
- Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia
| | - Anthony Spadaro
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - M. Kit Delgado
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
| | - Lewis S. Nelson
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Department of Emergency Medicine, Rutgers New Jersey Medical School
| | - Austin S. Kilaru
- Center for Addiction Medicine and Policy, Perelman School of Medicine, University of Pennsylvania
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania
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Chaiyachati KH, Shea JA, Ward M, Nelson MN, Ghosh M, Reilly J, Kelly S, Chisholm DL, Barbati Z, Hemmons JE, Abdel-Rahman D, Ebert JP, Xiong RA, Snider CK, Lee KC, Friedman AB, Meisel ZF, Kilaru AS, Asch DA, Delgado MK, Morgan AU. Patient and clinician perspectives of a remote monitoring program for COVID-19 and lessons for future programs. BMC Health Serv Res 2023; 23:698. [PMID: 37370059 PMCID: PMC10304230 DOI: 10.1186/s12913-023-09684-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2022] [Accepted: 06/11/2023] [Indexed: 06/29/2023] Open
Abstract
COVID Watch is a remote patient monitoring program implemented during the pandemic to support home dwelling patients with COVID-19. The program conferred a large survival advantage. We conducted semi-structured interviews of 85 patients and clinicians using COVID Watch to understand how to design such programs even better. Patients and clinicians found COVID Watch to be comforting and beneficial, but both groups desired more clarity about the purpose and timing of enrollment and alternatives to text-messages to adapt to patients' preferences as these may have limited engagement and enrollment among marginalized patient populations. Because inclusiveness and equity are important elements of programmatic success, future programs will need flexible and multi-channel human-to-human communication pathways for complex clinical interactions or for patients who do not desire tech-first approaches.
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Affiliation(s)
- Krisda H Chaiyachati
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA.
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA.
| | - Judy A Shea
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Michaela Ward
- Mixed Methods Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Maria N Nelson
- Mixed Methods Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Medha Ghosh
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Julianne Reilly
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Sheila Kelly
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Deena L Chisholm
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Zoe Barbati
- Mixed Methods Research Laboratory, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jessica E Hemmons
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Dina Abdel-Rahman
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jeffrey P Ebert
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Ruiying A Xiong
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- The Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Christopher K Snider
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
| | - Kathleen C Lee
- Comcast NBCUniversal in Philadelphia, PA, Philadelphia, USA
| | - Ari B Friedman
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- The Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Zachary F Meisel
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Penn Injury Science Center, University of Pennsylvania, Philadelphia, PA, USA
| | - Austin S Kilaru
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David A Asch
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
- The Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - M Kit Delgado
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- The Center for Health Incentives and Behavioral Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Anna U Morgan
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, PA, USA
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Solomon KT, O'Connor J, Gibbons JB, Kilaru AS, Feder KA, Xue L, Saloner B, Stuart EA, Cole ES, Hulsey E, Meisel Z, Patel E, Donohue JM. Association Between Hospital Adoption of an Emergency Department Treatment Pathway for Opioid Use Disorder and Patient Initiation of Buprenorphine After Discharge. JAMA Health Forum 2023; 4:e230245. [PMID: 36961457 DOI: 10.1001/jamahealthforum.2023.0245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/25/2023] Open
Abstract
Importance Emergency department (ED)-based initiation of buprenorphine has been shown to increase engagement in outpatient treatment and reduce the risk of subsequent opioid overdose; however, rates of buprenorphine treatment in the ED and follow-up care for opioid use disorder (OUD) remain low in the US. The Opioid Hospital Quality Improvement Program (O-HQIP), a statewide financial incentive program designed to increase engagement in OUD treatment for Medicaid-enrolled patients who have ED encounters, has the potential to increase ED-initiated buprenorphine treatment. Objective To evaluate the association between hospitals attesting to an ED buprenorphine treatment O-HQIP pathway and patients' subsequent initiation of buprenorphine treatment. Design, Setting, and Participants This cohort study included Pennsylvania patients aged 18 to 64 years with continuous Medicaid enrollment 6 months before their OUD ED encounter and at least 30 days after discharge between January 1, 2016, and December 31, 2020. Patients with a claim for medication for OUD 6 months before their index encounter were excluded. Exposures Hospital implementation of an ED buprenorphine treatment O-HQIP pathway. Main Outcomes and Measures The main outcome was patients' receipt of buprenorphine within 30 days of their index OUD ED visit. Between August 2021 and January 2023, data were analyzed using a difference-in-differences method to evaluate the association between hospitals' O-HQIP attestation status and patients' treatment with buprenorphine after ED discharge. Results The analysis included 17 428 Medicaid-enrolled patients (female, 43.4%; male, 56.6%; mean [SD] age, 37.4 [10.8] years; Black, 17.5%; Hispanic, 7.9%; White, 71.6%; other race or ethnicity, 3.0%) with OUD seen at O-HQIP-attesting or non-O-HQIP-attesting hospital EDs. The rate of prescription fills for buprenorphine within 30 days of an OUD ED discharge in the O-HQIP attestation hospitals before the O-HQIP intervention was 5%. The O-HQIP attestation was associated with a statistically significant increase (2.6 percentage points) in prescription fills for buprenorphine within 30 days of an OUD ED discharge (β, 0.026; 95% CI, 0.005-0.047). Conclusions and Relevance In this cohort study, the O-HQIP was associated with an increased initiation of buprenorphine in patients with OUD presenting to the ED. These findings suggest that statewide incentive programs may effectively improve outcomes for patients with OUD.
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Affiliation(s)
| | - Jason O'Connor
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Jason B Gibbons
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | | | - Kenneth A Feder
- Department of Mental Health, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Lingshu Xue
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | - Brendan Saloner
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Elizabeth A Stuart
- Department of Health Policy and Management, University of Pittsburgh School of Public Health, Pittsburgh, Pennsylvania
| | - Evan S Cole
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
| | | | | | - Esita Patel
- Advanced Practice Outcomes and Analytics, The Center for Advanced Practice, Atrium Health Carolinas Medical Center, Charlotte, North Carolina
| | - Julie M Donohue
- Department of Health Policy and Management, Johns Hopkins University Bloomberg School of Public Health, Baltimore, Maryland
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Spadaro A, Faude S, Perrone J, Thakrar AP, Lowenstein M, Delgado MK, Kilaru AS. Precipitated opioid withdrawal after buprenorphine administration in patients presenting to the emergency department: A case series. J Am Coll Emerg Physicians Open 2023; 4:e12880. [PMID: 36704210 PMCID: PMC9871399 DOI: 10.1002/emp2.12880] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023] Open
Abstract
Objectives Buprenorphine is a highly effective medication for the treatment of opioid use disorder, but it can cause precipitated withdrawal (PW) from opioids. Incidence, risk factors, and best approaches to management of PW are not well understood. Our objective was to describe adverse outcomes after buprenorphine administration among emergency department (ED) patients and assess whether they met the criteria for PW. Methods This study is a case series using retrospective chart review in a convenience sample of patients from 3 hospitals in an urban academic health system. This study included patients who were reported by clinicians as potential cases of PW. Relevant clinical data were abstracted from the electronic health record using a structured retrospective chart review instrument. Results A total of 13 cases were included and classified into the following 3 categories: (1) PW after buprenorphine administration consistent with guidelines (n = 5), (2) PW after deviating from guidelines (n = 4), and (3) protracted opioid withdrawal with no increase in Clinical Opiate Withdrawal Scale score (n = 4). A total of 11 patients had urine drug testing positive for fentanyl, and 11 patients received additional doses of buprenorphine for symptom management. Of the patients, 5 had self-directed hospital discharges, and 6 were ultimately discharged with prescriptions for buprenorphine. Conclusions Cases of adverse outcomes after buprenorphine administration in the ED and hospital meet criteria for PW, although some cases may have represented protracted opioid withdrawal. Further investigation into the incidence, risk factors, management of PW as well as patient perspectives is needed to expand and sustain the use of buprenorphine in EDs and hospitals.
