Reliability of a Measure of Admission Intensity for Emergency Physicians

STUDY OBJECTIVE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Defining Incidental Versus Non-incidental COVID-19 Hospitalizations

Background Rates of COVID-19 hospitalization are an important measure of the health system burden of severe COVID-19 disease and have been closely followed throughout the pandemic. The highly transmittable, but often less severe, Omicron COVID-19 variant has led to an increase in hospitalizations with incidental COVID-19 diagnoses where COVID-19 is not the primary reason for admission. There is a strong public health need for a measure that is implementable at low cost with standard electronic health record (EHR) datasets that can separate these incidental hospitalizations from non-incidental hospitalizations where COVID-19 is the primary cause or an important contributor. Two crude metrics are in common use. The first uses in-hospital administration of dexamethasone as a marker of non-incidental COVID-19 hospitalizations. The second, used by the United States (US) CDC, relies on a limited set of COVID-19-related diagnoses (i.e., respiratory failure, pneumonia). Both measures likely undercount non-incidental COVID-19 hospitalizations. We therefore developed an improved EHR-based measure that is better able to capture the full range of COVID-19 hospitalizations. Methods We conducted a retrospective study of ED visit data from a national emergency medicine group from April 2020 to August 2023. We assessed the CDC approach, the dexamethasone-based measure, and alternative approaches that rely on co-diagnoses likely to be related to COVID-19, to determine the proportion of non-incidental COVID-19 hospitalizations. Results Of the 153,325 patients diagnosed with COVID-19 at 112 general EDs in 17 US states, and admitted or transferred, our preferred measure classified 108,243 (70.6%) as non-incidental, compared to 71,066 (46.3%) using the dexamethasone measure and 77,399 (50.5%) using the CDC measure. Conclusions Identifying non-incidental COVID-19 hospitalizations using ED administration of dexamethasone or the CDC measure provides substantially lower estimates than our preferred measure.

Factors Associated with Veteran Self-Reported Use of Digital Health Devices

BACKGROUND

Digital health devices (DHDs), technologies designed to gather, monitor, and sometimes share data about health-related behaviors or symptoms, can support the prevention or management of chronic conditions. DHDs range in complexity and utility, from tracking lifestyle behaviors (e.g., pedometer) to more sophisticated biometric data collection for disease self-management (e.g., glucometers). Despite these positive health benefits, supporting adoption and sustained use of DHDs remains a challenge.

OBJECTIVE

This analysis examined the prevalence of, and factors associated with, DHD use within the Veterans Health Administration (VHA).

DESIGN

National survey.

PARTICIPANTS

Veterans who receive VHA care and are active secure messaging users.

MAIN MEASURES

Demographics, access to technology, perceptions of using health technologies, and use of lifestyle monitoring and self-management DHDs.

RESULTS

Among respondents, 87% were current or past users of at least one DHD, and 58% were provided a DHD by VHA. Respondents 65 + years were less likely to use a lifestyle monitoring device (AOR 0.57, 95% CI [0.39, 0.81], P = .002), but more likely to use a self-management device (AOR 1.69, 95% [1.10, 2.59], P = .016). Smartphone owners were more likely to use a lifestyle monitoring device (AOR 2.60, 95% CI [1.42, 4.75], P = .002) and a self-management device (AOR 1.83, 95% CI [1.04, 3.23], P = .037).

CONCLUSIONS

The current analysis describes the types of DHDs that are being adopted by Veterans and factors associated with their adoption. Results suggest that various factors influence adoption, including age, access to technology, and health status, and that these relationships may differ based on the functionalities of the device. VHA provision of devices was frequent among device users. Providing Veterans with DHDs and the training needed to use them may be important factors in facilitating device adoption. Taken together, this knowledge can inform future implementation efforts, and next steps to support patient-team decision making about DHD use.

Emergency Department Volume, Severity, and Crowding Since the Onset of the Coronavirus Disease 2019 Pandemic

STUDY OBJECTIVE

We describe emergency department (ED) visit volume, illness severity, and crowding metrics from the onset of the coronavirus disease 2019 (COVID-19) pandemic through mid-2022.

METHODS

We tabulated monthly data from 14 million ED visits on ED volumes and measures of illness severity and crowding from March 2020 through August 2022 compared with the same months in 2019 in 111 EDs staffed by a national ED practice group in 18 states.

RESULTS

Average monthly ED volumes fell in the early pandemic, partially recovered in 2022, but remained below 2019 levels (915 per ED in 2019 to 826.6 in 2022 for admitted patients; 3,026.9 to 2,478.5 for discharged patients). The proportion of visits assessed as critical care increased from 7.9% in 2019 to 11.0% in 2022, whereas the number of visits decreased (318,802 to 264,350). Visits billed as 99285 (the highest-acuity Evaluation and Management code for noncritical care visits) increased from 35.4% of visits in 2019 to 40.0% in 2022, whereas the number of visits decreased (1,434,454 to 952,422). Median and median of 90th percentile length of stay for admitted patients rose 32% (5.2 to 6.9 hours) and 47% (11.7 to 17.4 hours) in 2022 versus 2019. Patients leaving without treatment rose 86% (2.9% to 5.4%). For admitted psychiatric patients, the 90th percentile length of stay increased from 20 hours to more than 1 day.

CONCLUSION

ED visit volumes fell early in the pandemic and have only partly recovered. Despite lower volumes, ED crowding has increased. This issue is magnified in psychiatric patients.

The Cost Shifting Economics of United States Emergency Department Professional Services (2016-2019)

STUDY OBJECTIVE

We estimate the economics of US emergency department (ED) professional services, which is increasingly under strain given the longstanding effect of unreimbursed care, and falling Medicare and commercial payments.

METHODS

We used data from the Nationwide Emergency Department Sample (NEDS), Medicare, Medicaid, Health Care Cost Institute, and surveys to estimate national ED clinician revenue and costs from 2016 to 2019. We compare annual revenue and cost for each payor and calculate foregone revenue, the amount clinicians may have collected had uninsured patients had either Medicaid or commercial insurance.

RESULTS

In 576.5 million ED visits (2016 to 2019), 12% were uninsured, 24% were Medicare-insured, 32% Medicaid-insured, 28% were commercially insured, and 4% had another insurance source. Annual ED clinician revenue averaged $23.5 billion versus costs of $22.5 billion. In 2019, ED visits covered by commercial insurance generated $14.3 billion in revenues and cost $6.5 billion. Medicare visits generated $5.3 billion and cost $5.7 billion; Medicaid visits generated $3.3 billion and cost $7 billion. Uninsured ED visits generated $0.5 billion and cost $2.9 billion. The average annual foregone revenue for ED clinicians to treat the uninsured was $2.7 billion.

CONCLUSION

Large cost-shifting from commercial insurance cross-subsidizes ED professional services for other patients. This includes the Medicaid-insured, Medicare-insured, and uninsured, all of whom incur ED professional service costs that substantially exceed their revenue. Foregone revenue for treating the uninsured relative to what may have been collected if patients had health insurance is substantial.

