The way back home: The invisible burden of the emergency healthcare services

Ambulance services around the world vary according to regional, cultural and socioeconomic conditions. Many countries apply different health policies locally. In Turkey, transportation from hospital to home has started to form an important part of ambulance services in recent years. The increase in the number of patients whose treatment has been completed and waiting to be referred may hinder the work of the emergency services. The aim of this study was to examine the costs, indications, and impact on workload of patients sent home by ambulance. Patients were divided into two groups according to the reasons for referral. The distance to home, transport time and cost were calculated according to the reasons for transport. Patients who were transferred to other clinics or hospitals by ambulance were excluded from the study. The findings showed that the hospital-to-home transfer rate during the study period was 11.4%. Although 9.7% of all cases transferred from our hospital to home were due to social indications, these cases accounted for 16.26% of the total costs. These results suggest that providing home transport services to selected patient groups for medical reasons should be seen as part of the treatment. However, the indications for home transport should not be exceeded and an additional burden should not be placed on the fragile health service.

Healthcare and economic cost burden of emergency medical services treated non-traumatic shock using a population-based cohort in Victoria, Australia

OBJECTIVES

We aimed to assess the healthcare costs and impact on the economy at large arising from emergency medical services (EMS) treated non-traumatic shock.

DESIGN

We conducted a population-based cohort study, where EMS-treated patients were individually linked to hospital-wide and state-wide administrative datasets. Direct healthcare costs (Australian dollars, AUD) were estimated for each element of care using a casemix funding method. The impact on productivity was assessed using a Markov state-transition model with a 3-year horizon.

SETTING

Patients older than 18 years of age with shock not related to trauma who received care by EMS (1 January 2015-30 June 2019) in Victoria, Australia were included in the analysis.

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome assessed was the total healthcare expenditure. Secondary outcomes included healthcare expenditure stratified by shock aetiology, years of life lived (YLL), productivity-adjusted life-years (PALYs) and productivity losses.

RESULTS

A total of 21 334 patients (mean age 65.9 (±19.1) years, and 9641 (45.2%) females were treated by EMS with non-traumatic shock with an average healthcare-related cost of $A11 031 per episode of care and total cost of $A280 million. Annual costs remained stable throughout the study period, but average costs per episode of care increased (Ptrend=0.05). Among patients who survived to hospital, the average cost per episode of care was stratified by aetiology with cardiogenic shock costing $A24 382, $A21 254 for septic shock, $A19 915 for hypovolaemic shock and $A28 057 for obstructive shock. Modelling demonstrated that over a 3-year horizon the cohort lost 24 355 YLLs and 5059 PALYs. Lost human capital due to premature mortality led to productivity-related losses of $A374 million. When extrapolated to the entire Australian population, productivity losses approached $A1.5 billion ($A326 million annually).

CONCLUSION

The direct healthcare costs and indirect loss of productivity among patients with non-traumatic shock are high. Targeted public health measures that seek to reduce the incidence of shock and improve systems of care are needed to reduce the financial burden of this syndrome.

Does Every Minute Really Count? Road Time as an Indicator for the Economic Value of Emergency Medical Services

OBJECTIVES

This article builds on the literature regarding the association between emergency medical service (EMS) response times and patient outcomes (death and severe injury). Three issues are addressed in this article with respect to the empirical estimation of this relationship: the endogeneity of response time (systematically quicker response for higher degrees of urgency), the nonlinearity of this relationship, and the variation between such estimations for different patient outcomes.

METHODS

Binomial and multinomial logistic regression models are used to estimate the impact of response time on the probabilities of death and severe injury using data from French Fire and Rescue Services. These models are developed with response time as an explanatory variable and then with road time (dispatch to arrival) hypothesized as representing the exogenous variation within response time. Both models are also applied to data subsets based on response time intervals.

RESULTS

The results show that road time yields a higher estimate for the impact of response time on patient outcomes than (total) response time. The impact of road time on patient outcomes is also shown to be nonlinear. These results are of both statistical significance (model coefficients are significant at the 95% confidence level) and economical significance (when taking into account the number of annual interventions performed).

CONCLUSIONS

When using heterogeneous data on EMS interventions where endogeneity is a clear issue, road time is a more reliable indicator to estimate the impact of EMS response time on patient outcomes than (total) response time.

Evaluation of Length of Stay, Care Volume, In-Hospital Mortality, and Emergency Readmission Rate Associated With Use of Diagnosis-Related Groups for Internal Resource Allocation in Public Hospitals in Hong Kong

IMPORTANCE

Hong Kong's internal resource allocation system for public inpatient care changed from a global budget system to one based on diagnosis-related groups (DRGs) in 2009 and returned to a global budget system in 2012. Changes in patient and hospital outcomes associated with moving from a DRG-based system to a global budget system for inpatient care have rarely been evaluated.

OBJECTIVE

To examine associations between the introduction and discontinuation of DRGs and changes in length of stay, volume of care, in-hospital mortality rates, and emergency readmission rates in the inpatient population in acute care hospitals overall, stratified by age group, and across 5 medical conditions.

DESIGN, SETTING, AND PARTICIPANTS

This cross-sectional study included data from patients aged 45 years or older who were hospitalized in public acute care settings in Hong Kong before the introduction (April 2006 to March 2009), during implementation (April 2009 to March 2012), and after discontinuation (April 2012 to November 2014) of the DRG scheme. Data analysis was conducted from January to June 2021.

EXPOSURES

Public hospitals transitioned from a global budget payment system to a DRG-based system in April 2009 and returned to a global budget system in April 2014.

MAIN OUTCOMES AND MEASURES

The main outcome was the association of use of DRGs with patient-level length of stay, in-hospital mortality rate, 1-month emergency readmission rate, and population-level number of admissions per month. An interrupted time series design was used to estimate changes in the level and slope of outcome variables after introduction and discontinuation of DRGs, accounting for pretrends.

RESULTS

This study included 7 604 390 patient episodes. Overall, the mean (SD) age of patients was 68.97 (13.20) years, and 52.17% were male. The introduction of DRGs was associated with a 1.77% (95% CI, 1.23%-2.32%) decrease in the mean length of stay, a 2.90% (95% CI, 2.52%-3.28%) increase in the number of patients admitted, a 4.12% (95% CI, 1.89%-6.35%) reduction in in-hospital mortality, and a 2.37% (95% CI, 1.28%-3.46%) decrease in emergency readmissions. Discontinuation of the DRG scheme was associated with a 0.93% (95% CI, 0.42%-1.44%) increase in the mean length of stay and a 1.82% (95% CI, 1.47%-2.17%) reduction in the number of patients treated after adjusting for covariates; no statistically significant change was observed in in-hospital mortality (-0.14%; 95% CI, -2.29% to 2.01%) or emergency readmission rate (-0.29%; 95% CI, -1.30% to 0.71%).

CONCLUSIONS AND RELEVANCE

In this cross-sectional study, the introduction of DRGs was associated with shorter lengths of stay and increased hospital volume, and discontinuation was associated with longer lengths of stay and decreased hospital volume. In-hospital mortality and emergency readmission rates did not significantly change after discontinuation of DRGs.

Factors associated with destination of pediatric EMS transports

OBJECTIVE

Pediatric patients comprise 13% of emergency medical services (EMS) transports, and most are transported to general emergency departments (ED). EMS transport destination policies may guide when to transport patients to a children's hospital, especially for medical complaints. Factors that influence EMS providers 'decisions about where to transport children are unknown. Our objective was to evaluate the factors associated with pediatric EMS transports to children's hospitals for medical complaints.

METHODS

We performed a cross-sectional study of a large, urban EMS system over a 12-month period for all transports of patients 0-17 years old. We electronically queried the EMS database for demographic data, medical presentation and management, comorbidities, and documented reasons for choosing destination. Distances to the destination hospital and nearest children's and community hospital (if not the transport destination) were calculated. Univariate and multiple logistic regression analyses were conducted to determine the association between independent variables and the transport destination.