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Affiliation(s)
- Anthony Spadaro
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Sophia Faude
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Department of Emergency MedicineGrossman School of Medicine, New York University Langone Health, New York, New York, USA
| | - Jeanmarie Perrone
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Ashish P. Thakrar
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- National Clinician Scholars ProgramUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Margaret Lowenstein
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Division of General Internal MedicineDepartment of Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - M. Kit Delgado
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
| | - Austin S. Kilaru
- Center for Addiction Medicine and PolicyPerelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
- Center for Emergency Care Policy and ResearchDepartment of Emergency Medicine, Perelman School of Medicine, University of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Shah VV, Villaflores CW, Chuong LH, Leuchter RK, Kilaru AS, Vangala S, Sarkisian CA. Association Between In-Person vs Telehealth Follow-up and Rates of Repeated Hospital Visits Among Patients Seen in the Emergency Department. JAMA Netw Open 2022; 5:e2237783. [PMID: 36282505 PMCID: PMC9597390 DOI: 10.1001/jamanetworkopen.2022.37783] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2022] [Accepted: 08/30/2022] [Indexed: 11/14/2022] Open
Abstract
Importance For patients discharged from the emergency department (ED), timely outpatient in-person follow-up is associated with improved mortality, but the effectiveness of telehealth as follow-up modality is unknown. Objective To evaluate whether the rates of ED return visits and hospitalization differ between patients who obtain in-person vs telehealth encounters for post-ED follow-up care. Design, Setting, and Participants This retrospective cohort study included adult patients who presented to either of 2 in-system EDs of a single integrated urban academic health system from April 1, 2020, to September 30, 2021; were discharged home; and obtained a follow-up appointment with a primary care physician within 14 days of their index ED visit (15 total days). Exposures In-person vs telehealth post-ED discharge follow-up within 14 days. Main Outcomes and Measures Multivariable logistic regression was used to estimate the odds of ED return visits (primary outcome) or hospitalization (secondary outcome) within 30 days of an ED visit based on the modality of post-ED discharge follow-up. Models were adjusted for age, sex, primary language, race, ethnicity, Social Vulnerability Index, insurance type, distance to the ED, ambulatory billing codes for the index visit, and the time from ED discharge to follow-up. Results Overall, 12 848 patients with 16 987 ED encounters (mean [SD] age, 53 [20] years; 9714 [57%] women; 2009 [12%] Black or African American; 3806 [22%] Hispanic or Latinx; and 9858 [58%] White) were included; 11 818 (70%) obtained in-person follow-up, and 5169 (30%) obtained telehealth follow-up. Overall, 2802 initial ED encounters (17%) led to returns to the ED, and 676 (4%) led to subsequent hospitalization. In adjusted analyses, telehealth vs in-person follow-up visits were associated with increased rates of ED returns (28.3 [95% CI, 11.3-45.3] more ED returns per 1000 encounters) and hospitalizations (10.6 [95% CI, 2.9-18.3] more hospitalizations per 1000 encounters). Conclusions and Relevance In this cohort study of patients in an urban integrated health care system, those with telehealth follow-up visits after an ED encounter were more likely to return to the ED and be hospitalized than patients with in-person follow-up. The use of telehealth warrants further evaluation to examine its effectiveness as a modality for continuing care after an initial ED presentation for acute illness.
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Affiliation(s)
- Vivek V. Shah
- Department of Emergency Medicine, Harbor-UCLA Medical Center, Torrance, California
| | - Chad W. Villaflores
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Linh H. Chuong
- Fielding School of Public Health, Department of Health Policy and Management, University of California, Los Angeles
| | - Richard K. Leuchter
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Austin S. Kilaru
- Perelman School of Medicine, Center for Emergency Care Policy and Research, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute for Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Sitaram Vangala
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
| | - Catherine A. Sarkisian
- Division of General Internal Medicine and Health Services Research, Department of Medicine, David Geffen School of Medicine at UCLA, Los Angeles, California
- VA Greater Los Angeles Healthcare System, Los Angeles, California
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Kilaru AS, Illenberger N, Meisel ZF, Groeneveld PW, Liu M, Mondal A, Mitra N, Merchant RM. Incidence of Timely Outpatient Follow-Up Care After Emergency Department Encounters for Acute Heart Failure. Circ Cardiovasc Qual Outcomes 2022; 15:e009001. [PMID: 36073354 PMCID: PMC9489651 DOI: 10.1161/circoutcomes.122.009001] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Patients who are discharged from the emergency department (ED) after an encounter for acute heart failure are at high risk for return hospitalization. These patients may benefit from timely outpatient follow-up care to reassess volume status, adjust medications, and reinforce self-care strategies. This study examines the incidence of outpatient follow-up care after ED encounters for acute heart failure and describes patient characteristics associated with obtaining timely follow-up care. METHODS We conducted a retrospective cohort study using an administrative claims database for a large US commercial insurer, from January 1, 2012 to June 30, 2019. Participants included adult patients discharged from the ED with principal diagnosis of acute heart failure. The primary outcome was obtaining an in-person outpatient clinic visit for heart failure within 30 days. We also examined the competing risk of all-cause hospitalization within 30 days and without an intervening outpatient clinic visit. We estimated competing risk regression models to identify patient characteristics associated with obtaining outpatient follow-up and report cause-specific hazard ratios. RESULTS The cohort included 52 732 patients, with mean age of 73.9 years (95% CI, 73.8-74.0) and 27 395 (52.0% [95% CI, 51.5-52.4]) female patients. Within 30 days of the ED encounter, 12 279 (23.2%) patients attended an outpatient clinic visit for heart failure, with 8382 (15.9%) patients hospitalized before they could obtain an outpatient clinic visit. In the adjusted analysis, patients that were younger, women, reporting non-Hispanic Black race, and had fewer previous clinic visits were less likely to obtain outpatient follow-up care. CONCLUSIONS Few patients obtain timely outpatient follow-up after ED visits for heart failure, although nearly 20% require hospitalization within 30 days. Improved transitions following discharge from the ED may represent an opportunity to improve outcomes for patients with acute heart failure.
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Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Nicholas Illenberger
- Department of Population Health, NYU Grossman School of Medicine (N.I.), New York, New York
| | - Zachary F Meisel
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Peter W Groeneveld
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Manqing Liu
- Department of Epidemiology, T.H. Chan School of Public Health, Harvard University Boston, Massachusetts (M.L.)
| | - Angira Mondal
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics (N.M.), Wharton School, University of Pennsylvania Philadelphia
| | - Raina M Merchant
- Center for Emergency Care Policy and Research, Department of Emergency Medicine (A.S.K., R.M.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
- Penn Cardiovascular Outcomes, Quality, and Evaluative Research Center (A.S.K., R.M.M., P.W.G.), Wharton School, University of Pennsylvania Philadelphia
- Perelman School of Medicine, and Leonard Davis Institute of Health Economics (A.S.K., R.M.M., P.W.G., A.M., Z.F.M.), Wharton School, University of Pennsylvania Philadelphia
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Kilaru AS, Porges SB, Grossman L, Delgado MK, Morgan AU, Chaiyachati KH, Asch DA, Greysen SR, Lockwood AC, Hemmert KC, McGinley S, Mannion N, Huffenberger AM, Bressman E, O'Connor N, Khan N, Balachandran M, Snider CK, Xiong A, Mitra N, Lee KC. An accelerated hospital observation pathway to reduce length of stay for patients with COVID-19. Am J Manag Care 2022; 28:262-268. [PMID: 35738222 DOI: 10.37765/ajmc.2022.88789] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
OBJECTIVES Strategies to maintain hospital capacity during the COVID-19 pandemic included reducing hospital length of stay (LOS) for infected patients. We sought to evaluate the association between LOS and enrollment in the COVID Accelerated Care Pathway, which consisted of a hospital observation protocol and postdischarge automated text message-based monitoring. STUDY DESIGN Retrospective matched cohort study of patients hospitalized from December 14, 2020, to January 31, 2021. METHODS Participants were patients who presented to the emergency department with acute infection due to COVID-19, required hospitalization, and met pathway inclusion criteria. Participants were compared with a propensity score-matched cohort of patients with COVID-19 admitted to the same hospital during the 7 weeks preceding and following pathway implementation. RESULTS There were 44 patients in the intervention group and 83 patients in the propensity score-matched cohort. The mean (SD) hospital LOS for patients in the intervention group was 1.7 (2.6) days compared with 3.9 (2.3) days for patients in the matched cohort (difference, -2.2 days; 95% CI, -3.3 to -1.1). In the intervention group, 2 patients (5%; 95% CI, 0%-15%) were rehospitalized within 14 days compared with 8 (10%; 95% CI, 4%-17%) in the matched cohort. CONCLUSIONS Patients with COVID-19 who were managed through an accelerated hospital observation protocol and postdischarge monitoring service had reduced hospital LOS compared with patients receiving standard care. Hospital preparedness for future public health emergencies may involve the design of pathways that reduce the time that patients spend in the hospital, lower cost, and ensure continued recovery upon discharge.