Implementation of an emergency department back pain clinical management tool on the early diagnosis and testing of spinal epidural abscess

BACKGROUND

Spinal epidural abscess (SEA) is a rare, catastrophic condition for which diagnostic delays are common. Our national group develops evidence-based guidelines, known as clinical management tools (CMT), to reduce high-risk misdiagnoses. We study whether implementation of our back pain CMT improved SEA diagnostic timeliness and testing rates in the emergency department (ED).

METHODS

We conducted a retrospective observational study before and after implementation of a nontraumatic back pain CMT for SEA in a national group. Outcomes included diagnostic timeliness and test utilization. We used regression analysis to compare differences before (January 2016-June 2017) and after (January 2018-December 2019) with 95% confidence intervals (CIs) clustered by facility. We graphed monthly testing rates.

RESULTS

In 59 EDs, pre versus post periods included 141,273 (4.8%) versus 192,244 (4.5%) back pain visits and 188 versus 369 SEA visits, respectively. After implementation, SEA visits with prior related visits were unchanged (12.2% vs. 13.3%, difference +1.0%, 95% CI -4.5% to 6.5%). Mean number of days to diagnosis decreased but not significantly (15.2 days vs. 11.9 days, difference -3.3 days, 95% CI -7.1 to 0.6 days). Back pain visits receiving CT (13.7% vs. 21.1%, difference +7.3%, 95% CI 6.1% to 8.6%) and MRI (2.9% vs. 4.4%, difference +1.4%, 95% CI 1.0% to 1.9%) increased. Spine X-rays decreased (22.6% vs. 20.5%, difference 2.1%, 95% CI -4.3% to 0.1%). Back pain visits receiving erythrocyte sedimentation rate or C-reactive protein increased (1.9% vs. 3.5%, difference +1.6%, 95% CI 1.3% to 1.9%).

CONCLUSIONS

Back pain CMT implementation was associated with an increased rate of recommended imaging and laboratory testing in back pain. There was no associated reduction in the proportion of SEA cases with a related prior visit or time to SEA diagnosis.

Development and Internal Validation of an Emergency Department Admission Intensity Measure Using Data From a National Group

STUDY OBJECTIVE

We develop and assess variation in an emergency department (ED) admission intensity measure intended for value-based payment models. The measure includes ED diagnoses amenable to evidence-based protocols and where admission decisions vary based on physician discretion.

METHODS

Measure International Classification of Diseases (ICD)-10 codes were selected by face validity by 3 emergency physicians using expertise and administrative data. Feedback was sought from a separate technical panel. Using data from a national group (2018 to 2019), we assessed measure stability at the physician and facility level by quarter using descriptive plots, multilevel linear probability models, and intraclass correlation coefficients (ICC).

RESULTS

A total of 535 ICD-10 measure codes were selected from 23,590 codes. Across 127 EDs, facility-quarter admission rates averaged 26.1% (95% confidence interval [CI] 24.5 to 27.7). Between- and within-facility standard deviations were 9.2 (95% CI 8.2 to 10.5) and 2.9 (95% CI 2.7 to 3.0), respectively, with an ICC of 0.91. Most ED-quarters (749/961) fell within 2.5% of their facility's average. Among 2,398 physicians, quarterly rates averaged 29.1% (95% CI 28.6 to 29.6). The between- and within-physician standard deviation was 6.3 (95% CI 6.1 to 6.5) and 5.3 (95% CI 5.3 to 5.4), respectively, with an ICC of 0.58; 220 physicians (9.2%) had an admission rate consistently higher than average and 193 (8.0%) consistently lower.

CONCLUSION

This set of ICD-10 diagnoses demonstrates face validity and stability for quarterly admission rates at the facility and physician levels. The measure may be useful to monitor facility admission rates in value-based models and reliably identify high and low admitters within facilities to manage admission variation.

Estimating the uncertain effect of the COVID pandemic on drug overdoses

OBJECTIVE

U.S. drug-related overdose deaths and Emergency Department (ED) visits rose in 2020 and again in 2021. Many academic studies and the news media attributed this rise primarily to increased drug use resulting from the societal disruptions related to the coronavirus (COVID-19) pandemic. A competing explanation is that higher overdose deaths and ED visits may have reflected a continuation of pre-pandemic trends in synthetic-opioid deaths, which began to rise in mid-2019. We assess the evidence on whether increases in overdose deaths and ED visits are likely to be related primarily to the COVID-19 pandemic, increased synthetic-opioid use, or some of both.

METHODS

We use national data from the Centers for Disease Control and Prevention (CDC) on rolling 12-month drug-related deaths (2015-2021); CDC data on monthly ED visits (2019-September 2020) for EDs in 42 states; and ED visit data for 181 EDs in 24 states staffed by a national ED physician staffing group (January 2016-June 2022). We study drug overdose deaths per 100,000 persons during the pandemic period, and ED visits for drug overdoses, in both cases compared to predicted levels based on pre-pandemic trends.

RESULTS

Mortality. National overdose mortality increased from 21/100,000 in 2019 to 26/100,000 in 2020 and 30/100,000 in 2021. The rise in mortality began in mid-to-late half of 2019, and the 2020 increase is well-predicted by models that extrapolate pre-pandemic trends for rolling 12-month mortality to the pandemic period. Placebo analyses (which assume the pandemic started earlier or later than March 2020) do not provide evidence for a change in trend in or soon after March 2020. State-level analyses of actual mortality, relative to mortality predicted based on pre-pandemic trends, show no consistent pattern. The state-level results support state heterogeneity in overdose mortality trends, and do not support the pandemic being a major driver of overdose mortality. ED visits. ED overdose visits rose during our sample period, reflecting a worsening opioid epidemic, but rose at similar rates during the pre-pandemic and pandemic periods.

CONCLUSION

The reasons for rising overdose mortality in 2020 and 2021 cannot be definitely determined. We lack a control group and thus cannot assess causation. However, the observed increases can be largely explained by a continuation of pre-pandemic trends toward rising synthetic-opioid deaths, principally fentanyl, that began in mid-to-late 2019. We do not find evidence supporting the pandemic as a major driver of rising mortality. Policymakers need to directly address the synthetic opioid epidemic, and not expect a respite as the pandemic recedes.

Four- and three-year emergency medicine residency graduates perform similarly in their first year of practice compared to experienced physicians

INTRODUCTION

United States emergency medicine (EM) post-graduate training programs vary in training length, either 4 or 3 years. However, it is unknown if clinical care by graduates from the two curricula differs in the early post-residency period.

METHODS

We performed a retrospective observational study comparing measures of clinical care and practice patterns between new graduates from 4- and 3-year EM programs with experienced new physician hires as a reference group. We included emergency department (ED) encounters from a national EM group (2016-19) between newly hired physicians from 4- and 3- year programs and experienced new hires (>2 years' experience) during their first year of practice with the group. Primary outcomes were at the physician-shift level (patients per hour and relative value units [RVUs] per hour) and encounter-level (72-h return visits with admission/transfer and discharge length of stay [LOS]). Secondary outcomes included discharge opioid prescription rates, test ordering, computer tomography (CT) use, and admission/transfer rate. We compared outcomes using multivariable linear regression models that included patient, shift, and facility-day characteristics, and a facility fixed effect. We hypothesized that experienced new hires would be most efficient, followed by new 4-year graduates and then new 3-year graduates.