RESULTS

We identified 10,065 patients, of which 6982 (69%) were for medical complaints. Of these medical complaints, 3518 (50.4%) were transported to a children's hospital ED. Factors associated with transport to a children's hospital include ALS transport, greater transport distance, protocol determination, developmental delay, or altered consciousness. Factors associated with transport to general EDs were older age, unknown insurance status, lower income, greater distance to children's or community hospital, destination determined by closest facility or diversion, abnormal respiratory rate or blood glucose, psychiatric primary impression, or communication barriers present.

CONCLUSIONS

We found that younger patient age, EMS protocol requirements, and paramedic scene response may influence pediatric patient transport to both children's and community hospitals. Socioeconomic factors, ED proximity, diversion status, respiratory rate, chief complaints, and communication barriers may also be contributing factors. Further studies are needed to determine the generalizability of these findings to other EMS systems.

Methodology of emergency medical logistics for multiple epidemic areas in public health emergency

Coronavirus disease 2019(COVID-19) has brought great disasters to humanity, and its influence continues to intensify. In response to the public health emergencies, prompt relief supplies are key to reduce the damage. This paper presents a method of emergency medical logistics to quick response to emergency epidemics. The methodology includes two recursive mechanisms: (1) the time-varying forecasting of medical relief demand according to a modified susceptible-exposed-infected- Asymptomatic- recovered (SEIAR) epidemic diffusion model, (2) the relief supplies distribution based on a multi-objective dynamic stochastic programming model. Specially, the distribution model addresses a hypothetical network of emergency medical logistics with considering emergency medical reserve centers (EMRCs), epidemic areas and e-commerce warehousing centers as the rescue points. Numerical studies are conducted. The results show that with the cooperation of different epidemic areas and e-commerce warehousing centers, the total cost is 6% lower than without considering cooperation of different epidemic areas, and 9.7% lower than without considering cooperation of e-commerce warehousing centers. Particularly, the total cost is 20% lower than without considering any cooperation. This study demonstrates the importance of cooperation in epidemic prevention, and provides the government with a new idea of emergency relief supplies dispatching, that the rescue efficiency can be improved by mutual rescue between epidemic areas in public health emergency.

Trends in ambulance transports and costs among Medicare beneficiaries, 2007-2018

BACKGROUND

The primary purpose of this study was to evaluate trends in ambulance utilization and costs among Medicare beneficiaries from 2007 to 2018. Community characteristics associated with ambulance use and costs are also explored.

METHODS

Aggregated county-level fee-for-service (FFS) Medicare beneficiary claims data from 2007 to 2018 were used to assess ambulance transports per 1000 FFS Medicare beneficiaries and standardized inflation-adjusted ambulance costs. Multivariable linear mixed models were used to quantify trends in ambulance utilization and costs and to control for confounders.

RESULTS

A total of 37,675 county-years were included from 2007 to 2018. Ambulance transports per 1000 beneficiaries increased 15% from 299 (95% CI: 291.63, 307.30) to 345 (95% CI: 336.91, 353.10) from 2007 to 2018. Inflation-adjusted standardized per user costs exhibited an increasing (1.04, 95% CI: 1.04, 1.05), but non-linear relationship (0.996, 95% CI: 0.996, 0.996) over time with costs peaking in 2012. Indicators of lower socioeconomic status (SES) were associated with increases in both ambulance events and costs (p < .0001). A higher prevalence of Medicare beneficiaries utilizing Skilled Nursing Facilities was associated with increased levels of ambulance events per 1000 beneficiaries (95% CI: 8.06, 10.63). Rural location was associated with a 38% increase in ambulance costs (95% CI 1.30-1.47) compared to urban location.

CONCLUSIONS

Numerous policy solutions have been proposed to address growing ambulance costs in the Medicare program. While ambulance transports and costs continue to increase, a bend in the ambulance cost curve is detected suggesting that one or more policies altered Medicare ambulance costs, although utilization has continued to grow linearly. Ambulance use and costs vary significantly with community-level factors. As policy makers consider how to address growing ambulance use and costs, targeting identified community-level factors associated with greater costs and utilization, and their root causes, may offer a targeted approach to addressing current trends.

The development and validation of a resource consumption score of an emergency department consultation

Background

Emergency Department (ED) visits and health care costs are increasing globally, but little is known about contributing factors of ED resource consumption. This study aims to analyse and to predict the total ED resource consumption out of the patient and consultation characteristics in order to execute performance analysis and evaluate quality improvements.

Methods

Characteristics of ED visits of a large Swiss university hospital were summarized according to acute patient condition factors (e.g. chief complaint, resuscitation bay use, vital parameter deviations), chronic patient conditions (e.g. age, comorbidities, drug intake), and contextual factors (e.g. night-time admission). Univariable and multivariable linear regression analyses were conducted with the total ED resource consumption as the dependent variable.

Results

In total, 164,729 visits were included in the analysis. Physician resources accounted for the largest proportion (54.8%), followed by radiology (19.2%), and laboratory work-up (16.2%). In the multivariable final model, chief complaint had the highest impact on the total ED resource consumption, followed by resuscitation bay use and admission by ambulance. The impact of age group was small. The multivariable final model was validated (R² of 0.54) and a scoring system was derived out of the predictors.

Conclusions

More than half of the variation in total ED resource consumption can be predicted by our suggested model in the internal validation, but further studies are needed for external validation. The score developed can be used to calculate benchmarks of an ED and provides leaders in emergency care with a tool that allows them to evaluate resource decisions and to estimate effects of organizational changes.

Is hypoglycemia expensive in China?

BACKGROUND

As a common medical emergency in individuals with diabetes, hypoglycemia events can impose significant demands on hospital resources. Based on diabetes patients with and without hypoglycemia, we assess the cost of hypoglycemic events on China's hospital system.

METHOD

Our study sample comprised 7110 diabetes episodes, including 1417 patients with hypoglycemia (297 patients with severe and 1120 with non-severe hypoglycemia) and 5693 diabetes patients without hypoglycemia. Data on patient social-demographics, length of hospital stay, and hospitalization costs were collected on each patient from Health Information System in Shandong province, China. The additional hospital costs caused by hypoglycemia were assessed by the cost difference between diabetes patients with and without hypoglycemia, including severe and non-severe hypoglycemia. China-wide hospital costs of hypoglycemia were estimated based on adjusted additional hospital costs, comprising inspection, treatment, drugs, materials, nursing, general medical costs, and other costs, caused by hypoglycemia, the prevalence of diabetes and hypoglycemia events, and the rates of hospitalization. Multiple sensitivity analyses were conducted to assess the impact of variations in the key input parameters on the primary estimates.

RESULTS

Total hospital costs for patients with hypoglycemia (US$3020.61) were significantly higher than that of patients without hypoglycemia (US$1642.91). The average additional cost caused by hypoglycemia was US$1377.70, with higher average costs of US$1875.89 for severe hypoglycemia and lower average costs of US$1244.76 for non-severe hypoglycemia. The additional hospital cost caused by severe and non-severe hypoglycemia patients was higher for the 60 to 75 year old group, married patients and patients accessing free medical services. Generally, hypoglycemic patients with Urban and Rural Resident Basic Medical Insurance incurred higher additional hospital costs than patients with Urban Employees Basic Medical Insurance. Based on these estimates, the total annual additional hospital costs arising from hypoglycemia events in China were estimated to be US$67.52 million. Sensitivity analyses suggested that the costs of hypoglycemia events ranged up to US$49.99 million to 67.52 million.

CONCLUSION

: Hypoglycemic events imposed a substantial cost on China's hospital system, with certain subgroups of patients, such as older patients and those with free health insurance, using medical resources more intensively to treat hypoglycemia events. We recommend more effective planning of prevention and treatment regimes for hypoglycemia patients; further reform to China's health insurance schemes; and better hospital cost control for those accessing free hospital services.

Economic Analysis of Mobile Integrated Health Care Delivered by Emergency Medical Services Paramedic Teams

IMPORTANCE

Mobile integrated health care (MIH) is a new model of community-based health care to provide on-site urgent or nonurgent care. Niagara emergency medical services (NEMS) started MIH in 2018 to serve the Niagara region of Ontario, Canada. However, its economic impact is unknown.