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Affiliation(s)
- Austin S Kilaru
- University of Pennsylvania, 1310 Blockley Hall, 421 Guardian Dr, Philadelphia, PA 19104.
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11
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Lee KC, Morgan AU, Chaiyachati KH, Asch DA, Xiong RA, Do D, Kilaru AS, Lam D, Parambath A, Friedman AB, Meisel ZF, Snider CK, Chisholm DL, Kelly S, Hemmons JE, Abdel-Rahman D, Ebert J, Ghosh M, Reilly J, O'Malley CJ, Hahn L, Mannion NM, Huffenberger AM, McGinley S, Balachandran M, Khan N, Shea JA, Mitra N, Delgado MK. Pulse Oximetry for Monitoring Patients with Covid-19 at Home - A Pragmatic, Randomized Trial. N Engl J Med 2022; 386:1857-1859. [PMID: 35385625 PMCID: PMC9006781 DOI: 10.1056/nejmc2201541] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kathleen C Lee
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Anna U Morgan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - David A Asch
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ruiying A Xiong
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - David Do
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Austin S Kilaru
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Doreen Lam
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Andrew Parambath
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ari B Friedman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Zachary F Meisel
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Deena L Chisholm
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sheila Kelly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jessica E Hemmons
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Dina Abdel-Rahman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jeffrey Ebert
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Medha Ghosh
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Julianne Reilly
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | - Lauren Hahn
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nancy M Mannion
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Ann M Huffenberger
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Susan McGinley
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Mohan Balachandran
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Neda Khan
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Judy A Shea
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Nandita Mitra
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M Kit Delgado
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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12
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Kilaru AS, Crider CR, Chiang J, Fassas E, Sapra KJ. Health Care Leaders' Perspectives on the Maryland All-Payer Model. JAMA Health Forum 2022; 3:e214920. [PMID: 35977273 PMCID: PMC8903109 DOI: 10.1001/jamahealthforum.2021.4920] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2021] [Accepted: 12/07/2021] [Indexed: 11/16/2023] Open
Abstract
IMPORTANCE Since 2014, all hospitals in Maryland have operated under an all-payer global budget system. Hospital global budgets have gained renewed attention as a strategy for constraining cost growth, improving patient outcomes, and preserving health care access in rural and underserved communities. Lessons from the implementation of the Maryland All-Payer Model (MDAPM) may have implications for policy makers, payers, and hospitals in other settings seeking to adopt global budgets or other value-based payment models. OBJECTIVE To examine perspectives on the implementation of the MDAPM among health care leaders who participated in its design and execution. DESIGN SETTING AND PARTICIPANTS This qualitative study with semistructured telephone interviews was conducted from November 1, 2019, to February 11, 2020. The purposive sample of Maryland health care leaders represents diverse stakeholder groups, including hospitals, state government and regulatory agencies, the federal government, and payers. MAIN OUTCOMES AND MEASURES Key high-level themes were extracted from interviews using qualitative content analysis, with barriers and facilitators to implementation specified within each theme. RESULTS A total of 20 interviews were conducted with hospital leaders (n = 6), state regulators (n = 4), federal regulators (n = 4), payer representatives (n = 3), and state leaders (n = 3). Key themes were labeled as (1) expectations (setting bold yet achievable goals), (2) autonomy (allowing hospitals to follow individual strategies within MDAPM parameters), (3) communication (encouraging early and ongoing communication between stakeholders), (4) actionable data (sharing useful hospital and patient-level data between stakeholders), (5) global budget calibration (anticipating technical challenges when negotiating budgets for individual hospitals), and (6) shared commitment to change (harnessing collective motivation for system change). Together, these themes suggest that implementing the payment model followed an evolving and collaborative process that requires stakeholder communication, data to guide decisions, and commitment to operating within the new payment system. CONCLUSIONS AND RELEVANCE The implementation of hospital global budgets in the state of Maryland offers generalizable lessons that can inform the evolution and expansion of this approach to value-based payment in other states and settings.
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Affiliation(s)
- Austin S. Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Christina R. Crider
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
| | - Joshua Chiang
- currently a medical student at Perelman School of Medicine, University of Pennsylvania, Philadelpia
| | - Elisabeth Fassas
- currently a medical student at University of Maryland School of Medicine, Baltimore
| | - Katherine J. Sapra
- Center for Medicare and Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, Maryland
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13
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Delgado MK, Morgan AU, Asch DA, Xiong R, Kilaru AS, Lee KC, Do D, Friedman AB, Meisel ZF, Snider CK, Lam D, Parambath A, Wood C, Wilson CM, Perez M, Chisholm DL, Kelly S, O'Malley CJ, Mannion N, Huffenberger AM, McGinley S, Balachandran M, Khan N, Mitra N, Chaiyachati KH. Comparative Effectiveness of an Automated Text Messaging Service for Monitoring COVID-19 at Home. Ann Intern Med 2022; 175:179-190. [PMID: 34781715 PMCID: PMC8722738 DOI: 10.7326/m21-2019] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND Although most patients with SARS-CoV-2 infection can be safely managed at home, the need for hospitalization can arise suddenly. OBJECTIVE To determine whether enrollment in an automated remote monitoring service for community-dwelling adults with COVID-19 at home ("COVID Watch") was associated with improved mortality. DESIGN Retrospective cohort analysis. SETTING Mid-Atlantic academic health system in the United States. PARTICIPANTS Outpatients who tested positive for SARS-CoV-2 between 23 March and 30 November 2020. INTERVENTION The COVID Watch service consists of twice-daily, automated text message check-ins with an option to report worsening symptoms at any time. All escalations were managed 24 hours a day, 7 days a week by dedicated telemedicine clinicians. MEASUREMENTS Thirty- and 60-day outcomes of patients enrolled in COVID Watch were compared with those of patients who were eligible to enroll but received usual care. The primary outcome was death at 30 days. Secondary outcomes included emergency department (ED) visits and hospitalizations. Treatment effects were estimated with propensity score-weighted risk adjustment models. RESULTS A total of 3488 patients enrolled in COVID Watch and 4377 usual care control participants were compared with propensity score weighted models. At 30 days, COVID Watch patients had an odds ratio for death of 0.32 (95% CI, 0.12 to 0.72), with 1.8 fewer deaths per 1000 patients (CI, 0.5 to 3.1) (P = 0.005); at 60 days, the difference was 2.5 fewer deaths per 1000 patients (CI, 0.9 to 4.0) (P = 0.002). Patients in COVID Watch had more telemedicine encounters, ED visits, and hospitalizations and presented to the ED sooner (mean, 1.9 days sooner [CI, 0.9 to 2.9 days]; all P < 0.001). LIMITATION Observational study with the potential for unobserved confounding. CONCLUSION Enrollment of outpatients with COVID-19 in an automated remote monitoring service was associated with reduced mortality, potentially explained by more frequent telemedicine encounters and more frequent and earlier presentation to the ED. PRIMARY FUNDING SOURCE Patient-Centered Outcomes Research Institute.