RESULTS

We included 1,084,085 ED encounters by 4-year graduates (n = 39), 3-year graduates (n = 70), and experienced new hires (n = 476). There were no differences in physician-level and encounter-level primary outcomes except discharge LOS was 10.60 min (2.551, 18.554) longer for 4-year graduates compared to experienced new hires. Secondary outcomes were similar among the three groups except 4- and 3-year new graduates were less likely to prescribe opioids to discharged patients, -3.70% (-5.768, -1.624) and - 3.38% (-5.136, -1.617) compared to experienced new hires.

CONCLUSIONS

In this sample, measures of clinical care and practice patterns related to efficiency, safety, and flow were largely similar between the physician groups; however, experienced new hires were more likely to prescribe opioids than new graduates. These results do not support recommending a specific length of residency training in EM.

Prescription Drug Shortages: Pediatric Emergency and Critical Care Medications

OBJECTIVES

Drug shortages have been increasing over the past 2 decades. There are limited data on drug shortages and their effect on pediatric emergency and critical care. Our objective was to describe pediatric emergency and critical care drug shortages.

METHODS

Drug shortage data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Services. Shortages were reviewed, identifying agents used in pediatric emergency and critical care. Shortage data were analyzed for the type of drug, formulation, shortage reason, duration, marketing status (generic vs brand name), or if it was a pediatric-friendly formulation, used for a high-acuity condition, or a single-source product. The availability of a substitute was also described.

RESULTS

Of 1883 products on shortage, 779 were used in pediatric emergency or critical care. The annual number of shortages decreased from 2001 to 2004, but then increased, reaching a high in 2011. The median duration for resolved shortages was 7.6 months (interquartile range, 3.0-17.6 months). The most common category affected was infectious disease drugs. High-acuity agents were involved in 27% of shortages and in 11% of pediatric-friendly formulations. An alternative agent was available for 95% of drugs, yet 43% of alternatives were also affected at some time during the study period. The most common reported reason for a shortage was manufacturing problems.

CONCLUSIONS

From 2001 to 2015, drug shortages affected a substantial number of agents used in pediatric emergency and critical care. This has had implications to the medications available for use and may impact patient outcomes. Providers must be aware of current shortages and implement mitigation strategies to optimize patient care.

The effect of the COVID-19 pandemic on emergency department visits for serious cardiovascular conditions

OBJECTIVE

We examine how emergency department (ED) visits for serious cardiovascular conditions evolved in the coronavirus (COVID-19) pandemic over January-October 2020, compared to 2019, in a large sample of U.S. EDs.

METHODS

We compared 2020 ED visits before and during the COVID-19 pandemic, relative to 2019 visits in 108 EDs in 18 states in 115,716 adult ED visits with diagnoses for five serious cardiovascular conditions: ST-segment elevation myocardial infarction (STEMI), non-ST-segment elevation myocardial infarction (NSTEMI), ischemic stroke (IS), hemorrhagic stroke (HS), and heart failure (HF). We calculated weekly ratios of ED visits in 2020 to visits in 2019 in the pre-pandemic (Jan 1-March 10), early-pandemic (March 11-April 21), and later-pandemic (April 22-October 31) periods.

RESULTS

ED visit ratios show that NSTEMI, IS, and HF visits dropped to lows of 56%, 64%, and 61% of 2019 levels, respectively, in the early-pandemic and gradually returned to 2019 levels over the next several months. HS visits also dropped early pandemic period to 60% of 2019 levels, but quickly rebounded. We find mixed evidence on whether STEMI visits fell, relative to pre-pandemic rates. Total adult ED visits nadired at 57% of 2019 volume during the early-pandemic period and have only party recovered since, to approximately 84% of 2019 by the end of October 2020.

CONCLUSION

We confirm prior studies that ED visits for serious cardiovascular conditions declined early in the COVID-19 pandemic for NSTEMI, IS, HS, and HF, but not for STEMI. Delays or non-receipt in ED care may have led to worse outcomes.

Patient portal engagement and diabetes management among new portal users in the Veterans Health Administration

OBJECTIVE

The study sought to investigate whether consistent use of the Veterans Health Administration's My HealtheVet (MHV) online patient portal is associated with improvement in diabetes-related physiological measures among new portal users.

MATERIALS AND METHODS

We conducted a retrospective cohort study of new portal users with type 2 diabetes that registered for MHV between 2012 and 2016. We used random-effect linear regression models to examine associations between months of portal use in a year (consistency) and annual means of the physiological measures (hemoglobin A1c [HbA1c], low-density lipoproteins [LDLs], and blood pressure [BP]) in the first 3 years of portal use.

RESULTS

For patients with uncontrolled HbA1c, LDL, or BP at baseline, more months of portal use in a year was associated with greater improvement. Compared with 1 month of use, using the portal 12 months in a year was associated with annual declines in HbA1c of -0.41% (95% confidence interval [CI], -0.46% to -0.36%) and in LDL of -6.25 (95% CI, -7.15 to -5.36) mg/dL. Twelve months of portal use was associated with minimal improvements in BP: systolic BP of -1.01 (95% CI, -1.33 to -0.68) mm Hg and diastolic BP of -0.67 (95% CI, -0.85 to -0.49) mm Hg. All associations were smaller or not present for patients in control of these measures at baseline.

CONCLUSIONS

We found consistent use of the patient portal among new portal users to be associated with modest improvements in mean HbA1c and LDL for patients at increased risk at baseline. For patients with type 2 diabetes, self-management supported by online patient portals may help control HbA1c, LDL, and BP.

The Effect of the COVID-19 Pandemic on the Economics of United States Emergency Care

Study objective

We describe how the coronavirus disease 2019 (COVID-19) pandemic affected the economics of emergency department care (ED).

Methods

We conducted an observational study of 136 EDs from January 2019 to September 2020, using 2020-to-2019 3-week moving ratios for ED visits, complexity, revenue, and staffing expenses. We tabulated 2020-to-2019 staffing ratios and calculated hour and full-time-equivalent changes.

Results

Following the COVID-19 pandemic’s onset, geriatric (age ≥65), adult (age 18 to 64), and pediatric (age <18) ED visits declined by 43%, 40%, and 73%, respectively, compared to 2019 visits and rose thereafter but remained below 2019 levels through September. Relative value units per visit rose by 8%, 9%, and 18%, respectively, compared to 2019, while ED admission rates rose by 32%. Both fell subsequently but remained above 2019 levels through September. Revenues dropped sharply early in the pandemic and rose gradually but remained below 2019 levels. In medium and large EDs, staffing and expenses were lowered with a lag, largely compensating for lower revenue at these sites, and barely at freestanding EDs. Staffing and expense reductions could not match revenue losses in smaller EDs. During the pandemic, emergency physician and advanced practice provider clinical hours and compensation fell 15% and 27%, respectively, corresponding to 174 lost physician and 193 lost advanced practice provider full-time-equivalent positions.