OBJECTIVE

To compare time on task and cost between MIH and ambulance delivered by NEMS from a public payer's perspective.

DESIGN, SETTING, AND PARTICIPANTS

This economic evaluation was an analysis of the NEMS databases regarding responses to emergency calls by the NEMS from 2016 to 2019. Emergency calls serviced by MIH in 2018 to 2019 were used as an intervention cohort. Propensity score matching was used to identify a 1:1 matched cohort of calls serviced by regular ambulance response for the same period and 2 years prior. Statistical analyses were performed from January to April 2020.

EXPOSURES

MIH compared with matched ambulance services.

MAIN OUTCOMES AND MEASURES

The main outcomes were the time on task (including time on scene and time at hospital) and costs. Costs were calculated in 2019 Canadian dollars using cost per minute and compared with the 3 ambulance cohorts.

RESULTS

In 2018 to 2019, there were 1740 calls serviced by MIH for which a matched ambulance cohort was identified for the same period and 2 years prior. The mean (SD) time on task was 72.7 (51.0) minutes for MIH, compared with 84.1 (52.0) minutes, 84.3 (54.1) minutes, and 79.4 (42.0) minutes for matched ambulance in 2018 to 2019, 2017 to 2018, and 2016 to 2017, respectively. Of calls serviced by MIH, 498 (28.6%) required ED transport (ie, after MIH team assessment, transport to ED was deemed to be necessary or demanded by the patient), compared with 1300 (74.7%) calls serviced by ambulance in 2018 to 2019, 1294 (74.4%) in 2017 to 2018, and 1359 (78.1%) in 2016 to 2017. The mean (SD) total cost per 1000 calls was $122 760 ($78 635) for MIH compared with $294 336 ($97 245), $299 797 ($104 456), and $297 269 ($81 144) for regular ambulance responses in the 3 matched cohorts, respectively.

CONCLUSIONS AND RELEVANCE

Compared with regular ambulance response, MIH was associated with a substantial reduction in the proportion of patients transported to the ED, leading to a substantial saving in total costs. This finding suggests that the MIH model is a promising and viable solution to meeting urgent health care needs in the community, while substantially improving the use of scarce health care resources.

Pediatric emergency care in a low-income country: Characteristics and outcomes of presentations to a tertiary-care emergency department in Mozambique

Background

An effective pediatric emergency care (PEC) system is key to reduce pediatric mortality in low-income countries. While data on pediatric emergencies from these countries can drive the development and adjustment of such a system, they are very scant, especially from Africa. We aimed to describe the characteristics and outcomes of presentations to a tertiary-care Pediatric Emergency Department (PED) in Mozambique.

Methods

We retrospectively reviewed PED presentations to the "Hospital Central da Beira" between April 2017 and March 2018. Multivariable logistic regression was used to identify predictors of hospitalization and death.

Results

We retrieved 24,844 presentations. The median age was 3 years (IQR 1-7 years), and 92% lived in the urban area. Complaints were injury-related in 33% of cases and medical in 67%. Data on presenting complaints (retrieved from hospital paper-based registries) were available for 14,204 (57.2%) records. Of these, respiratory diseases (29.3%), fever (26.7%), and gastrointestinal disorders (14.2%) were the most common. Overall, 4,997 (20.1%) encounters resulted in hospitalization. Mortality in the PED was 1.6% (62% ≤4 hours from arrival) and was the highest in neonates (16%; 89% ≤4 hours from arrival). A younger age, especially younger than 28 days, living in the extra-urban area and being referred to the PED by a health care provider were all significantly associated with both hospitalization and death in the PED at the multivariable analysis.

Conclusions

Injuries were a common presentation to a referral PED in Mozambique. Hospitalization rate and mortality in the PED were high, with neonates being the most vulnerable. Optimization of data registration will be key to obtain more accurate data to learn from and guide the development of PEC in Mozambique. Our data can help build an effective PEC system tailored to the local needs.

Outcomes of multidisciplinary team interventions in the management of sickle cell disease patients with opioid use disorders. A retrospective cohort study

Objectives:

To identify the magnitude of opioid use disorder (OUD) among sickle cell disease (SCD) patients; emphasize on multidisciplinary team (MDT) role; estimate cost-effectiveness following the proper use of therapeutic guidelines; and facilitate the reduction of emergency room (ER) visits and the length of stay (LOS).

Methods:

This retrospective cohort study included SCD patients aged 14 years and above, who have OUD. Data was collected between January 2016 and December 2018. Data included ER visits, hospital LOS, opioid consumption, and narcotic prescription tracking. The target group was followed with a set of interventions for pain management and healthcare resource utilization.

Results:

Twenty one SCD patients were identified with OUD. Following the interventions, there was a statistically significant decrease in ER visits of these OUD patients (from 8709 visits in 2016 to only 94 in 2018). Morphine consumption decreased by 82% and meperidine by 60%, over the 3-year period. Moreover, there was a huge reduction in both ER and LOS costs for this cohort of patients.

Conclusion:

Establishing an MDT and a series of interventions for SCD patients with OUD, including educational activities for caregivers and patients; establishing a palliative/pain clinic and a SCD addiction clinic; and implementing an adequate opioid prescription tracking system resulted in a significant reduction in both the cost and number of ER visits and hospital LOS and dramatically decreased opioid consumption.

Cost-effectiveness of emergency care interventions in low and middle-income countries: a systematic review

OBJECTIVE

To systematically review and appraise the quality of cost-effectiveness analyses of emergency care interventions in low- and middle-income countries.

METHODS

Following the PRISMA guidelines, we systematically searched PubMed®, Scopus, EMBASE®, Cochrane Library and Web of Science for studies published before May 2019. Inclusion criteria were: (i) an original cost-effectiveness analysis of emergency care intervention or intervention package, and (ii) the analysis occurred in a low- and middle-income setting. To identify additional primary studies, we hand searched the reference lists of included studies. We used the Consolidated Health Economic Evaluation Reporting Standards guideline to appraise the quality of included studies.

RESULTS

Of the 1674 articles we identified, 35 articles met the inclusion criteria. We identified an additional four studies from the reference lists. We excluded many studies for being deemed costing assessments without an effectiveness analysis. Most included studies were single-intervention analyses. Emergency care interventions evaluated by included studies covered prehospital services, provider training, treatment interventions, emergency diagnostic tools and facilities and packages of care. The reporting quality of the studies varied.

CONCLUSION

We found large gaps in the evidence surrounding the cost-effectiveness of emergency care interventions in low- and middle-income settings. Given the breadth of interventions currently in practice, many interventions remain unassessed, suggesting the need for future research to aid resource allocation decisions. In particular, packages of multiple interventions and system-level changes represent a priority area for future research.

Emergency medical care of incarcerated patients: Opportunities for improvement and cost savings

In the United States (US), the lifetime incidence of incarceration is 6.6%, exceeding that of any other nation. Compared to the general US population, incarcerated individuals are disproportionally affected by chronic health conditions, mental illness, and substance use disorders. Barriers to accessing medical care are common in correctional facilities. We sought to characterize the local incarcerated patient population and explore barriers to medical care in these patients. We conducted a retrospective, observational cohort study by reviewing the medical records of incarcerated patients presenting to the adult emergency department (ED) of a single academic, tertiary care facility with medical or psychiatric (med/psych) and trauma-related emergencies between January 2012 and December 2014. Data on demographics, medical complexity, trauma intentionality, and barriers to medical care were analyzed using descriptive statistics, unpaired student’s t-test or one-way analysis of variance for continuous variables, and chi-square analysis or Fisher’s exact test as appropriate. Trauma patients were younger with fewer medical comorbidities and were less likely to be admitted to the hospital than med/psych patients. 47.8% of injuries resulted from violence or were self-inflicted. Most trauma-related complaints were managed by the emergency medicine physician in the ED. While barriers to medical care were not correlated with hospital admission, 5.4% of med/psych and 2.9% of trauma patients reported barriers as a contributing factor to the ED encounter. Med/psych patients commonly reported a lack of access to medications, while trauma patients reported a delay in medical care. Trauma-related presentations were less medically complex than med/psych-related complaints. Medical management of most injuries required no hospital resources outside of the ED, indicating a potential role for outpatient management of trauma-related complaints. Additional opportunities for health care improvement and cost savings include the implementation of programs that target violence, prevent injuries, and promote the continuity of medical care while incarcerated.