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Affiliation(s)
- M Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, and Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (M.K.D.)
| | - Anna U Morgan
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (A.U.M.)
| | - David A Asch
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Wharton School, and Leonard Davis Institute of Health Economics, University of Pennsylvania, and Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (D.A.A.)
| | - Ruiying Xiong
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, and Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (R.X.)
| | - Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (A.S.K., A.B.F., Z.F.M.)
| | - Kathleen C Lee
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, and Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (K.C.L.)
| | - David Do
- Department of Neurology, Perelman School of Medicine, University of Pennsylvania, and Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (D.D.)
| | - Ari B Friedman
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (A.S.K., A.B.F., Z.F.M.)
| | - Zachary F Meisel
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (A.S.K., A.B.F., Z.F.M.)
| | - Christopher K Snider
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (C.K.S., D.L., A.P., M.P., C.J.O., M.B., N.K.)
| | - Doreen Lam
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (C.K.S., D.L., A.P., M.P., C.J.O., M.B., N.K.)
| | - Andrew Parambath
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (C.K.S., D.L., A.P., M.P., C.J.O., M.B., N.K.)
| | - Christian Wood
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (C.W., C.M.W., D.L.C.)
| | - Chidinma M Wilson
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (C.W., C.M.W., D.L.C.)
| | - Michael Perez
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (C.K.S., D.L., A.P., M.P., C.J.O., M.B., N.K.)
| | - Deena L Chisholm
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (C.W., C.M.W., D.L.C.)
| | - Sheila Kelly
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania (S.K.)
| | - Christina J O'Malley
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (C.K.S., D.L., A.P., M.P., C.J.O., M.B., N.K.)
| | - Nancy Mannion
- Center for Connected Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania (N.M., A.M.H., S.M.)
| | - Ann Marie Huffenberger
- Center for Connected Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania (N.M., A.M.H., S.M.)
| | - Susan McGinley
- Center for Connected Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania (N.M., A.M.H., S.M.)
| | - Mohan Balachandran
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (C.K.S., D.L., A.P., M.P., C.J.O., M.B., N.K.)
| | - Neda Khan
- Center for Health Care Innovation, University of Pennsylvania Health System, Philadelphia, Pennsylvania (C.K.S., D.L., A.P., M.P., C.J.O., M.B., N.K.)
| | - Nandita Mitra
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, and Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania (N.M.)
| | - Krisda H Chaiyachati
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, Leonard Davis Institute of Health Economics, University of Pennsylvania, and Center for Health Care Innovation and Center for Connected Care, University of Pennsylvania Health System, Philadelphia, Pennsylvania (K.H.C.)
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14
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Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute for Health Economics, Wharton School, University of Pennsylvania, Philadelphia
| | - Margaret Lowenstein
- Leonard Davis Institute for Health Economics, Wharton School, University of Pennsylvania, Philadelphia
- Division of General Internal Medicine, Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Anish K Agarwal
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute for Health Economics, Wharton School, University of Pennsylvania, Philadelphia
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Veerabagu SA, Cheng B, Wang S, Etzkorn JR, Kilaru AS, Noe MH, Miller CJ, Sobanko JF, Shin TM, Higgins HW, McMurray SL, Krausz AE, Walker JL, Giordano CN. Rates of Opioid Prescriptions Obtained After Mohs Surgery: A Claims Database Analysis From 2009 to 2020. JAMA Dermatol 2021; 157:1299-1305. [PMID: 34550299 DOI: 10.1001/jamadermatol.2021.3468] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Importance To curtail the opioid epidemic, physicians have been advised to limit opioid prescriptions. Objective To characterize the frequency and changes over time (2009-2020) of opioid prescriptions following Mohs micrographic surgery. Design, Setting, and Participants This cross-sectional study using Optum Clinformatics DataMart (Optum CDM), a nationally representative insurance claims database, included patients aged 18 years and older who had Mohs micrographic surgery insurance claims in the Optum CDM database from 2009 to 2020. Data were analyzed from November 11, 2020, to March 30, 2021. Exposures Opioid prescription following Mohs surgery. Main Outcomes and Measures The primary outcome was the proportion of patients who underwent Mohs surgery and obtained an opioid prescription within 2 days of surgery. Secondary outcomes included type and opioid quantity prescribed. Results Among 358 012 patients with Mohs micrographic surgery claims (mean [SD] age, 69 [13] years; 205 609 [57.4%] were men), the proportion of patients obtaining an opioid prescription after Mohs micrographic surgery increased from 2009 (34.6%) to 2011 (39.6%). This proportion then declined each year, reaching a low of 11.7% in 2020 (27.9% absolute decrease from 2011 to 2020). Hydrocodone, codeine, oxycodone, and tramadol were the 4 most commonly prescribed opioids. By 2020, hydrocodone was obtained less (2009: 47.5%; 2011: 67.1%; 2020: 45.4%; 21.7% absolute decrease from 2011 to 2020) and tramadol was obtained more (2009: 1.6%; 2020: 27.9%; 26.3% absolute increase from 2009 to 2020). Conclusions and Relevance In this cross-sectional study of Mohs micrographic surgery claims, patients obtained fewer postsurgery opioid prescriptions over the study period, suggesting responsiveness of patients and dermatologic surgeons to public health concerns regarding the opioid epidemic. During this decline, prescriptions for hydrocodone decreased and tramadol increased.
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Affiliation(s)
| | - Brian Cheng
- University of South Carolina School of Medicine, Columbia
| | - Sonia Wang
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Jeremy R Etzkorn
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Austin S Kilaru
- Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia
| | - Megan H Noe
- Department of Dermatology, Brigham and Women's Hospital, Harvard School of Medicine, Boston, Massachusetts
| | - Christopher J Miller
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Joseph F Sobanko
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Thuzar M Shin
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - H William Higgins
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Stacy L McMurray
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Aimee E Krausz
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Joanna L Walker
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
| | - Cerrene N Giordano
- Department of Dermatology, Hospital of the University of Pennsylvania, Philadelphia
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Kilaru AS, Lubitz SF, Davis J, Eriksen W, Siegel S, Kelley D, Perrone J, Meisel ZF. A State Financial Incentive Policy to Improve Emergency Department Treatment for Opioid Use Disorder: A Qualitative Study. Psychiatr Serv 2021; 72:1048-1056. [PMID: 33593105 DOI: 10.1176/appi.ps.202000501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
OBJECTIVE In 2019, Pennsylvania established a voluntary financial incentive program designed to increase the engagement in addiction treatment for Medicaid patients with opioid use disorder after emergency department (ED) encounters. In this qualitative study involving hospital leaders, the authors examined decisions leading to participation in this program as well as barriers and facilitators that influenced its implementation. METHODS Twenty semistructured interviews were conducted with leaders from a diverse sample of hospitals and health systems across Pennsylvania. Interviews were planned and analyzed following the Consolidated Framework for Implementation Research. An iterative approach was used to analyze the interviews and determine key themes and patterns regarding implementation of this policy initiative in hospitals. RESULTS The authors identified six key themes that reflected barriers and facilitators to hospital participation in the program. Participation in the program was facilitated by community partners capable of arranging outpatient treatment for opioid use disorder, incentive payments focusing hospital leadership on opioid treatment pathways, multidisciplinary planning, and flexibility in adapting pathways for local needs. Barriers to program participation concerned the implementation of buprenorphine prescribing and the measurement of treatment outcomes. CONCLUSIONS A financial incentive policy encouraged hospitals to enact rapid system and practice changes to support treatment for opioid use disorder, although challenges remained in implementing evidence-based treatment-specifically, initiation of buprenorphine-for patients visiting the ED. Analysis of treatment outcomes is needed to further evaluate this policy initiative, but new delivery and payment models may improve systems to treat patients who have an opioid use disorder.
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Affiliation(s)
- Austin S Kilaru
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Su Fen Lubitz
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Jessica Davis
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Whitney Eriksen
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Sari Siegel
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - David Kelley
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Jeanmarie Perrone
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
| | - Zachary F Meisel
- National Clinician Scholars Program, University of Pennsylvania, and Corporal Michael J. Crescenz Veterans Affairs (VA) Medical Center, Philadelphia (Kilaru); Center for Emergency Care Policy and Research, Department of Emergency Medicine (Kilaru, Lubitz, Perrone, Meisel), and Mixed Methods Research Lab, Department of Family Medicine and Community Health (Davis, Eriksen), Perelman School of Medicine, University of Pennsylvania, Philadelphia; Center for Addiction Medicine and Policy, University of Pennsylvania, Philadelphia (Perrone, Meisel); Hospital and Healthsystem Association of Pennsylvania, Harrisburg (Siegel); Office of Medical Assistance Programs, Pennsylvania Department of Human Services, Harrisburg (Kelley)
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Zhang H, Kilaru AS, Meisel ZF, Bao Y. Prescription Drug Monitoring Program Mandates and Opioids Dispensed Following Emergency Department Encounters for Patients With Sickle Cell Disease or Cancer With Bone Metastasis. JAMA 2021; 326:274-276. [PMID: 34125882 PMCID: PMC8204257 DOI: 10.1001/jama.2021.10161] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
This study examines the association between prescription drug monitoring program mandates and changes in opioids dispensed to patients with sickle cell disease or cancer with bone metastasis who presented to the emergency department in 29 US states.