Conclusion

The COVID-19 pandemic adversely impacted the economics of ED care, with large drops in overall and, in particular, low-acuity ED visits, necessitating reductions in clinical hours. Staffing cutbacks could not match reduced revenue at small EDs with minimum emergency physician coverage requirements.

How emergency department visits for substance use disorders have evolved during the early COVID-19 pandemic

OBJECTIVE

Higher opioid overdoses and drug use have reportedly occurred during the COVID-19 pandemic. We provide evidence on how emergency department (ED) visits for substance use disorders (SUD) changed in the early pandemic period.

METHODS

Using retrospective data from January-July 2020 compared to January-July 2019, we calculated weekly 2020/2019 visit ratios for opioid-related, alcohol-related, other drug-related disorders, and all non-COVID-19 visits. We assess how this ratio as well as overall visit numbers changed after the mid-March 2020 onset of general pandemic restrictions.

RESULTS

In 4.5 million ED visits in 2020 and 2019 to 108 EDs in 18 U.S. states, SUD visits were higher in early 2020 compared to 2019. During the peak-pandemic restriction period (March 13-July 31), non-COVID-19, non-SUD visits fell by approximately 45% early on, and then partly recovered with an average decline of 33% relative to 2019 levels. Visits for opioid-related, alcohol-related, and other drug-related disorders also declined, although less sharply, with an average drop of 17%, which was similar across SUD types. The visit ratios for 2020/2019 partially or fully recovered later in our sample period, depending on SUD type, but did not exceed early-2020 levels. However, substantial variation occurred across SUD types and across states. SUD visit declines were most prominent in the 65+ age group, except for alcohol-related visits where trends were similar across ages. SUD visits arriving by ambulance declined less or increased relative to self-transport visits, and ED deaths were rare.

CONCLUSIONS

The 2020/2019 ratios of SUD ED visits fell substantially early in the COVID-19 pandemic, yet less than non-SUD, non-COVID ED visits. SUD ED visit ratios partly or fully recovered to 2019 levels by early June 2020, but did not exceed early 2020 ratios.

Emergency Physician and Advanced Practice Provider Diagnostic Testing and Admission Decisions in Chest Pain and Abdominal Pain

OBJECTIVE

We compare utilization of diagnostic resources and admissions in emergency department (ED) patients with chest pain and abdominal pain when managed by advanced practice providers (APPs) and physicians.

METHODS

We used 2016 to 2019 data from a national emergency medicine group. We compared visits managed by physicians and APPs based on demographics and observed resource utilization (labs, radiography, computed tomography) use and hospital admission/transfer, stratified by patient age. To reduce selection bias, we created inverse propensity score weights (IPWs). To estimate the average treatment effect for APP visits for each outcome, we included IPWs in a multivariable linear probability model with a dummy variable indicating treatment by an APP and used a facility fixed effect. We then estimated the average treatment effect comparing physician to APP visit for all visits and for discharged visits separately, stratified by the study outcomes. Sensitivity analyses were performed using different cohort definitions and adjusting for past medical history.

RESULTS

In chest pain, we included 77,568 visits seen by 1,011 APPs and 586,031 visits seen by 1,588 physicians. In abdominal pain, we included 184,812 ED visits seen by 1,080 APPs and 761,230 visits seen by 1,689 physicians. For both chest pain and abdominal pain visits, physicians saw more older adult patients (55+ years) and admitted a higher percentage of visits than APPs. For chest pain, physicians saw more circulatory system diseases (70.7% vs. 58.6%); APPs saw more respiratory system diseases (17.1% vs. 9.8%). In abdominal pain, emergency physicians saw more digestive system diseases (28.5% vs. 23.3%); APPs saw more genitourinary system diseases. After matching with IPW, predicted probabilities of laboratory, radiology, and admissions either did not vary or were slightly lower for APPs compared to physicians for all outcomes. Sensitivity analyses showed similar results, including controlling for past medical history.

CONCLUSION

Diagnostic testing and hospitalization rates for chest pain and abdominal pain between APPs and physicians is largely similar after matching for severity and complexity. This suggests that APPs do not have observably higher use of ED and hospital resources in these conditions in this national group.

Characterizing pediatric emergency department visits during the COVID-19 pandemic

Objective

We determine how pediatric emergency department (ED) visits changed during the COVID-19 pandemic in a large sample of U.S. EDs.

Methods

Using retrospective data from January–June 2020, compared to a similar 2019 period, we calculated weekly 2020–2019 ratios of Non-COVID-19 ED visits for adults and children (age 18 years or less) by age range. Outcomes were pediatric ED visit rates before and after the onset of pandemic, by age, disposition, and diagnosis.

Results

We included data from 2,213,828 visits to 144 EDs and 4 urgent care centers in 18 U.S. states, including 7 EDs in children's hospitals. During the pandemic period, adult non-COVID-19 visits declined to 60% of 2019 volumes and then partially recovered but remained below 2019 levels through June 2020. Pediatric visits declined even more sharply, with peak declines through the week of April 15 of 74% for children age < 10 years and 67% for 14–17 year. Visits recovered by June to 72% for children age 14–17, but to only 50% of 2019 levels for children < age 10 years. Declines were seen across all ED types and locations, and across all diagnoses, with an especially sharp decline in non-COVID-19 communicable diseases. During the pandemic period, there was 22% decline in common serious pediatric conditions, including appendicitis.

Conclusion

Pediatric ED visits fell more sharply than adult ED visits during the COVID-19 pandemic, and remained depressed through June 2020, especially for younger children. Declines were also seen for serious conditions, suggesting that parents may have avoided necessary care for their children.

Impact of Patient-Clinical Team Secure Messaging on Communication Patterns and Patient Experience: Randomized Encouragement Design Trial

BACKGROUND

Although secure messaging (SM) between patients and clinical team members is a recommended component of continuous care, uptake by patients remains relatively low. We designed a multicomponent Supported Adoption Program (SAP) to increase SM adoption among patients using the Veterans Health Administration (VHA) for primary care.

OBJECTIVE

Our goals were to (1) conduct a multisite, randomized, encouragement design trial to test the effectiveness of an SAP designed to increase patient engagement with SM through VHA's online patient portal (My HealtheVet [MHV]) and (2) evaluate the impact of the SAP and patient-level SM adoption on perceived provider autonomy support and communication. Patient-reported barriers to SM adoption were also assessed.

METHODS

We randomized 1195 patients at 3 VHA facilities who had MHV portal accounts but had never used SM. Half were randomized to receive the SAP, and half served as controls receiving usual care. The SAP consisted of encouragement to adopt SM via mailed educational materials, proactive SM sent to patients, and telephone-based motivational interviews. We examined differences in SM adoption rates between SAP recipients and controls at 9 months and 21 months. Follow-up telephone surveys were conducted to assess perceived provider autonomy support and self-report of telephone communication with clinical teams.