Cost-effectiveness Analysis of the Elder-Friendly Approaches to the Surgical Environment (EASE) Intervention for Emergency Abdominal Surgical Care of Adults Aged 65 Years and Older

IMPORTANCE

The Elder-Friendly Approaches to the Surgical Environment (EASE) initiative is a novel approach to acute surgical care for elderly patients.

OBJECTIVE

To determine the cost-effectiveness of EASE.

DESIGN, SETTING, AND PARTICIPANTS

An economic evaluation from the perspective of the health care system was conducted as part of the controlled before-and-after EASE study at 2 tertiary care centers, the University of Alberta Hospital and Foothills Medical Centre. Participants included elderly adults (aged ≥65 years) admitted for emergency abdominal surgery between 2014 and 2017. Data were analyzed from April 2018 to February 2019.

MAIN OUTCOMES AND MEASURES

Data were captured at both control and intervention sites before and after implementation of the EASE intervention. Resource use was captured over 6 months of follow-up and was converted to costs. Utility was measured with the EuroQol Five-Dimensions Three-Levels instrument at 6 weeks and 6 months of follow-up. The differences-in-differences method was used to estimate the association of the intervention with cost and quality-adjusted life-years. For a subset of participants, self-reported out-of-pocket health care costs were collected using the Resource Use Inventory at 6 months.

RESULTS

A total of 675 participants were included (mean [SD] age, 75.3 [7.9] years; 333 women [49.3%]), 289 in the intervention group and 386 in the control group. The mean (SD) cost per control participant was $36 995 ($44 169) before EASE and $35 032 ($43 611) after EASE (all costs are shown in 2018 Canadian dollars). The mean (SD) cost per intervention participant was $56 143 ($74 039) before EASE and $39 001 ($59 854) after EASE. Controlling for age, sex, and Clinical Frailty Score, the EASE intervention was associated with a mean (SE) cost reduction of 23.5% (12.5%) (P = .02). The change in quality-adjusted life-years observed associated with the intervention was not statistically significant (mean [SE], 0.00001 [0.0001] quality-adjusted life-year; P = .72). The Resource Use Inventory was collected for 331 participants. The mean (SE) odds ratio for having 0 out-of-pocket expenses because of the intervention, compared with having expenses greater than 0, was 15.77 (3.37) (P = .02). Among participants with Resource Use Inventory costs greater than 0, EASE was not associated with a change in spending (mean [SE] reduction associated with EASE, 19.1% [45.2%]; P = .57).

CONCLUSIONS AND RELEVANCE

This study suggests that the EASE intervention was associated with a reduction in costs and no change in quality-adjusted life-years. In locations that lack capacity to implement this intervention, costs to increase capacity should be weighed against the estimated costs avoided.

Early intravenous iron administration in the Emergency Department reduces red blood cell unit transfusion, hospitalisation, re-transfusion, length of stay and costs

BACKGROUND

Moderate to severe iron deficiency anaemia is a common finding in patients admitted to the Emergency Department (ED). According to Patient Blood Management principles, intravenous iron should be the therapy of choice instead of blood transfusion for selected cases affected by chronic iron deficiency anaemia. However, this option is only rarely taken into account by physicians in the ED. As a result, in many circumstances, treatment of iron deficiency anaemia in the ED can differ from that of the Anaemia Clinic. With the aim of reducing inappropriate transfusions, and to implement intravenous iron usage, we shared a specific protocol with the ED.

MATERIAL AND METHODS

We reviewed the medical records of all subjects admitted to the ED (n=267, Post-protocol group) with hemoglobin ≤9.0 g/dL and mean corpuscular volume <80 fL in a 13-month period, except if the massive transfusion protocol was activated, and results were compared with an equivalent Pre-protocol historical cohort (n=226).

RESULTS

In comparison with the Pre-protocol series, the number of patients transfused did not change, but the appropriateness in terms of transfusion and red blood cell volume transfused improved sharply (87.0 vs 13.3%; p<0.001) with a significant increase in intravenous iron administration (50.2 vs 4.4% of cases; p<0.001). As a positive consequence, both the time spent in the ED by patients who were then directly discharged and costs per subject treated dropped by 37.9% and 59.0%, respectively. Treatment with infusion only in comparison with transfusion only led to a statistically significant Relative Risk reduction in transfusion on the ward and post-discharge transfusion of 55.6% and 44.4%, respectively.

DISCUSSION

The implementation of Patient Blood Management principles and early intravenous iron therapy in the Emergency Department have proved to be effective tools to optimise resources both in terms of units transfused and costs.

A Technology-Enabled Concussion Care Pathway Reduces Costs and Enhances Care

BACKGROUND

The standardization of care along disease lines is recommended to improve outcomes and reduce health care costs. The multiple disciplines involved in concussion management often result in fragmented and disparate care. A fundamental gap exists in the effective utilization of rehabilitation services for individuals with concussion.

PURPOSE

The purpose of this project was to (1) characterize changes in health care utilization following implementation of a concussion carepath, and (2) present an economic evaluation of patient charges following carepath implementation.

DESIGN

This was a retrospective cohort study.

METHODS

A review of electronic medical and financial records was conducted of individuals (N = 3937), ages 18 to 45 years, with primary diagnosis of concussion who sought care in the outpatient or emergency department settings over a 7-year period (2010-2016). Outcomes including encounter length, resource utilization, and charges were compared for each year to determine changes from pre- to post-carepath implementation.

RESULTS

Concussion volumes increased by 385% from 2010 to 2015. Utilization of physical therapy increased from 9% to 20% while time to referral decreased from 72 to 23 days post-injury. Utilization of emergency medicine and imaging were significantly reduced. Efficient resource utilization led to a 20.7% decrease in median charges (estimated ratio of means [CI] 7.72 [0.53, 0.96]) associated with concussion care.

LIMITATIONS

Encounter lengths served as a proxy for recovery time.

CONCLUSIONS

The implementation of the concussion carepath was successful in optimizing clinical practice with respect to facilitating continuity of care, appropriate resource utilization, and effective handoffs to physical therapy. The utilization of enabling technology to facilitate the collection of common outcomes across providers was vital to the success of standardizing clinical care without compromising patient outcomes.

Effects of implementing free maternity service policy in Kenya: an interrupted time series analysis

BACKGROUND

Maternal and perinatal mortality is a major public health concern across the globe and more so in low and middle-income countries. In Kenya, more than 6000 maternal deaths, and 35,000 stillbirths occur each year. The Government of Kenya abolished user fee for maternity care under the Free Maternity Service policy, in June of 2013 in all public health facilities, a move to make maternity services accessible and affordable, and to reduce maternal and perinatal mortality.

METHOD

An observational retrospective study was carried out in 3 counties in Kenya. Six maternal health output indicators were observed monthly, 2 years pre and 2 years post- policy implementation. Data was collected from daily maternity registers in 90 public health facilities across the 3 counties all serving an estimated population of 3 million people. Interrupted Time Series Analysis (ITSA) with a single group was used to assess the effects of the policy. Standard linear regression using generalized least squares (gls) model, was used to run the results for each of the six variables of interest. Absolute and relative changes were calculated using the gls model coefficients.

RESULTS

Significant sustained increase of 89, 97, and 98% was observed in the antenatal care visits, health facility deliveries, and live births respectively, after the policy implementation. An immediate and significant increase of 27% was also noted for those women who received Emergency Obstetric Care (EmONC) services in either the level 5, 4 and 3 health facilities. No significant changes were observed in the stillbirth rate and caesarean section rate following policy implementation.