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Affiliation(s)
- Hao Zhang
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
| | - Austin S. Kilaru
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia
| | - Zachary F. Meisel
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia
| | - Yuhua Bao
- Department of Population Health Sciences, Weill Cornell Medicine, New York, New York
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Kilaru AS, Lee K, Grossman L, Mankoff Z, Snider CK, Bressman E, Porges SB, Hemmert KC, Greysen SR, Asch DA, Delgado MK. Short-Stay Hospitalizations for Patients with COVID-19: A Retrospective Cohort Study. J Clin Med 2021; 10:1966. [PMID: 34063729 PMCID: PMC8125769 DOI: 10.3390/jcm10091966] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2021] [Revised: 04/20/2021] [Accepted: 04/22/2021] [Indexed: 12/24/2022] Open
Abstract
OBJECTIVE Patients requiring hospital care for COVID-19 may be stable for discharge soon after admission. This study sought to describe patient characteristics associated with short-stay hospitalization for COVID-19. METHODS We performed a retrospective cohort study of patients with COVID-19 admitted to five United States hospitals from March to December 2020. We used multivariable logistic regression to identify patient characteristics associated with short hospital length-of-stay. RESULTS Of 3103 patients, 648 (20.9%) were hospitalized for less than 48 h. These patients were significantly less likely to have an age greater than 60, diabetes, chronic kidney disease; emergency department vital sign abnormalities, or abnormal initial diagnostic testing. For patients with no significant risk factors, the adjusted probability of short-stay hospitalization was 62.4% (95% CI 58.9-69.6). CONCLUSION Identification of candidates for early hospital discharge may allow hospitals to streamline throughput using protocols that optimize the efficiency of hospital care and coordinate post-discharge monitoring.
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Affiliation(s)
- Austin S. Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (K.L.); (S.B.P.); (K.C.H.); (M.K.D.)
- National Clinical Scholars Program, Corporal Michael J. Crescenz Philadelphia VA Medical Center, Philadelphia, PA 19104, USA;
| | - Kathleen Lee
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (K.L.); (S.B.P.); (K.C.H.); (M.K.D.)
| | - Lindsay Grossman
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (L.G.); (Z.M.)
| | - Zachary Mankoff
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (L.G.); (Z.M.)
| | - Christopher K. Snider
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA 19104, USA; (C.K.S.); (D.A.A.)
| | - Eric Bressman
- National Clinical Scholars Program, Corporal Michael J. Crescenz Philadelphia VA Medical Center, Philadelphia, PA 19104, USA;
| | - Stefanie B. Porges
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (K.L.); (S.B.P.); (K.C.H.); (M.K.D.)
| | - Keith C. Hemmert
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (K.L.); (S.B.P.); (K.C.H.); (M.K.D.)
| | - Scott R. Greysen
- Penn Medicine Center for Evidence-Based Practice, Section of Hospital Medicine, Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA;
| | - David A. Asch
- Penn Medicine Center for Health Care Innovation, Philadelphia, PA 19104, USA; (C.K.S.); (D.A.A.)
| | - Mucio K. Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA; (K.L.); (S.B.P.); (K.C.H.); (M.K.D.)
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Kilaru AS, Liu M, Gupta R, Perrone J, Delgado MK, Meisel ZF, Lowenstein M. Naloxone prescriptions following emergency department encounters for opioid use disorder, overdose, or withdrawal. Am J Emerg Med 2021; 47:154-157. [PMID: 33812332 DOI: 10.1016/j.ajem.2021.03.056] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2020] [Revised: 03/08/2021] [Accepted: 03/18/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVE To determine the rate at which commercially-insured patients fill prescriptions for naloxone after an opioid-related ED encounter as well as patient characteristics associated with obtaining naloxone. METHODS This is a retrospective cohort study of adult patients discharged from the ED following treatment for an opioid-related condition from 2016 to 2018 using a commercial insurance claims database (Optum Clinformatics® Data Mart). The primary outcome was a pharmacy claim for naloxone in the 30 days following the ED encounter. A multivariable logistic regression model examined the association of patient characteristics with filled naloxone prescriptions, and predictive margins were used to report adjusted probabilities with 95% confidence intervals. RESULTS 21,700 patients had opioid-related ED encounters during the study period, of which 1743 (8.0%) had encounters for heroin overdose, 8825 (40.7%) for overdose due to other opioids, 5400 (24.9%) for withdrawal, and 5732 (26.4%) for other opioid use disorder conditions. 230 patients (1.1%) filled a prescription for naloxone within 30 days. Patients with heroin overdose (2.6%; 95%CI 1.7 to 3.4), recent prescriptions for opioid analgesics (1.4%; 95%CI 1.1 to 1.7), recent prescriptions for buprenorphine (1.9%; 95%CI 1.0 to 2.9), and naloxone prescriptions in the prior year (3.3%; 95%CI 1.8 to 4.8) were more likely to obtain naloxone. The rate was significantly higher in 2018 [1.9% (95%CI 1.5 to 2.2)] as compared to 0.4% (95%CI 0.3 to 0.6) in 2016. CONCLUSIONS Few patients use insurance to obtain naloxone by prescription following opioid-related ED encounters. Clinical and policy interventions should expand distribution of this life-saving medication in the ED.
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Affiliation(s)
- Austin S Kilaru
- National Clinician Scholars Program at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States; Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States.
| | - Manqing Liu
- Leonard Davis Institute of Health Economics, University of Pennsylvania, United States
| | - Ravi Gupta
- National Clinician Scholars Program at the Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States
| | - Jeanmarie Perrone
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States
| | - M Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States
| | - Zachary F Meisel
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States; Leonard Davis Institute of Health Economics, University of Pennsylvania, United States
| | - Margaret Lowenstein
- Leonard Davis Institute of Health Economics, University of Pennsylvania, United States; Department of General Internal Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, United States
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Affiliation(s)
- Austin S. Kilaru
- Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
| | - Rebekah E. Gee
- Louisiana State University Health Care Services Division, New Orleans
- Louisiana State University School of Medicine, New Orleans
- Louisiana State University School of Public Health, New Orleans
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Kilaru AS, Lee K, Snider CK, Meisel ZF, Asch DA, Mitra N, Delgado MK. Return Hospital Admissions Among 1419 COVID-19 Patients Discharged from Five U.S. Emergency Departments. Acad Emerg Med 2020; 27:1039-1042. [PMID: 32853423 PMCID: PMC7461233 DOI: 10.1111/acem.14117] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 08/12/2020] [Accepted: 08/15/2020] [Indexed: 12/15/2022]
Affiliation(s)
- Austin S. Kilaru
- From the National Clinician Scholars Program at the University of Pennsylvania and Corporal Michael J. Crescenz VA Medical Center PhiladelphiaPAUSA
- the Department of Emergency Medicine Center for Emergency Care Policy and ResearchPerelman School of Medicine at the University of Pennsylvania PhiladelphiaPAUSA
| | - Kathleen Lee
- the Department of Emergency Medicine Center for Emergency Care Policy and ResearchPerelman School of Medicine at the University of Pennsylvania PhiladelphiaPAUSA
- the Penn Medicine Center for Health Care Innovation University of Pennsylvania PhiladelphiaPAUSA
| | - Christopher K. Snider
- the Penn Medicine Center for Health Care Innovation University of Pennsylvania PhiladelphiaPAUSA
| | - Zachary F. Meisel
- the Department of Emergency Medicine Center for Emergency Care Policy and ResearchPerelman School of Medicine at the University of Pennsylvania PhiladelphiaPAUSA
| | - David A. Asch
- From the National Clinician Scholars Program at the University of Pennsylvania and Corporal Michael J. Crescenz VA Medical Center PhiladelphiaPAUSA