RESULTS

Patients randomized to the SAP had significantly higher rates of SM adoption than the control group (101/595, 17.0% vs 40/600, 6.7%; P<.001). Most adopters in the SAP sent their first message without a motivational interview (71/101, 70.3%). The 10-percentage point difference in adoption persisted a full year after the encouragement ended (23.7%, 142/600 in the SAP group vs 13.5%, 80/595 in the control group, P<.001). We obtained follow-up survey data from 49.54% (592/1195) of the participants. SAP participants reported higher perceived provider autonomy support (5.7 vs 5.4, P=.007) and less telephone use to communicate with their provider (68.8% vs 76.0%, P=.05), compared to patients in the control group. Patient-reported barriers to SM adoption included self-efficacy (eg, not comfortable using a computer, 24%), no perceived need for SM (22%), and difficulties with portal password or login (17%).

CONCLUSIONS

The multicomponent SAP was successful in increasing use of SM 10 percentage points above standard care; new SM adopters reported improved perceptions of provider autonomy support and less use of the telephone to communicate with their providers. Still, despite the encouragement and technical assistance provided through the SAP, adoption rates were lower than anticipated, reaching only 24% at 21 months (10% above controls). Common barriers to adoption such as limited perceived need for SM may be more challenging to address and require different interventions than barriers related to patient self-efficacy or technical difficulties.

TRIAL REGISTRATION

ClinicalTrials.gov NCT02665468; https://clinicaltrials.gov/ct2/show/NCT02665468.

The Impact of Advanced Practice Provider Staffing on Emergency Department Care: Productivity, Flow, Safety, and Experience

OBJECTIVES

We examined emergency department (ED) advanced practice provider (APP) productivity and how APP staffing impacted ED productivity, safety, flow, and experience.

METHODS

We used 2014 to 2018 data from a national emergency medicine group. The exposure was APP coverage: APP hours as a percentage of total clinician hours at the ED-day level. Multivariable regression was used to assess the relationship between APP coverage and productivity outcomes (patients/clinician hour, relative value units [RVUs]/clinician hour, RVUs/visit, and RVUs/salary-adjusted hour), flow outcomes (length of stay and left without treatment), safety (72-hour returns, incident reports), and experience (Press-Ganey scores), adjusting for patient and facility characteristics.

RESULTS

In 13.02 million patient visits in 105,863 ED-days across 94 EDs from 2014 to 2018, nurse practitioners and physician assistants managed 5.4 and 18.6% of visits independently, 74.6% by emergency physicians alone, and 1.4% jointly. APP visits had lower RVUs/visit (2.8 vs. 3.7) and lower patients/hour (1.1 vs. 2.2) compared to physician visits. Higher APP coverage (by 10%) at the ED-day level was associated with lower patients/clinician hour by 0.12 (95% confidence interval [CI] = -0.15 to -0.10) and lower RVUs/clinician hour by 0.4 (95% CI = -0.5 to -0.3). There was no impact of increasing APP coverage on RVUs/salary-adjusted hour or RVUs/visit. There was also no effect of increasing APP coverage on flow, safety, or patient experience.

CONCLUSION

In this group, APPs treated less complex visits and half as many patients/hour compared to physicians. Higher APP coverage allowed physicians to treat higher-acuity cases. We found no economies of scale for APP coverage, suggesting that increasing APP staffing may not lower staffing costs. However, there were also no adverse observed effects of APP coverage on ED flow, clinical safety, or patient experience, suggesting little risk of increased APP coverage on clinical care delivery.

Secure Messaging, Diabetes Self-management, and the Importance of Patient Autonomy: a Mixed Methods Study

BACKGROUND

Diabetes is a complex, chronic disease that requires patients' effective self-management between clinical visits; this in turn relies on patient self-efficacy. The support of patient autonomy from healthcare providers is associated with better self-management and greater diabetes self-efficacy. Effective provider-patient secure messaging (SM) through patient portals may improve disease self-management and self-efficacy. SM that supports patients' sense of autonomy may mediate this effect by providing patients ready access to their health information and better communication with their clinical teams.

OBJECTIVE

We examined the association between healthcare team-initiated SM and diabetes self-management and self-efficacy, and whether this association was mediated by patients' perceptions of autonomy support from their healthcare teams.

DESIGN

We surveyed and analyzed content of messages sent to a sample of patients living with diabetes who use the SM feature on the VA's My HealtheVet patient portal.

PARTICIPANTS

Four hundred forty-six veterans with type 2 diabetes who were sustained users of SM.

MAIN MEASURES

Proactive (healthcare team-initiated) SM (0 or ≥ 1 messages); perceived autonomy support; diabetes self-management; diabetes self-efficacy.

KEY RESULTS

Patients who received at least one proactive SM from their clinical team were significantly more likely to engage in better diabetes self-management and report a higher sense of diabetes self-efficacy. This relationship was mediated by the patient's perception of autonomy support. The majority of proactive SM discussed scheduling, referrals, or other administrative content. Patients' responses to team-initiated communication promoted patient engagement in diabetes self-management behaviors.

CONCLUSIONS

Perceived autonomy support is important for diabetes self-management and self-efficacy. Proactive communication from clinical teams to patients can help to foster a patient's sense of autonomy and encourage better diabetes self-management and self-efficacy.

Critical procedure performance in pediatric patients: Results from a national emergency medicine group

STUDY OBJECTIVE

We sought to examine the frequency of pediatric critical procedures performed in a national group of emergency physicians.

METHODS

We performed a retrospective analysis of an administrative billing and coding dataset for procedural performance documentation verification from 2014 to 2018. We describe and compare incident rates of pediatric (age <18 years) patient critical procedure performance by emergency physicians in general emergency departments (EDs), pediatric EDs, and freestanding ED/urgent care centers. Critical procedures were endotracheal intubation, electrical cardioversion, central venous placement, intraosseous access, and chest tube insertion.

RESULTS

Among 2290 emergency physicians working in 186 EDs (1844 working in 129 general EDs, 125 in 8 pediatric EDs, and 321 in 49 freestanding EDs/urgent cares), a total of 2233 pediatric critical procedures were performed during the study period. Many physicians at general EDs and freestanding EDs/urgent cares performed zero pediatric procedures per year (53.9% and 89% respectively). Per 1000 ED visits seen (All patient ages), physicians working in general EDs performed fewer pediatric critical procedures than physicians in pediatric EDs (0.12/1000 visits vs 0.68/1000 visits; rate difference = 0.56, 95% confidence interval [CI] 0.51-0.61). Per 1000 clinical hours worked, physicians working in general EDs performed 0.26 procedures compared to 1.66 for physicians in pediatric EDs (rate difference = 1.39; 95% CI 1.27-1.52).

CONCLUSION

Pediatric critical procedures are rarely performed by emergency physicians and are exceedingly rare in general EDs and freestanding EDs/urgent cares. The rarity of performance of these skills has implications for ED pediatric readiness.

The Effect of Operational Stressors on Emergency Department Clinician Scheduling and Patient Throughput

STUDY OBJECTIVE

We assess the effect of emergency department (ED) operational stressors on clinician scheduling and throughput.

METHODS

We evaluated 2014 to 2018 data from a national ED group. Operational stressors included measures of workload, patient acuity, and complexity. We used multilevel linear regression to estimate the effect of operational stressors, temporal factors, and facility characteristics on ED clinician scheduling; patient throughput, measured as shift-level patient departures per corrected clinician hour; and length of stay.