CONCLUSION

After 2 years of implementing the Free Maternity Service policy in Kenya, immediate and sustained increase in the use of skilled care during pregnancy and childbirth was observed. The study suggest that hospital cost is a major expense incurred by most women and their families whilst seeking maternity care services and a barrier to maternity care utilization. Overall, Free Maternity Service policy, as a health financing strategy, has exhibited the potential of realizing the full beneficial effects of maternal morbidity and mortality reduction by increasing access to skilled care.

Three-month use of idarucizumab at Christchurch Hospital through the emergency department and MedChartTM

AIMS

To examine idarucizumab use via the emergency department (ED), Christchurch Hospital; adherence to Hospital Medicines List (HML) criteria, licensed dosing and local coagulation monitoring guidelines.

METHODS

All patients given idarucizumab were recorded over three months. Data collected included demographics, coagulation tests, dabigatran dosing and timing of idarucizumab administration.

RESULTS

Twelve patients received idarucizumab. The median age (range) was 73 (56-83) years and male:female was 4:8. HML criteria were met in 11 patients. Eleven patents had idarucizumab administered within licence. Coagulation tests were taken pre-idarucizumab in all patients and post-idarucizumab in eight patients. The median thrombin clotting times pre- and post-idarucizumab were 153 and 16 seconds respectively.

CONCLUSION

The indications for idarucizumab use were within HML criteria and administration was as per licensed dosing regimen in 11 of 12 patients. Appropriate monitoring of coagulation parameters was carried out in all patients as per local guidelines prior to idarucizumab administration, and thrombin clotting times pre and post were as expected for all but one patient.

Cost-effectiveness of advanced life support and prehospital critical care for out-of-hospital cardiac arrest in England: a decision analysis model

OBJECTIVES

This research aimed to answer the following questions: What are the costs of prehospital advanced life support (ALS) and prehospital critical care for out-of-hospital cardiac arrest (OHCA)? What is the cost-effectiveness of prehospital ALS? What improvement in survival rates from OHCA would prehospital critical care need to achieve in order to be cost-effective?

SETTING

A single National Health Service ambulance service and a charity-funded prehospital critical care service in England.

PARTICIPANTS

The patient population is adult, non-traumatic OHCA.

METHODS

We combined data from previously published research with data provided by a regional ambulance service and air ambulance charity to create a decision tree model, coupled with a Markov model, of costs and outcomes following OHCA. We compared no treatment for OHCA to the current standard of care of prehospital ALS, and prehospital ALS to prehospital critical care. To reflect the uncertainty in the underlying data, we used probabilistic and two-way sensitivity analyses.

RESULTS

Costs of prehospital ALS and prehospital critical care were £347 and £1711 per patient, respectively. When costs and outcomes of prehospital, in-hospital and postdischarge phase of OHCA care were combined, prehospital ALS was estimated to be cost-effective at £11 407/quality-adjusted life year. In order to be cost-effective in addition to ALS, prehospital critical care for OHCA would need to achieve a minimally economically important difference (MEID) in survival to hospital discharge of 3%-5%.

CONCLUSION

This is the first economic analysis to address the question of cost-effectiveness of prehospital critical care following OHCA. While costs of either prehospital ALS and/or critical care per patient with OHCA are relatively low, significant costs are incurred during hospital treatment and after discharge in patients who survive. Knowledge of the MEID for prehospital critical care can guide future research in this field.

TRIAL REGISTRATION NUMBER

ISRCTN18375201.

Interfacility patient transfers in Lebanon-A culture-changing initiative to improve patient safety and outcomes

Organizing interfacility transfers is an essential component of regionalized care to improve patient outcomes. This study examines transfer characteristics after establishing a transfer center in a tertiary care center in Beirut Lebanon, and identifies predictors of success in patient transfers.This retrospective observational chart review examined all transfer center requests to and from the tertiary care center over a 4-year period (2013-2017). Descriptive analysis was done, followed by a bivariate analysis comparing transfers based on final decision (accepted yes/no) and by a multivariate logistic regression to identify predictors of successful transfers.A total of 4100 transfer requests were analyzed. Incoming transfer requests were more common than outgoing requests (56.5% vs 43.4%) and were mainly for adult patients (71.0% incoming and 78.7% outgoing). Reasons of transfers were mostly medical (99.4%) for incoming transfers and financial (73.1%) and medical (17.9%) for outgoing transfers. Requested level of care was most commonly intensive care unit for incoming transfers (61.6%) and regular floor for outgoing transfers (48.6%). Outgoing transfers were more successful than incoming transfers (59.9% vs 39.6%). Predictors of success in patient transfers within the healthcare system were identified: These included specific types of financial coverage, diagnoses, levels of care, and medical services for incoming transfers in addition to age groups and receiving hospital location for outgoing transfers.Transfer centers can be implemented successfully in any healthcare system to improve patient care and safety. Identifying facilitators and barriers to successful transfers can help healthcare administrators and policymakers address gaps in the system and improve access to care.

Austerity measures and the transforming role of A&E professionals in a weakening welfare system

In 2010, the UK embarked on a self-imposed programme of contractionary measures signalling the beginning of a so-called "age of austerity" for the country. It was argued that budgetary cuts were the most appropriate means of eliminating deficits and decreasing national debt as percentage of General Domestic Product (GDP). Although the budget for the National Health Service (NHS) was not reduced, a below-the-average increase in funding, and cuts in other areas of public spending, particularly in social care and welfare spending, impacted significantly on the NHS. One of the areas where the impact of austerity was most dramatically felt was in Accidents and Emergency Departments (A&E). A number of economic and statistical reports and quantitative studies have explored and documented the effects of austerity in healthcare in the UK, but there is a paucity of research looking at the effects of austerity from the standpoint of the healthcare professionals. In this paper, we report findings from a qualitative study with healthcare professionals working in A&E departments in England. The study findings are presented thematically in three sections. The main theme that runs through all three sections is the perceptions of austerity as shaping the functioning of A&E departments, of healthcare professions and of professionals themselves. The first section discusses the rising demand for services and resources, and the changed demographic of A&E patients-altering the meaning of A&E from 'Accidents and Emergencies' to the Department for 'Anything and Everything'. The second section in this study's findings, explores how austerity policies are perceived to affect the character of healthcare in A&E. It discusses how an increased focus on the procedures, time-keeping and the operationalisation of healthcare is considered to detract from values such as empathy in interactions with patients. In the third section, the effects of austerity on the morale and motivations of healthcare professionals themselves are presented. Here, the concepts of moral distress and burnout are used in the analysis of the experiences and feelings of being devalued. From these accounts and insights, we analyse austerity as a catalyst or mechanism for a significant shift in the practice and function of the NHS-in particular, a shift in what is counted, measured and valued at departmental, professional and personal levels in A&E.

Calculating the economic burden of fatal drowning in Australia

BACKGROUND

Aquatic activities provide physical and social benefits, while the risk of drowning generates countervailing social costs. Drawing on estimates of fatal drowning gathered by Royal Life Saving Society - Australia, this paper outlines a method for estimating the economic burden attributable to fatal drowning.

METHODS

This study estimated the burden of fatal drowning by combining Value of a Statistical Life Year (VSLY), hospitalization, productivity and emergency services costs. All unintentional fatal drowning cases in Australia between 1-July-2002 and 30-June-2017 were included. Foregone life years from each drowning were estimated based on Australian life expectancies for the year of death. The societal value of these Years of Life Lost was calculated using the VSLY for Australia, adjusted to reflect income elasticity. Corrections to discounting of VSLY were applied. Estimates of productivity losses not captured in VSLY were produced using net national capital growth. Time spent in hospital was found using coronial data and existing estimates of search, ambulance and coronial costs were adapted and incorporated.

RESULTS

The study covers 4285 cases of unintentional fatal drowning over 15 years. Based on this sample and estimates for the VSLY ($203,000), the economic burden of fatal drowning for Australia over this 14 year period was $18.63 billion in 2017 Australian dollars, averaging $1.24 billion annually.