- the Penn Medicine Center for Health Care Innovation University of Pennsylvania PhiladelphiaPAUSA
| | - Nandita Mitra
- and the Department of Biostatistics, Epidemiology, and Informatics Perelman School of Medicine at the University of Pennsylvania Philadelphia PAUSA
| | - M. Kit Delgado
- the Department of Emergency Medicine Center for Emergency Care Policy and ResearchPerelman School of Medicine at the University of Pennsylvania PhiladelphiaPAUSA
- and the Department of Biostatistics, Epidemiology, and Informatics Perelman School of Medicine at the University of Pennsylvania Philadelphia PAUSA
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Affiliation(s)
- Austin S Kilaru
- From the National Clinician Scholars Program (A.S.K.), the Department of Emergency Medicine (A.S.K.), and Office of the Chief Executive Officer, University of Pennsylvania Health System (K.B.M.), Perelman School of Medicine, University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (A.S.K.) - both in Philadelphia
| | - Kevin B Mahoney
- From the National Clinician Scholars Program (A.S.K.), the Department of Emergency Medicine (A.S.K.), and Office of the Chief Executive Officer, University of Pennsylvania Health System (K.B.M.), Perelman School of Medicine, University of Pennsylvania, and the Corporal Michael J. Crescenz Veterans Affairs Medical Center (A.S.K.) - both in Philadelphia
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Kilaru AS, Xiong A, Lowenstein M, Meisel ZF, Perrone J, Khatri U, Mitra N, Delgado MK. Incidence of Treatment for Opioid Use Disorder Following Nonfatal Overdose in Commercially Insured Patients. JAMA Netw Open 2020; 3:e205852. [PMID: 32459355 PMCID: PMC7254182 DOI: 10.1001/jamanetworkopen.2020.5852] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
IMPORTANCE Timely initiation and referral to treatment for patients with opioid use disorder seen in the emergency department is associated with reduced mortality. It is not known how often commercially insured adults obtain follow-up treatment after nonfatal opioid overdose. OBJECTIVE To investigate the incidence of follow-up treatment following emergency department discharge after nonfatal opioid overdose and patient characteristics associated with receipt of follow-up treatment. DESIGN, SETTING, AND PARTICIPANTS A retrospective cohort study was conducted using an administrative claims database for a large US commercial insurer, from October 1, 2011, to September 30, 2016. Data analysis was performed from May 1, 2019, to September 26, 2019. Adult patients discharged from the emergency department after an index opioid overdose (no overdose in the preceding 90 days) were included. Patients with cancer and without continuous insurance enrollment were excluded. MAIN OUTCOMES AND MEASURES The primary outcome was follow-up treatment in the 90 days following overdose, defined as a combined outcome of claims for treatment encounters or medications for opioid use disorder (buprenorphine and naltrexone). Analysis was stratified by whether patients received treatment for opioid use disorder in the 90 days before the overdose. Logistic regression models were used to identify patient characteristics associated with receipt of follow-up treatment. Marginal effects were used to report the average adjusted probability and absolute risk differences (ARDs) in follow-up for different patient characteristics. RESULTS A total of 6451 patients were identified with nonfatal opioid overdose; the mean (SD) age was 45.0 (19.3) years, 3267 were women (50.6%), and 4676 patients (72.5%) reported their race as non-Hispanic white. A total of 1069 patients (16.6%; 95% CI, 15.7%-17.5%) obtained follow-up treatment within 90 days after the overdose. In adjusted analysis of patients who did not receive treatment before the overdose, black patients were half as likely to obtain follow-up compared with non-Hispanic white patients (ARD, -5.9%; 95% CI, -8.6% to -3.6%). Women (ARD, -1.7%; 95% CI, -3.3% to -0.5%) and Hispanic patients (ARD, -3.5%; 95% CI, -6.1% to -0.9%) were also less likely to obtain follow-up. For each additional year of age, patients were 0.2% less likely to obtain follow-up (95% CI, -0.3% to -0.1%). CONCLUSIONS AND RELEVANCE Efforts to improve the low rate of timely follow-up treatment following opioid overdose may seek to address sex, race/ethnicity, and age disparities.
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Affiliation(s)
- Austin S. Kilaru
- National Clinician Scholars Program, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
| | - Aria Xiong
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Margaret Lowenstein
- National Clinician Scholars Program, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
| | - Zachary F. Meisel
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
| | - Jeanmarie Perrone
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Utsha Khatri
- National Clinician Scholars Program, Corporal Michael J. Crescenz Veterans Affairs Medical Center, University of Pennsylvania, Philadelphia
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
| | - Nandita Mitra
- Perelman School of Medicine, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
| | - M. Kit Delgado
- Center for Emergency Care Policy and Research, Perelman School of Medicine, Department of Emergency Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, Philadelphia, Pennsylvania
- Perelman School of Medicine, Department of Biostatistics and Epidemiology, University of Pennsylvania, Philadelphia
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Kilaru AS, Perrone J, Kelley D, Siegel S, Lubitz SF, Mitra N, Meisel ZF. Participation in a Hospital Incentive Program for Follow-up Treatment for Opioid Use Disorder. JAMA Netw Open 2020; 3:e1918511. [PMID: 31899526 PMCID: PMC6991234 DOI: 10.1001/jamanetworkopen.2019.18511] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Accepted: 10/29/2019] [Indexed: 11/14/2022] Open
Affiliation(s)
- Austin S. Kilaru
- National Clinician Scholars Program, University of Pennsylvania, Philadelphia
- Corporal Michael J. Crescenz VA Medical Center, Philadelphia, Pennsylvania
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - David Kelley
- Office of Medical Assistance Programs, Department of Human Services, Commonwealth of Pennsylvania, Harrisburg
| | - Sari Siegel
- The Hospital and Healthsystem Association of Pennsylvania, Harrisburg
| | - Su Fen Lubitz
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Nandita Mitra
- Department of Biostatistics and Epidemiology, Perelman School of Medicine, University of Pennsylvania, Philadelphia
| | - Zachary F. Meisel
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Penn Injury Science Center, University of Pennsylvania, Philadelphia
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25
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Carr BG, Kilaru AS, Karp DN, Delgado MK, Wiebe DJ. Quality Through Coopetition: An Empiric Approach to Measure Population Outcomes for Emergency Care-Sensitive Conditions. Ann Emerg Med 2019; 72:237-245. [PMID: 29685369 DOI: 10.1016/j.annemergmed.2018.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Revised: 01/29/2018] [Accepted: 02/28/2018] [Indexed: 10/28/2022]
Abstract
STUDY OBJECTIVE We develop a novel approach for measuring regional outcomes for emergency care-sensitive conditions. METHODS We used statewide inpatient hospital discharge data from the Pennsylvania Healthcare Cost Containment Council. This cross-sectional, retrospective, population-based analysis used International Classification of Diseases, Ninth Revision, Clinical Modification diagnosis codes to identify admissions for emergency care-sensitive conditions (ischemic stroke, ST-segment elevation myocardial infarction, out-of-hospital cardiac arrest, severe sepsis, and trauma). We analyzed the origin and destination patterns of patients, grouped hospitals with a hierarchical cluster analysis, and defined boundary shapefiles for emergency care service regions. RESULTS Optimal clustering configurations determined 10 emergency care service regions for Pennsylvania. CONCLUSION We used cluster analysis to empirically identify regional use patterns for emergency conditions requiring a communitywide system response. This method of attribution allows regional performance to be benchmarked and could be used to develop population-based outcome measures after life-threatening illness and injury.
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Affiliation(s)
- Brendan G Carr
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA.