RESULTS

In greater than 14 million ED visits across 359 facility-years, the mean of patient departures per corrected clinician hour was 2.23 (95% confidence interval [CI] 2.15 to 2.31). Temporal and facility effects had the greatest influence on patient departures per hour (eg, -0.55 [95% CI -0.75 to -0.36] in 7 am to 3 pm shifts versus midnight to 7 am on Mondays, 0.25 [95% CI 0.03 to 0.47]) in teaching versus nonteaching hospitals, and 0.43 (95% CI 0.24 to 0.61) in larger EDs (30,000 to 59,999 ED visits/year) versus smaller EDs. Operational stressors had significant but small effects on patient departures per hour (eg, length of stay [per-minute increase] 0.002 [95% CI 0.0019 to 0.0023] and percentage admitted [per 1% increase] -0.003 [95% CI -0.004 to -0.001]). Weekday nights, particularly Mondays, had the highest proportion of shifts with increasing length of stay compared with previous years in the same ED.

CONCLUSION

ED operational stressors had minimal influence on patient throughput when included in adjusted ED clinician scheduling models, whereas temporal and facility factors were more influential. Therefore, incorporating operational stressors into ED clinician scheduling is less likely to balance workloads than accounting for temporal and facility-level factors alone. Length of stay on some shifts, particularly Monday nights, became increasingly long, suggesting they require additional resources.

The rising cost of commonly used emergency department medications (2006-15)

OBJECTIVE

We determine how aggregate costs have changed for commonly used emergency department (ED) medications, and assess drivers of cost increases.

METHODS

Using the National Hospital Ambulatory Medical Care Survey (NHAMCS), we identified the top 150 ED medications administered and prescribed at discharge in 2015. We used average wholesale prices (AWP) for each year from 2006 to 15 from the Red Book (Truven Health Analytics Inc.). Average wholesale price per patient (AWPP) was calculated by dividing AWP by drug uses. This was then multiplied by the total drug administrations or prescriptions to estimate the total cost in a given the year. All prices were converted to 2015 dollars.

RESULTS

Aggregate costs of drugs administered in the ED increased from $688.7 million in 2006 to $882.4 million in 2015. For discharge prescriptions, aggregate costs increased from $2.031 billion in 2006 to $4.572 billion in 2015. AWPP for drugs administered in the ED in 2015 was 14.5% higher than in 2006 and 24.3% higher at discharge. The largest absolute increase in AWPP for drugs administered was for glucagon, which increased from $111 in 2006 to $235 in 2015. The largest AWPP increase at discharge was for epinephrine auto-injector, which increased from $124 in 2006 and to $481 in 2015.

CONCLUSION

Over the course of the study period, the aggregate costs of the most common medications administered in the ED increased by 28% while the costs of medications prescribed at discharge increased 125%.

Longitudinal trends in U.S. shortages of sterile solutions, 2001-17

PURPOSE

Trends in the shortages of sterile solutions in the United States were evaluated.

METHODS

A retrospective review of shortage data from the University of Utah Drug Information Service (UUDIS) was performed. Shortages of sterile solutions, including saline, dextrose, lactated Ringer's, and sterile water for injection, were identified. We extracted the product name, reason for the shortage, shortage duration, and primary use of the solution, examining trends in shortages over time.

RESULTS

There were 37 sterile solution shortages in the UUDIS data set, 22 of which had been resolved. The mean ± S.D. duration of a resolved shortage was 13.9 ± 9.6 months. The most common category of solution shortage was for saline products (n = 11). Manufacturing delay was the most common reason given for shortages (n = 19). In 2017, 12 new shortages were reported, and 15 solutions remained in shortage by year's end. This was the highest number of shortages at any time during the study period. The longest active shortage was for 5% dextrose/0.45% sodium chloride, which began in October 2007 and has yet to be resolved.

CONCLUSION

There were 37 shortages of sterile solutions from 2001 through 2017. Shortages became more severe after Hurricane Maria damaged manufacturing facilities in Puerto Rico, with 12 new shortages reported in 2017.

Integrating Point-of-care Testing Into a Community Emergency Department: A Mixed-methods Evaluation

OBJECTIVE

Point-of-care testing (POCT) is a commonly used technology that hastens the time to laboratory results in emergency departments (ED). We evaluated an ED-based POCT program on ED length of stay (LOS) and time to care, coupled with qualitative interviews of local ED stakeholders.

METHODS

We conducted a mixed-methods study (2012-2016) to examine the impact of POCT in a single, community ED. The quantiative analysis involved an observational before-after study comparing time to laboratory test result (POC troponin or POC chemistry) and ED LOS after implementation of POCT, using a propensity-weighted interrupted time series analysis (ITSA). A complementary qualitative analysis involved five semistructured interviews with staff using grounded theory on the benefits and challenges to ED POCT.

RESULTS

A total of 47,399 ED visits were included in the study (24,705 in the preintervention period and 22,694 in the postintervention period). After POCT implementation, overall laboratory testing increased marginally from 61% to 62%. Central laboratory troponin and chemistry declined by > 50% and was replaced by POCT. Prior to POCT implementation, time to troponin and chemistry had declined steadily due to other improvements in laboratory efficiency. After POCT implementation, there was an immediate 20-minute further decline (p < 0.001) in both time to troponin and time to chemistry results using the propensity-weighted comparisons. However, the declining trend observed prior to POCT implementation did not continue at the same rate after implementation. Similarly, prior to POCT implementation, ED LOS declined due to other quality improvements. After POCT implementation, LOS continued declined at a similar rate. Because of this prior trend, the ITSA did not show a significant decline in LOS attributable to POCT. Common benefits of POCT perceived by staff in qualitative interviews included improved quality of care (64%) and reductions in time to test results (44%). Common challenges included concerns over POCT accuracy (32%) and technical barriers (29%).

CONCLUSION

In the study ED, implementation of POCT was associated with a reduction in time to test result for both troponin and chemistry. Local staff felt that faster time to test result improved quality of care; however, concerns were raised with POCT accuracy.

Prescription Drug Shortages: Implications for Ambulatory Pediatrics

OBJECTIVE

To describe contemporary drug shortages affecting general ambulatory pediatrics.

STUDY DESIGN

Data from January 2001 to December 2015 were obtained from the University of Utah Drug Information Service. Two pediatricians reviewed drug shortages and identified agents used in ambulatory pediatrics. Shortage data were analyzed by the type of drug, formulation, reason for shortage, duration, marketing status, if a pediatric friendly-formulation was available, or if it was a single-source product. The availability of an alternative, and whether that alternative was affected by a shortage, also was noted.

RESULTS

Of 1883 products in shortage during the study period, 314 were determined to be used in ambulatory pediatrics. The annual number of new pediatric shortages decreased initially but then increased to a high of 38 in 2011. Of the 314 pediatric shortages, 3.8% were unresolved at the end of the study. The median duration of resolved shortages was 7.6 months. The longest shortage was for ciprofloxacin 500-mg tablets. The most common class involved was infectious disease drugs. Pediatric-friendly dosage forms were affected in 19.1% of shortages. An alternative agent was available for 86% drugs; however, 29% of these also were affected. The most common reason for shortage was manufacturing problems.