CONCLUSIONS

Fatal drowning represents a significant source of health burden in Australia, underlining the need for further preventative measures.

PRACTICAL APPLICATIONS

We provide an easily-understood estimate of the scale of Australia's fatal drowning problem, permitting comparison with other social problems. They can also be used in determining net benefits of proposed drowning prevention policies and to identify situations where burden of fatal drowning is disproportionate. Suggestions for improving the calculation of societal burden of illness can be incorporated in cost-benefit analyses in related fields of study.

Analysis of a Commercial Insurance Policy to Deny Coverage for Emergency Department Visits With Nonemergent Diagnoses

IMPORTANCE

Insurers have increasingly adopted policies to reduce emergency department (ED) visits that they consider unnecessary. One common approach is to retrospectively deny coverage if the ED discharge diagnosis is determined by the insurer to be nonemergent.

OBJECTIVE

To characterize ED visits that may be denied coverage if the ED coverage denial policy of a large national insurer, Anthem, Inc, is widely adopted.

DESIGN, SETTING, AND PARTICIPANTS

A cross-sectional analysis of probability-sampled ED visits from the nationally representative National Hospital Ambulatory Medical Care Survey ED subsample occurring from January 1, 2011, to December 31, 2015, was conducted. Visits by commercially insured patients aged 15 to 64 years were examined. Those with ED discharge diagnoses defined by Anthem's policy as nonemergent and therefore subject to possible denial of coverage were classified as denial diagnosis visits. The primary presenting symptoms among denial diagnosis visits were identified, and all visits by commercially insured adults presenting with these primary symptoms were classified as denial symptom visits.

MAIN OUTCOMES AND MEASURES

Each visit cohort as a weighted proportion of commercially insured adult ED visits. The proportion of each visit cohort that received ED-level care, defined as visits where patients were triaged as urgent or emergent, received 2 or more diagnostic tests, or were admitted or transferred, was also examined.

RESULTS

From 2011 to 2015, 15.7% (95% CI, 15.0%-16.4%) of commercially insured adult ED visits (4440 of 28 304) were denial diagnosis visits (mean [SD] patient age, 36.6 [14.0] years; 2592 [58.7%] female and 2962 [63.5%] white). Among these visits, 39.7% (95% CI, 37.1%-42.3%) received ED-level care: 24.5% (95% CI, 21.7%-27.4%) were initially triaged as urgent or emergent and 26.0% (95% CI, 23.8%-28.3%) received 2 or more diagnostic tests. These denial diagnosis visits shared the same presenting symptoms as 87.9% (95% CI, 87.3%-88.4%) of commercially insured adult ED visits (24 882 of 28 304) (mean [SD] patient age, 38.5 [14.1] years; 14 362 [57.9%] female and 17 483 [68.7%] white). Among these denial symptom visits, 65.1% (95% CI, 63.4%-66.9%) received ED-level care: 43.2% (95% CI, 40.2%-46.4%) were triaged as urgent or emergent, 51.9% (95% CI, 50.0%-53.9%) received 2 or more diagnostic tests, and 9.7% (95% CI, 8.8%-10.6%) were admitted or transferred.

CONCLUSIONS AND RELEVANCE

Anthem's nonemergent ED discharge diagnoses were not associated with identification of unnecessary ED visits when assessed from the patient's perspective. This cost-reduction policy could place many patients who reasonably seek ED care at risk of coverage denial.

Clarification of Final Rules for Grandfathered Plans, Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, Dependent Coverage, Appeals, and Patient Protections Under the Affordable Care Act. Final rule; clarification

On November 18, 2015, the Departments of Labor, Health and Human Services, and the Treasury (the Departments) published a final rule in the Federal Register titled "Final Rules for Grandfathered Plans, Preexisting Condition Exclusions, Lifetime and Annual Limits, Rescissions, Dependent Coverage, Appeals, and Patient Protections Under the Affordable Care Act" (the November 2015 final rule), regarding, in part, the coverage of emergency services by non- grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage, including the requirement that non-grandfathered group health plans and health insurance issuers offering non-grandfathered group or individual health insurance coverage limit cost-sharing for out-of-network emergency services and, as part of that rule, pay at least a minimum amount for out-of-network emergency services. The American College of Emergency Physicians (ACEP) filed a complaint in the United States District Court for the District of Columbia, which on August 31, 2017 granted in part and denied in part without prejudice ACEP's motion for summary judgment and remanded the case to the Departments to respond to the public comments from ACEP and others. In response, the Departments are issuing this notice of clarification to provide a more thorough explanation of the Departments' decision not to adopt recommendations made by ACEP and certain other commenters in the November 2015 final rule.

The YEARS algorithm for suspected pulmonary embolism: shorter visit time and reduced costs at the emergency department

Essentials The YEARS algorithm was designed to simplify the diagnostic workup of suspected pulmonary embolism. We compared emergency ward turnaround time of YEARS and the conventional algorithm. YEARS was associated with a significantly shorter emergency department visit time of ˜60 minutes. Treatment of pulmonary embolism was initiated 53 minutes earlier with the YEARS algorithm SUMMARY: Background Recently, the safety of the YEARS algorithm, designed to simplify the diagnostic work-up of pulmonary embolism (PE), was demonstrated. We hypothesize that by design, YEARS would be associated with a shorter diagnostic emergency department (ED) visit time due to simultaneous assessment of pre-test probability and D-dimer level and reduction in number of CT scans. Aim To investigate whether implementation of the YEARS diagnostic algorithm is associated with a shorter ED visit time compared with the conventional algorithm and to evaluate the associated cost savings. Methods We selected consecutive outpatients with suspected PE from our hospital included in the YEARS study and ADJUST-PE study. Different time-points of the diagnostic process were extracted from the to-the-minute accurate electronic patients' chart system of the ED. Further, the costs of the ED visits were estimated for both algorithms. Results All predefined diagnostic turnaround times were significantly shorter after implementation of YEARS: patients were discharged earlier from the ED; 54 min (95% CI, 37-70) for patients managed without computed tomography pulmonary angiography (CTPA) and 60 min (95% CI, 44-76) for the complete study population. Importantly, patients diagnosed with PE by CTPA received the first dose of anticoagulants 53 min (95% CI, 22-82) faster than those managed according to the conventional algorithm. Total costs were reduced by on average €123 per visit. Conclusion YEARS was shown to be associated with a shorter ED visit time compared with the conventional diagnostic algorithm, leading to faster start of treatment in the case of confirmed PE and savings on ED resources.

Chemotherapy Use, End-of-Life Care, and Costs of Care Among Patients Diagnosed With Stage IV Pancreatic Cancer

CONTEXT

For patients with metastatic cancer and limited life expectancy, potential benefits of chemotherapy must be balanced against harms to quality of life near death and increased out-of-pocket costs of care.

OBJECTIVES

To evaluate the association between chemotherapy use by patients with Stage IV pancreatic cancer and health care use and Medicare and out-of-pocket costs in the last 30 days of life.

METHODS

We conducted a retrospective cohort study of 3825 patients aged 66 years or older when diagnosed with Stage IV pancreatic cancer in 2006-2011, using the linked Surveillance, Epidemiology, and End Results-Medicare data. Using a propensity score matched sample, we examined associations between initiation of chemotherapy shortly after the metastatic diagnosis (and secondarily, continued chemotherapy use in the last 30 days of life) and health care use and costs (both Medicare payment and patient out-of-pocket costs) in the last 30 days of life.

RESULTS

Chemotherapy use was associated with increased rates of hospital admissions (45.0% vs. 29.2%, P < 0.001), emergency department visits (41.3% vs. 27.2%, P < 0.001), and death in a hospital (14.2% vs. 9.1%, P < 0.001); fewer days in hospice care (11.5 days vs. 15.7 days, P < 0.001); and more than 50% increase in patient out-of-pocket costs for care ($1311.5 vs. $841.0, P < 0.001) in the last 30 days of life. Among patients who initiated chemotherapy, more stark differences in these outcomes were found by whether patients received chemotherapy in the last 30 days of life.