| | - Austin S Kilaru
- Department of Emergency Medicine, Highland Hospital, Oakland, CA
| | - David N Karp
- Department of Emergency Medicine, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, PA; Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - M Kit Delgado
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Douglas J Wiebe
- Department of Biostatistics, Epidemiology, and Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Meisel ZF, Metlay JP, Sinnenberg L, Kilaru AS, Grossestreuer A, Barg FK, Shofer FS, Rhodes KV, Perrone J. A Randomized Trial Testing the Effect of Narrative Vignettes Versus Guideline Summaries on Provider Response to a Professional Organization Clinical Policy for Safe Opioid Prescribing. Ann Emerg Med 2016; 68:719-728. [PMID: 27133392 DOI: 10.1016/j.annemergmed.2016.03.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2016] [Revised: 02/20/2016] [Accepted: 02/29/2016] [Indexed: 10/21/2022]
Abstract
STUDY OBJECTIVE Clinical guidelines are known to be underused by practitioners. In response to the challenges of treating pain amid a prescription opioid epidemic, the American College of Emergency Physicians (ACEP) published an evidence-based clinical policy for opioid prescribing in 2012. Evidence-based narratives, an effective method of communicating health information in a variety of settings, offer a novel strategy for disseminating guidelines to physicians and engaging providers with clinical evidence. We compare whether narrative vignettes embedded in the ACEP daily e-newsletter improved dissemination of the clinical policy to ACEP members, and engagement of members with the clinical policy, compared with traditional summary text. METHODS A prospective randomized controlled study, titled Stories to Promote Information Using Narrative trial, was performed. Derived from qualitative interviews with 61 ACEP physicians, 4 narrative vignettes were selected and refined, using a consensus panel of clinical and implementation experts. All ACEP members were then block randomized by state of residence to receive alternative versions of a daily e-mailed newsletter for a total of 24 days during a 9-week period. Narrative newsletters contained a selection of vignettes that referenced opioid prescription dilemmas. Control newsletters contained a selection of descriptive text about the clinical policy, using length and appearance similar to that of the narrative vignettes. Embedded in the newsletters were Web links to the complete vignette or traditional summary text, as well as additional links to the full ACEP clinical policy and a Web site providing assistance with prescription drug monitoring program enrollment. The newsletters were otherwise identical. Outcomes measured were the percentage of subjects who visited any of the Web pages that contained additional guideline-related information and the odds of any unique physician visiting these Web pages during the study. RESULTS There were 27,592 physicians randomized, and 21,226 received the newsletter during the study period. When each physician was counted once during the study period, there were 509 unique visitors in the narrative group and 173 unique visitors in the control group (4.8% versus 1.6%; difference 3.2%; 95% confidence interval [CI] 2.7% to 3.7%). There were 744 gross visits from the e-newsletter to any of the 3 Web pages in the narrative group compared with 248 in the control group (7.0% versus 2.3%; odds ratio 3.2; 95% CI 2.7 to 3.6). During the study, the odds ratio of any physician in the narrative group visiting one of the 3 informational Web sites compared with the control group was 3.1 (95% CI 2.6 to 3.6). CONCLUSION Among a national sample of emergency physicians, narrative vignettes outperformed traditional guideline text in promoting engagement with an evidence-based clinical guideline related to opioid prescriptions.
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Affiliation(s)
- Zachary F Meisel
- Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA.
| | - Joshua P Metlay
- Division of General Internal Medicine, Massachusetts General Hospital, Boston, MA
| | - Lauren Sinnenberg
- Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Austin S Kilaru
- Department of Emergency Medicine, Highland Hospital, Oakland, CA
| | - Anne Grossestreuer
- Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Frances K Barg
- Department of Family Medicine and Department of Anthropology, University of Pennsylvania, Philadelphia, PA
| | - Frances S Shofer
- Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Karin V Rhodes
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA; Department of Emergency Medicine, Northshore Long Island Jewish Hospital, New Hyde Park, NY
| | - Jeanmarie Perrone
- Center for Emergency Care Policy Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA; Division of Medical Toxicology, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
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Kilaru AS, Meisel ZF, Paciotti B, Ha YP, Smith RJ, Ranard BL, Merchant RM. What do patients say about emergency departments in online reviews? A qualitative study. BMJ Qual Saf 2015. [PMID: 26208538 DOI: 10.1136/bmjqs-2015-004035] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Patients have adopted web-based tools to report on the quality of their healthcare experiences. We seek to examine online reviews for US emergency departments (EDs) posted on Yelp, a popular consumer ratings website. METHODS We conducted a qualitative analysis of unstructured, publicly accessible reviews for hospitals available on http://www.yelp.com. We collected all reviews describing experiences of ED care for a stratified random sample of 100 US hospitals. We analysed the content of the reviews using themes derived from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) inpatient care survey. We also used modified grounded theory to iteratively code the text of the reviews, identifying additional themes specific to emergency care. The data were double-coded, and discrepancies were evaluated to ensure consensus. RESULTS Of the 1736 total reviews, 573 (33%) described patient experiences involving the ED. The reviews contained several themes assessed by the HCAHPS survey, including communication with nurses, communication with doctors, and pain control. The reviews also contained key themes specific to emergency care: waiting and efficiency; decisions to seek care in the ED; and events following discharge, including administrative difficulties. CONCLUSIONS These exploratory findings suggest that online reviews for EDs contain similar themes to survey-based assessments of inpatient hospital care as well as themes specific to emergency care. Consumer rating websites allow patients to provide rapid and public feedback on their experience of medical care. Web-based platforms may offer a novel strategy for assessing patient-centred quality in emergency care.
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Affiliation(s)
- Austin S Kilaru
- Department of Emergency Medicine, Highland Hospital, Oakland, California, USA
| | - Zachary F Meisel
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Breah Paciotti
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Yoonhee P Ha
- Penn Medicine Social Media and Health Innovation Lab, University of Pennsylvania, Philadelphia, Pennsylvania, USA Center for Public Health Initiatives, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Robert J Smith
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Penn Medicine Social Media and Health Innovation Lab, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Benjamin L Ranard
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Penn Medicine Social Media and Health Innovation Lab, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Raina M Merchant
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, USA Penn Medicine Social Media and Health Innovation Lab, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Smith RJ, Kilaru AS, Perrone J, Paciotti B, Barg FK, Gadsden SM, Meisel ZF. How, why, and for whom do emergency medicine providers use prescription drug monitoring programs? Pain Med 2015; 16:1122-31. [PMID: 25688454 DOI: 10.1111/pme.12700] [Citation(s) in RCA: 49] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The prescription opioid epidemic is currently responsible for the greatest number of unintentional deaths in the United States. One potential strategy for decreasing this epidemic is implementation of state-based Prescription Drug Monitoring Programs (PDMPs), which are designed for providers to identify patients who "doctor shop" for prescriptions. Emergency medicine physicians are some of the most frequent PDMP users and opioid prescribers, but little is known about how they actually use PDMPs, for which patients, and for what reasons. METHODS We conducted and transcribed semistructured qualitative interviews with 61 physicians at a national academic conference in October 2012. Deidentified transcripts were entered into QSR NVivo 10.0, coded, and analyzed for themes using modified grounded theory. RESULTS There is variation in pattern and frequency of PDMP access by emergency physicians. Providers rely on both structural characteristics of the PDMP, such as usability, and also their own clinical gestalt impression when deciding to use PDMPs for a given patient encounter. Providers use the information in PDMPs to alter clinical decisions and guide opioid prescribing patterns. Physicians describe alternative uses for the databases, such as improving their ability to facilitate discussions on addiction and provide patient education. CONCLUSION PDMPs are used for multiple purposes, including identifying opioid misuse and enhancing provider-patient communication. Given variation in practice, standards may help direct indication and manner of physician use. Steps to minimize administrative barriers to PDMP access are warranted. Finally, alternative PDMP uses should be further studied to determine their appropriateness and potentially expand their role in clinical practice.
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Affiliation(s)
- Robert J Smith
- Department of Emergency Medicine, Center for Emergency Care Policy & Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Austin S Kilaru
- Department of Emergency Medicine, Center for Emergency Care Policy & Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Department of Emergency Medicine, Highland Hospital, Oakland, California
| | - Jeanmarie Perrone
- Department of Emergency Medicine, Center for Emergency Care Policy & Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania.,Division of Medical Toxicology, Department of Emergency Medicine, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Breah Paciotti
- Department of Emergency Medicine, Center for Emergency Care Policy & Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Frances K Barg
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sarah M Gadsden
- Mixed Methods Research Lab, Department of Family Medicine and Community Health, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Zachary F Meisel
- Department of Emergency Medicine, Center for Emergency Care Policy & Research, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, Pennsylvania
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Griffis HM, Kilaru AS, Werner RM, Asch DA, Hershey JC, Hill S, Ha YP, Sellers A, Mahoney K, Merchant RM. Use of social media across US hospitals: descriptive analysis of adoption and utilization. J Med Internet Res 2014; 16:e264. [PMID: 25431831 PMCID: PMC4260061 DOI: 10.2196/jmir.3758] [Citation(s) in RCA: 128] [Impact Index Per Article: 12.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2014] [Revised: 10/03/2014] [Accepted: 10/12/2014] [Indexed: 11/13/2022] Open
Abstract
Background Use of social media has become widespread across the United States. Although businesses have invested in social media to engage consumers and promote products, less is known about the extent to which hospitals are using social media to interact with patients and promote health. Objective The aim was to investigate the relationship between hospital social media extent of adoption and utilization relative to hospital characteristics. Methods We conducted a cross-sectional review of hospital-related activity on 4 social media platforms: Facebook, Twitter, Yelp, and Foursquare. All US hospitals were included that reported complete data for the Centers for Medicare and Medicaid Services Hospital Consumer Assessment of Healthcare Providers and Systems survey and the American Hospital Association Annual Survey. We reviewed hospital social media webpages to determine the extent of adoption relative to hospital characteristics, including geographic region, urban designation, bed size, ownership type, and teaching status. Social media utilization was estimated from user activity specific to each social media platform, including number of Facebook likes, Twitter followers, Foursquare check-ins, and Yelp reviews. Results Adoption of social media varied across hospitals with 94.41% (3351/3371) having a Facebook page and 50.82% (1713/3371) having a Twitter account. A majority of hospitals had a Yelp page (99.14%, 3342/3371) and almost all hospitals had check-ins on Foursquare (99.41%, 3351/3371). Large, urban, private nonprofit, and teaching hospitals were more likely to have higher utilization of these accounts. Conclusions Although most hospitals adopted at least one social media platform, utilization of social media varied according to several hospital characteristics. This preliminary investigation of social media adoption and utilization among US hospitals provides the framework for future studies investigating the effect of social media on patient outcomes, including links between social media use and the quality of hospital care and services.