CONCLUSIONS

Drug shortages affected a substantial number of agents used in general ambulatory pediatrics. Shortages for single-source products are a concern if a suitable alternative is unavailable. Providers working in the ambulatory setting must be aware of current shortages and implement mitigation strategies to optimize patient care.

The Effect of Point-of-Care Testing at Triage: An Observational Study in a Teaching Hospital in Saudi Arabia

Introduction

Prolonged waiting times during episodes of emergency department (ED) crowding are associated with poor outcomes. Point-of-care testing (POCT) at ED triage prior to physician evaluation may help identify critically ill patients. We studied the impact of ED POCT in a single ED with a high degree of crowding for patients with high-risk complaints who were triaged as non-critically ill.

Methods

We conducted the study from April-July 2017 at King Abdulaziz University (KAU) Hospital in Jeddah, Saudi Arabia. Patients with one of seven complaints received triage POCT. The primary outcome was whether POCT results at triage resulted in immediate transfer of the patient from the waiting room into the ED. Secondary outcomes were whether the triage nurse felt that the POCT results were useful, and whether triage POCT changed triage acuity. We used simple descriptive statistics to summarize the data.

Results

A total of 94 patients were enrolled and received i-STAT® POCT. The most common symptoms and triage protocols were for chest pain (42%), abdominal pain (31%), and shortness of breath (22%). In 11 cases (12%), care was changed as a result of triage POCT. In 12 cases (13%), triage level was changed. The triage nurse found POCT helpful in 93% of cases.

Conclusion

In this ED, triage POCT was a helpful adjunct at ED triage and resulted in immediate care (transfer to an ED room) in one in eight cases. Therefore, POCT at triage may be a useful adjunct to improve patient safety, particularly in crowded EDs.

A Comparison of Care Delivered in Hospital-based and Freestanding Emergency Departments

OBJECTIVE

We compare case mix, hospitalization rates, length of stay (LOS), and resource use in independent freestanding emergency departments (FSEDs) and hospital-based emergency departments (H-EDs).

METHODS

Data from 74 FSEDs (2013-2015) in Texas and Colorado were compared to H-ED data from the 2013-2014 National Hospital Ambulatory Medical Care Survey. In the unrestricted sample, large differences in visit characteristics (e.g., payer and case mix) were found between patients that use FSEDs compared to H-EDs. Therefore, we restricted our analysis to patients commonly treated in both settings (<65 years, privately insured, nonambulance) and used inverse propensity score weighting (IPW) to balance the two settings on observable patient characteristics. We then compared ED LOS and as well as hospital admission rates and resource utilization rates in the IPW-weighted samples.

RESULTS

Before balancing, FSEDs saw more young adults (age 25-44) and fewer older adults (age 45-64) than H-EDs. FSED patients had fewer comorbidities, more injuries and respiratory infections, and fewer diagnoses of chest or abdominal pain. In balanced samples, LOS for FSED visits was 46% shorter (60 minutes) than H-ED patients. Hospital admission rates were 37% lower overall (95% confidence interval = -51% to -23%) in FSEDs and varied considerably by primary discharge diagnosis. X-ray and electrocardiogram use was significantly lower at FSEDs while others measures of resource utilization were similar (ultrasound, computed tomography scans, and laboratory tests).

CONCLUSION

In this sample of FSEDs, a greater proportion of younger patients with fewer comorbidities and more injuries and respiratory system diseases were evaluated, and almost all patients had private health insurance. When restricted to < 65 years, privately insured, and nonambulance patients in both samples, LOS was considerably shorter and hospital admission rates lower at FSEDs, as well as the use of some diagnostic testing. This study is limited as diagnoses codes may not fully capture severity and patients who perceived greater need of hospital admission may have chosen a H-ED over FSEDs.

Shortage of generic neurologic therapeutics: An escalating threat to patient care

OBJECTIVE

To assess longitudinal trends in shortages of generic drugs used for neurologic conditions over a 15-year period in the United States.

METHODS

Drug shortage data from the University of Utah Drug Information Service (UUDIS) from 2001 to 2015 were analyzed. Medications were included that were likely to be prescribed by a neurologist to treat a primary neurologic condition or critical for care of a patient with a neurologic condition. Trends in shortage length were assessed using standard descriptive statistics.

RESULTS

A total of 2,081 shortages were reported by UUDIS and 311 (15%) involved medications for neurologic conditions. After excluding discontinued products, 291 shortages were analyzed. The median number of neurologic drugs in shortage was 21 per month with a median duration of 7.4 months. During the three 5-year periods of 2001-2005, 2006-2010, and 2011-2015, a median of 12.5, 14, and 45 drugs were in shortage, respectively. A maximum of 50 drugs in shortage was reached in December 2012 and December 2014. By the end of the study period, 30 neurologic drugs remained in shortage. In over half of the shortages, manufacturers did not provide a reason for the shortage. When reported, manufacturing delays, followed by supply/demand issues, raw material shortages, regulatory issues, and business decisions were cited.

CONCLUSIONS

Continued drug shortages may compromise the care of patients with neurologic conditions. Manufacturers, together with professional organizations, patient advocacy groups, and the government, need to continue to address this issue, which may escalate with a growing burden of neurologic disease.

U.S. vaccine and immune globulin product shortages, 2001-15

PURPOSE

Trends in shortages of vaccines and immune globulin products from 2001 through 2015 in the United States are described.

METHODS

Drug shortage data from January 2001 through December 2015 were obtained from the University of Utah Drug Information Service. Shortage data for vaccines and immune globulins were analyzed, focusing on the type of product, reason for shortage, shortage duration, shortages requiring vaccine deferral, and whether the drug was a single-source product. Inclusion of the product into the pediatric vaccination schedule was also noted.

RESULTS

Of the 2,080 reported drug shortages, 59 (2.8%) were for vaccines and immune globulin products. Of those, 2 shortages (3%) remained active at the end of the study period. The median shortage duration was 16.8 months. The most common products on shortage were viral vaccines (58%), especially hepatitis A, hepatitis B, rabies, and varicella vaccines (4 shortages each). A vaccine deferral was required for 21 shortages (36%), and single-source products were on shortage 30 times (51%). The most common reason for shortage was manufacturing problems (51%), followed by supply-and-demand issues (7%). Thirty shortages (51%) were for products on the pediatric schedule, with a median duration of 21.7 months.

CONCLUSION

Drug shortages of vaccines and immune globulin products accounted for only 2.8% of reported drug shortages within a 15-year period, but about half of these shortages involved products on the pediatric vaccination schedule, which may have significant public health implications.