CONCLUSION

Chemotherapy use among older patients diagnosed with metastatic pancreatic cancer was associated with substantially increased use of health care and higher patient out-of-pocket costs near death.

Earlier Initiation of Community-Based Palliative Care Is Associated With Fewer Unplanned Hospitalizations and Emergency Department Presentations in the Final Months of Life: A Population-Based Study Among Cancer Decedents

CONTEXT

Although community-based palliative care (CPC) is associated with decreased acute care use in the lead up to death, it is unclear how the timing of CPC initiation affects this association.

OBJECTIVES

We aimed to explore the association between timing of CPC initiation and hospital use, over the final one, three, six, and 12 months of life.

METHODS

We conducted a retrospective, population-based study in Perth, Western Australia. Linked administrative data including cancer registry, mortality, hospital admissions, emergency department (ED), and CPC records were obtained for cancer decedents from 1 January, 2001 to 31 December, 2011. The exposure was month of CPC initiation; outcomes were unplanned hospitalizations, ED presentations, and associated costs.

RESULTS

Of 28,331 decedents residing in the CPC catchment area, 16,439 (58%) accessed CPC, mostly (64%) in the last three months of life. Initiation of CPC before the last six months of life was associated with a lower mean rate of unplanned hospitalizations in the last six months of life (1.4 vs. 1.7 for initiation within six months of death); associated costs were also lower ($(A2012) 12,976 vs. $13,959, comparing the same groups). However, those initiating CPC earlier did show a trend toward longer time in hospital when admitted, compared to those initiating in the final month of life.

CONCLUSIONS

When viewed at a population level, these results argue against temporally restricting access to CPC, as earlier initiation may pay dividends in the final few months of life in terms of fewer unplanned hospitalizations and ED presentations.

The effect of informal caregiver support on utilization of acute health services among home care clients: a prospective observational study

BACKGROUND

Emergency department visits and hospitalizations (EDVH) place a large burden on patients and the health care system. The presence of informal caregivers may be beneficial for reducing EDVH among patients with specific diagnoses. Our objective was to determine whether the presence of an informal caregiver was associated with the occurrence of an EDVH among clients 50 years of age or older.

METHODS

Using a database accessed through the Toronto Central Community Care Access Centre (CCAC), we identified 479 adults over 50 years of age who received home care in Toronto, Canada. Exposure variables were extracted from the interRAI health assessment form completed at the time of admission to the CCAC. EDVH data were linked to provincial records through the CCAC database. Data on emergency room visits were included for up to 6 months after time of admission to home care. Multiple logistic regression analysis was used to identify factors associated with the occurrence of an EDVH.

RESULTS

Approximately half of all clients had an EDVH within 180 days of admission to CCAC home care. No significant association was found between the presence of an informal caregiver and the occurrence of an EDVH. Significant factors associated with an EDVH included: Participants having a poor perception of their health (adjusted OR = 1.68, 95% CI: 1.11-2.56), severe cardiac disorders (adjusted OR = 1.54, 95% CI: 1.04-2.29), and pulmonary diseases (adjusted OR = 1.99, 95% CI: 1.16-3.47).

CONCLUSIONS

The presence of an informal caregiver was not significantly associated with the occurrence of an EDVH. Future research should examine the potential associations between length of hospital stay or quality of life and the presence of an informal caregiver. In general, our work contributes to a growing body of literature that is increasingly concerned with the health of our aging population, and more specifically, health service use by elderly patients, which may have implications for health care providers.

A mathematical model for efficient emergency transportation in a disaster situation

This work focuses on a real-life patient transportation problem derived from emergency medical services (EMS), whereby providing ambulatory service for emergency requests during disaster situations. Transportation of patients in congested traffic compounds already time sensitive treatment. An urgent situation is defined as individuals with major or minor injuries requiring EMS assistance simultaneously. Patients are either (1) slightly injured and treated on site or (2) are seriously injured and require transfer to points of care (PoCs). This paper will discuss enhancing the response-time of EMS providers by improving the ambulance routing problem (ARP). A genetic based algorithm is proposed to efficiently guide the ARP while simultaneously solving two scenarios.

Department of Veterans Affairs. Reimbursement for Emergency Treatment. Interim final rule

The Department of Veterans Affairs (VA) revises its regulations concerning payment or reimbursement for emergency treatment for non-service-connected conditions at non-VA facilities to implement the requirements of a recent court decision. Specifically, this rulemaking expands eligibility for payment or reimbursement to include veterans who receive partial payment from a health-plan contract for non-VA emergency treatment and establishes a corresponding reimbursement methodology. This rulemaking also expands the eligibility criteria for veterans to receive payment or reimbursement for emergency transportation associated with the emergency treatment, in order to ensure that veterans are adequately covered when emergency transportation is a necessary part of their non-VA emergency treatment.

Incremental cost and cost-effectiveness of low-dose, high-frequency training in basic emergency obstetric and newborn care as compared to status quo: part of a cluster-randomized training intervention evaluation in Ghana

BACKGROUND

Low-dose, high-frequency (LDHF) training is a new approach best practices to improve clinical knowledge, build and retain competency, and transfer skills into practice after training. LDHF training in Ghana is an opportunity to build health workforce capacity in critical areas of maternal and newborn health and translate improved capacity into better health outcomes.

METHODS

This study examined the costs of an LDHF training approach for basic emergency obstetric and newborn care and calculates the incremental cost-effectiveness of the LDHF training program for health outcomes of newborn survival, compared to the status quo alternative of no training. The costs of LDHF were compared to costs of traditional workshop-based training per provider trained. Retrospective program cost analysis with activity-based costing was used to measure all resources of the LDHF training program over a 3-year analytic time horizon. Economic costs were estimated from financial records, informant interviews, and regional market prices. Health effects from the program's impact evaluation were used to model lives saved and disability-adjusted life years (DALYs) averted. Uncertainty analysis included one-way and probabilistic sensitivity analysis to explore incremental cost-effectiveness results when fluctuating key parameters.

RESULTS

For the 40 health facilities included in the evaluation, the total LDHF training cost was $823,134. During the follow-up period after the first LDHF training-1 year at each participating facility-approximately 544 lives were saved. With deterministic calculation, these findings translate to $1497.77 per life saved or $53.07 per DALY averted. Probabilistic sensitivity analysis, with mean incremental cost-effectiveness ratio of $54.79 per DALY averted ($24.42-$107.01), suggests the LDHF training program as compared to no training has 100% probability of being cost-effective above a willingness to pay threshold of $1480, Ghana's gross national income per capita in 2015.

CONCLUSION

This study provides insight into the investment of LDHF training and value for money of this approach to training in-service providers on basic emergency obstetric and newborn care. The LDHF training approach should be considered for expansion in Ghana and integrated into existing in-service training programs and health system organizational structures for lower cost and more efficiency at scale.

ED-based care coordination reduces costs for frequent ED users

OBJECTIVES

We evaluated a pilot quality improvement intervention implemented in an urban academic medical center emergency department (ED) to improve care coordination and reduce ED visits and hospitalizations among frequent ED users.

STUDY DESIGN

Randomized controlled trial.

METHODS

We identified the most frequent ED users in both the 30 days prior to the intervention and the 12 months prior to the intervention. We randomized the top 72 patients to receive either our pilot intervention or usual care. The intervention consisted of a community health worker who assisted patients with navigating care and identifying unmet social needs and an ED-based clinical team that developed interdisciplinary acute care plans for eligible patients. After 7 months, we analyzed ED visits, hospitalizations, and costs for the intervention and control groups.

RESULTS

We randomized 72 patients to the intervention (n = 36) and control (n = 36) groups. Patients randomized to the intervention group had 35% fewer ED visits (P = .10) and 31% fewer admissions from the ED (P = .20) compared with the control group. Average ED direct costs per patient were 15% lower and average inpatient direct costs per patient were 8% lower for intervention patients compared with control patients.

CONCLUSIONS

ED-based care coordination is a promising approach to reduce ED use and hospitalizations among frequent ED users. Our program also demonstrated a decrease in costs per patient. Future efforts to promote population health and control costs may benefit from incorporating similar programs into acute care delivery systems.