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Affiliation(s)
- Heather M Griffis
- Penn Social Media and Health Innovation Lab, University of Pennsylvania, Philadelphia, PA, United States
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Merchant RM, Griffis HM, Ha YP, Kilaru AS, Sellers AM, Hershey JC, Hill SS, Kramer-Golinkoff E, Nadkarni L, Debski MM, Padrez KA, Becker LB, Asch DA. Hidden in plain sight: a crowdsourced public art contest to make automated external defibrillators more visible. Am J Public Health 2014; 104:2306-12. [PMID: 25320902 DOI: 10.2105/ajph.2014.302211] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
OBJECTIVES We sought to explore the feasibility of using a crowdsourcing study to promote awareness about automated external defibrillators (AEDs) and their locations. METHODS The Defibrillator Design Challenge was an online initiative that asked the public to create educational designs that would enhance AED visibility, which took place over 8 weeks, from February 6, 2014, to April 6, 2014. Participants were encouraged to vote for AED designs and share designs on social media for points. Using a mixed-methods study design, we measured participant demographics and motivations, design characteristics, dissemination, and Web site engagement. RESULTS Over 8 weeks, there were 13 992 unique Web site visitors; 119 submitted designs and 2140 voted. The designs were shared 48 254 times on Facebook and Twitter. Most designers-voters reported that they participated to contribute to an important cause (44%) rather than to win money (0.8%). Design themes included: empowerment, location awareness, objects (e.g., wings, lightning, batteries, lifebuoys), and others. CONCLUSIONS The Defibrillator Design Challenge engaged a broad audience to generate AED designs and foster awareness. This project provides a framework for using design and contest architecture to promote health messages.
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Affiliation(s)
- Raina M Merchant
- Raina M. Merchant, Heather M. Griffis, Yoonhee P. Ha, Austin S. Kilaru, Allison M. Sellers, Emily Kramer-Golinkoff, Lindsay Nadkarni, Margaret M. Debski, Kevin A. Padrez, John C. Hershey, and Shawndra S. Hill are with the Social Media and Health Innovation Lab, Penn Medicine Center for Health Care Innovation, University of Pennsylvania, Philadelphia. Lance B. Becker is with the Department of Emergency Medicine, University of Pennsylvania, Philadelphia. David A. Asch is with the Center for Health Equity Research and Promotion, Philadelphia VA Medical Center, Philadelphia
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Affiliation(s)
- Austin S Kilaru
- At the time of writing, Austin S. Kilaru and Allison Sellers were with the Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia. David A. Asch and Raina M. Merchant are with the Penn Medicine Social Media and Health Innovation Lab, Penn Medicine Center for Health Care Innovation, University of Pennsylvania
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Kilaru AS, Perrone J, Auriemma CL, Shofer FS, Barg FK, Meisel ZF. Evidence-based narratives to improve recall of opioid prescribing guidelines: a randomized experiment. Acad Emerg Med 2014; 21:244-9. [PMID: 24761456 DOI: 10.1111/acem.12326] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
OBJECTIVES Physicians adopt evidence-based guidelines with variable consistency. Narratives, or stories, offer a novel dissemination strategy for clinical recommendations. The study objective was to compare whether evidence-based narrative versus traditional summary improved recall of opioid prescribing guidelines from the American College of Emergency Physicians (ACEP). METHODS This was a prospective, randomized controlled experiment to compare whether narrative versus summary promoted short-term recall of six themes contained in the ACEP opioid guideline. The experiment was modeled after the free-recall test, an established technique in studies of memory. At a regional conference, emergency physicians (EPs) were randomized to read either a summary of the guideline (control) or a narrative (intervention). The fictional narrative was constructed to match the summary in content and length. One hour after reading the text, participants listed all content that they could recall. Two reviewers independently scored the responses to assess recall of the six themes. The primary outcome was the total number of themes recalled per participant. Secondary outcomes included the proportion of responses in each study arm that recalled individual themes and the proportion of responses in each arm that contained falsely recalled or extraneous information. RESULTS Ninety-five physicians were randomized. Eighty-two physicians completed the experiment, for a response rate of 86%. The mean of the total number of themes recalled per participant was 3.1 in the narrative arm versus 2.0 in the summary arm (difference = 1.1, 95% confidence interval [CI] = 0.6 to 1.7). For three themes, the proportion of responses that recalled the theme was significantly greater in the narrative arm compared to the summary arm, with the differences ranging from 20% to 51%. For one theme, recall was significantly greater in the summary arm. For two themes, there was no statistically significant difference in recall between the arms. In the summary arm, 54% of responses were found to contain falsely recalled or extraneous information versus 21% of responses in the narrative arm (difference = 33%, 95% CI = 14% to 53%). CONCLUSIONS Physicians exposed to a narrative about opioid guidelines were more likely to recall guideline content at 1 hour than those exposed to a summary of the guidelines. Future studies should examine whether the incorporation of narratives in dissemination campaigns improves guideline adoption and changes clinical practice
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Affiliation(s)
- Austin S. Kilaru
- Center for Emergency Care Policy Research; Department of Emergency Medicine; Philadelphia PA
| | - Jeanmarie Perrone
- Center for Emergency Care Policy Research; Department of Emergency Medicine; Philadelphia PA
| | - Catherine L. Auriemma
- Perelman School of Medicine at the University of Pennsylvania; Philadelphia PA
- Leonard Davis Institute of Health Economics; University of Pennsylvania; Philadelphia PA
| | - Frances S. Shofer
- Center for Emergency Care Policy Research; Department of Emergency Medicine; Philadelphia PA
| | - Frances K. Barg
- Department of Family Medicine and Community Health; Philadelphia PA
| | - Zachary F. Meisel
- Center for Emergency Care Policy Research; Department of Emergency Medicine; Philadelphia PA
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Glickman SW, Kit Delgado M, Hirshon JM, Hollander JE, Iwashyna TJ, Jacobs AK, Kilaru AS, Lorch SA, Mutter RL, Myers SR, Owens PL, Phelan MP, Pines JM, Seymour CW, Ewen Wang N, Branas CC. Defining and measuring successful emergency care networks: a research agenda. Acad Emerg Med 2010; 17:1297-305. [PMID: 21122011 DOI: 10.1111/j.1553-2712.2010.00930.x] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
The demands on emergency services have grown relentlessly, and the Institute of Medicine (IOM) has asserted the need for "regionalized, coordinated, and accountable emergency care systems throughout the country." There are large gaps in the evidence base needed to fix the problem of how emergency care is organized and delivered, and science is urgently needed to define and measure success in the emerging network of emergency care. In 2010, Academic Emergency Medicine convened a consensus conference entitled "Beyond Regionalization: Integrated Networks of Emergency Care." This article is a product of the conference breakout session on "Defining and Measuring Successful Networks"; it explores the concept of integrated emergency care delivery and prioritizes a research agenda for how to best define and measure successful networks of emergency care. The authors discuss five key areas: 1) the fundamental metrics that are needed to measure networks across time-sensitive and non-time-sensitive conditions; 2) how networks can be scalable and nimble and can be creative in terms of best practices; 3) the potential unintended consequences of networks of emergency care; 4) the development of large-scale, yet feasible, network data systems; and 5) the linkage of data systems across the disease course. These knowledge gaps must be filled to improve the quality and efficiency of emergency care and to fulfill the IOM's vision of regionalized, coordinated, and accountable emergency care systems.
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Affiliation(s)
- Seth W Glickman
- Department of Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
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