Bringing voice in policy building

Purpose The purpose of this paper is to describe the use of group concept mapping (GCM) as a tool for developing a conceptual model of an episode of acute, unscheduled care from illness or injury to outcomes such as recovery, death and chronic illness. Design/methodology/approach After generating a literature review drafting an initial conceptual model, GCM software (CS Global MAX^TM) is used to organize and identify strengths and directionality between concepts generated through feedback about the model from several stakeholder groups: acute care and non-acute care providers, patients, payers and policymakers. Through online and in-person population-specific focus groups, the GCM approach seeks feedback, assigned relationships and articulated priorities from participants to produce an output map that described overarching concepts and relationships within and across subsamples. Findings A clustered concept map made up of relational data points that produced a taxonomy of feedback was used to update the model for use in soliciting additional feedback from two technical expert panels (TEPs), and finally, a public comment exercise was performed. The results were a stakeholder-informed improved model for an acute care episode, identified factors that influence process and outcomes, and policy recommendations, which were delivered to the Department of Health and Human Services's (DHHS) Assistant Secretary for Preparedness and Response. Practical implications This study provides an example of the value of cross-population multi-stakeholder input to increase voice in shared problem health stakeholder groups. Originality/value This paper provides GCM results and a visual analysis of the relational characteristics both within and across sub-populations involved in the study. It also provides an assessment of observational key factors supporting how different stakeholder voices can be integrated to inform model development and policy recommendations.

A Conceptual Model for Episodes of Acute, Unscheduled Care

We engaged in a 1-year process to develop a conceptual model representing an episode of acute, unscheduled care. Acute, unscheduled care includes acute illnesses (eg, nausea and vomiting), injuries, or exacerbations of chronic conditions (eg, worsening dyspnea in congestive heart failure) and is delivered in emergency departments, urgent care centers, and physicians' offices, as well as through telemedicine. We began with a literature search to define an acute episode of care and to identify existing conceptual models used in health care. In accordance with this information, we then drafted a preliminary conceptual model and collected stakeholder feedback, using online focus groups and concept mapping. Two technical expert panels reviewed the draft model, examined the stakeholder feedback, and discussed ways the model could be improved. After integrating the experts' comments, we solicited public comment on the model and made final revisions. The final conceptual model includes social and individual determinants of health that influence the incidence of acute illness and injury, factors that affect care-seeking decisions, specific delivery settings where acute care is provided, and outcomes and costs associated with the acute care system. We end with recommendations for how researchers, policymakers, payers, patients, and providers can use the model to identify and prioritize ways to improve acute care delivery.

Longitudinal Trends in U.S. Drug Shortages for Medications Used in Emergency Departments (2001-2014)

OBJECTIVES

This was a study of longitudinal trends in U.S. drug shortages within the scope of emergency medicine (EM) practice from 2001 to 2014.

METHODS

Drug shortage data from the University of Utah Drug Information Service were analyzed from January 2001 to March 2014. Two board-certified emergency physicians classified drug shortages based on whether they were within the scope of EM practice, whether they are used for lifesaving interventions or high-acuity conditions, and whether a substitute for the drug exists for its routine use in emergency care. Trends in the length of shortages for drugs used in EM practice were described using standard descriptive statistics and regression analyses.

RESULTS

Of the 1,798 drug shortages over the approximately 13-year period (159 months), 610 shortages (33.9%) were classified as within the scope of EM practice. Of those, 321 (52.6%) were for drugs used as lifesaving interventions or for high-acuity conditions, and of those, 32 (10.0%) were for drugs with no available substitute. The prevalence of EM drug shortages fell from 2002 to 2007; however, between January 2008 and March 2014, the number of EM drug shortages sharply increased by 435% from 23 to 123. From January 2008 to March 2014 shortages in drugs used as a direct lifesaving intervention or for high-acuity conditions increased 393% from 14 to 69, and shortages for drugs with no available substitute grew 125% from four to nine. Almost half (46.6%) of all EM drug shortages were caused by unknown reasons (the manufacturer did not cite a specific reason when contacted). Infectious disease drugs were the most common EM drugs on shortage, with 148 drug shortages totaling 2,213 months during the study period.

CONCLUSIONS

Drug shortages impacting emergency care have grown dramatically since 2008. The majority of shortages are for drugs used for lifesaving interventions or high-acuity conditions. For some, no substitute is available.

The Relationship of Financial Pressures and Community Characteristics to Closure of Private Safety Net Clinics

In order to better understand what threatens vulnerable populations' access to primary care, it is important to understand the factors associated with closing safety net clinics. This article examines how a clinic's financial position, productivity, and community characteristics are associated with its risk of closure. We examine patterns of closures among private-run primary care clinics (PCCs) in California between 2006 and 2012. We use a discrete-time proportional hazard model to assess relative hazard ratios of covariates, and a random-effect hazard model to adjust for unobserved heterogeneity among PCCs. We find that lower net income from patient care, smaller amount of government grants, and lower productivity were associated with significantly higher risk of PCC closure. We also find that federally qualified health centers and nonfederally qualified health centers generally faced the same risk factors of closure. These results underscore the critical role of financial incentives in the long-term viability of safety net clinics.

Comparison of Mortality and Costs at Trauma and Nontrauma Centers for Minor and Moderately Severe Injuries in California

STUDY OBJECTIVE

We examine differences in inpatient mortality and hospitalization costs at trauma and nontrauma centers for injuries of minor and moderate severity.

METHODS

Inpatient data sets from the California Office of Statewide Health Planning and Development were analyzed for 2009 to 2011. The study population included patients younger than 85 years and admitted to general, acute care hospitals with a primary diagnosis of a minor or moderate injury. Minor injuries were defined as having a New Injury Severity Score less than 5 and moderate injuries as having a score of 5 to 15. Multivariate logistic regression and generalized linear model with log-link and γ distribution were used to estimate differences in adjusted inpatient mortality and costs.

RESULTS

A total of 126,103 admissions with minor or moderate injury were included in the study population. The unadjusted mortality rate was 6.4 per 1,000 admissions (95% confidence interval [CI] 5.9 to 6.8). There was no significant difference found in mortality between trauma and nontrauma centers in unadjusted (odds ratio 1.2; 95% CI 0.97 to 1.48) or adjusted models (odds ratio 1.1; 95% CI 0.79 to 1.57). The average cost of a hospitalization was $13,465 (95% CI $12,733 to $14,198) and, after adjustment, was 33.1% higher at trauma centers compared with nontrauma centers (95% CI 16.9% to 51.6%).

CONCLUSION

For patients admitted to hospitals for minor and moderate injuries, hospitalization costs in this study population were higher at trauma centers than nontrauma centers, after adjustments for patient clinical-, demographic-, and hospital-level characteristics. Mortality was a rare event in the study population and did not significantly differ between trauma and nontrauma centers.

Variation in emergency department admission rates across the United States

There were more than 19 million hospitalizations in 2008 from hospital-based emergency departments (EDs), representing nearly 50% of all U.S. admissions. Factors related to variation in hospital-level ED admission rates are unknown. Generalized linear models were used to assess patient-, hospital-, and community-level factors associated with ED admission rates across a sample of U.S. hospitals using Healthcare Cost and Utilization Project data. In 1,376 EDs, the mean ED admission rate, when defined as direct admissions and also transfers from one ED to another hospital, was 17.5% and varied from 9.8% to 25.8% at the 10th and 90th percentiles. Higher proportions of Medicare and uninsured patients, more inpatient beds, lower ED volumes, for-profit ownership, trauma center status, and higher hospital occupancy rates were associated with higher ED admission rates. Also, hospitals in counties with fewer primary care physicians per capita and higher county-level ED admission rates had higher ED admission rates.