Protocol for an economic evaluation of the randomised controlled trial of culprit lesion only PCI versus immediate multivessel PCI in acute myocardial infarction complicated by cardiogenic shock: CULPRIT-SHOCK trial

INTRODUCTION

Emergency percutaneous coronary intervention (PCI) of the culprit lesion for patients with acute myocardial infarctions is an accepted practice. A majority of patients present with multivessel disease with additional relevant stenoses apart from the culprit lesion. In haemodynamically stable patients, there is increasing evidence from randomised trials to support the practice of immediate complete revascularisation. However, in the presence of cardiogenic shock, the optimal management strategy for additional non-culprit lesions is unknown. A multicentre randomised controlled trial, CULPRIT-SHOCK, is examining whether culprit vessel only PCI with potentially subsequent staged revascularisation is more effective than immediate multivessel PCI. This paper describes the intended economic evaluation of the trial.

METHODS AND ANALYSIS

The economic evaluation will be conducted using a pre-trial decision model and within-trial analysis. The modelling-based analysis will provide expected costs and health outcomes, and incremental cost-effectiveness ratio over the lifetime for the cohort of patients included in the trial. The within-trial analysis will provide estimates of cost per life saved at 30 days and in 1 year, and estimates of health-related quality of life. Bootstrapping and cost-effectiveness acceptability curves will be used to address any uncertainty around these estimates. Different types of regression models within a generalised estimating equation framework will be used to examine how the total cost and quality-adjusted life years are explained by patients' characteristics, revascularisation strategy, country and centre. The cost-effectiveness analysis will be from the perspective of each country's national health services, where costs will be expressed in euros adjusted for purchasing power parity.

ETHICS AND DISSEMINATION

Ethical approval for the study was granted by the local Ethics Committee at each recruiting centre. The economic evaluation analyses will be published in peer-reviewed journals of the concerned literature and communicated through the profiles of the authors at www.twitter.com and www.researchgate.net.

TRIAL REGISTRATION NUMBER

NCT01927549; Pre-results.

Uncovering waste in US healthcare: Evidence from ambulance referral patterns

There is widespread agreement that the US healthcare system wastes as much as 5% of GDP, yet much less agreement on the source of the waste. This paper uses the effectively random assignment of patients to ambulance companies to generate comparisons across similar patients treated at different hospitals. We find that assignment to hospitals whose patients receive large amounts of care over the three months following a health emergency have only modestly better survival outcomes compared to hospitals whose patients receive less. Outcomes are related to different forms of spending. Patients assigned to hospitals with high levels of inpatient spending are more likely to survive to one year, while high levels of outpatient spending result in lower survival. In particular, we discovered that downstream spending at skilled nursing facilities (SNF) is a strong predictor of mortality. Our results highlight SNF admissions as a quality measure to complement the commonly used measure of hospital readmissions and suggest that in the search for waste in the US healthcare, post-acute SNF care is a prime candidate.

Incidence, recurrence and cost of hyperglycaemic crises requiring emergency treatment in Andalusia, Spain

AIMS

Hyperglycaemic crises (diabetic ketoacidosis and hyperosmolar hyperglycaemic state) are medical emergencies in people with diabetes. We aimed to determine their incidence, recurrence and economic impact.

METHODS

An observational study of hyperglycaemic crises cases using the database maintained by the out-of-hospital emergency service, the Healthcare Emergency Public Service (EPES) during 2012. The EPES provides emergency medical services to the total population of Andalusia, Spain (8.5 million inhabitants) and records data on the incidence, resource utilization and cost of out-of-hospital medical care. Direct costs were estimated using public prices for health services updated to 2012.

RESULTS

Among 1 137 738 emergency calls requesting medical assistance, 3157 were diagnosed with hyperglycaemic crises by an emergency coordinator, representing 2.9 cases per 1000 persons with diabetes [95% confidence intervals (CI) 2.8 to 3.0]. The incidence of diabetic ketoacidosis was 2.5 cases per 1000 persons with diabetes (95% CI 2.4 to 2.6) and the incidence of hyperosmolar hyperglycaemic state was 0.4 cases per 1000 persons with diabetes (95% CI 0.4 to 0.5). In total, 17.7% (n = 440) of people had one or more hyperglycaemic crisis. The estimated total direct cost was €4 662 151, with a mean direct cost per episode of €1476.8 ± 217.8.

CONCLUSIONS

Hyperglycaemic crises require high resource utilization of emergency medical services and have a significant economic impact on the health system.

The Shifting Landscape in Utilization of Inpatient, Observation, and Emergency Department Services Across Payers

Recent policies by public and private payers have increased incentives to reduce hospital admissions. Using data from four states from the Agency for Healthcare Research and Quality Healthcare Cost and Utilization Project, this study compared the payer-specific population-based rates of adults using inpatient, observation, and emergency department (ED) services for 10 common medical conditions in 2009 and in 2013. Patients had an expected primary payer of private insurance, Medicare, Medicaid, or no insurance. Across all four payer populations, inpatient admissions declined, and care shifted toward treat-and-release observation stays and ED visits. The percentage of hospitalizations that began with an observation stay increased. Implications for quality of care and costs to patients warrant further examination. Journal of Hospital Medicine 2017;12:443-446.

Electric bicycle-related injuries presenting to a provincial hospital in China: A retrospective study

The use of electric bicycles (EBs) in China is growing. In the present study, we aimed to characterize the pattern and outcomes of EB-related injuries presenting to a major general hospital in China.This was a retrospective review of EB-related injuries presenting to Zhejiang Provincial People's Hospital from 2008 to 2011. Cases were identified from medical records according to diagnosis codes. Data captured included demographics, injury characteristics, and outcomes.A total of 3156 cases were reviewed in the present study. There were 1460 cases of traffic accidents, of which 482 cases were EB-related (32.7%). In addition, most of EB-related cases (44.6%) belonged to the 41- to 60-year-old age group. Median injury severity score was 10. Moreover, 34.9% underwent surgery and 24.7% were admitted to intensive care unit. The median hospitalization cost was 14,269 USD. Fracture (56.5%) was the most frequently diagnosed injury type, and head was the most commonly injured body region (31.1%).EB-related injuries have become a major health concern, making up a sizeable proportion of injuries presenting to the emergency department. Therefore, it is necessary to establish injury prevention and strategies for EB road safety. Implementation of policy such as compulsory helmet use, as well as popularization of EB road safety education should be considered to improve the current situation of EB-related injuries in China.

Balance Billing by Health Care Providers: Assessing Consumer Protections Across States

ISSUE: Privately insured consumers expect that if they pay premiums and use in-network providers, their insurer will cover the cost of medically necessary care beyond their cost-sharing. However, when obtaining care at emergency departments and in-network hospitals, patients treated by an out-of-network provider may receive an unexpected "balance bill" for an amount beyond what the insurer paid. With no explicit federal protections against balance billing, some states have stepped in to protect consumers from this costly and confusing practice. GOAL: To better understand the scope of state laws to protect consumers from balance billing. METHODS: Analysis of laws in all 50 states and the District of Columbia and interviews with officials in eight states. FINDINGS AND CONCLUSIONS: Most states do not have laws that directly protect consumers from balance billing by an out-of-network provider for care delivered in an emergency department or in-network hospital. Of the 21 states offering protections, only six have a comprehensive approach to safeguarding consumers in both settings, and gaps remain even in these states. Because a federal policy solution might prove difficult, states may be better positioned in the short term to protect consumers.

Wilderness Emergency Medical Services Systems

Wilderness emergency medical services (WEMS) are designed to provide high quality health care in wilderness environments. A WEMS program should have oversight by a qualified physician responsible for protocol development, education, and quality improvement. The director is also ideally fully trained as a member of that wilderness rescue program, supporting the team with real-time patient care. WEMS providers function with scopes of practice approved by the local medical director and regulatory authority. With a focus on providing quality patient care, it is time for the evolution of WEMS as an integrated element of a local emergency response system.