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McDonald N, Antkowiak PS, Burke R, Chiu DT, Stenson BA, Sanchez LD. Emergency physician resource utilization varies by years of experience. J Am Coll Emerg Physicians Open 2024; 5:e13162. [PMID: 38659596 PMCID: PMC11040178 DOI: 10.1002/emp2.13162] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 02/12/2024] [Accepted: 03/11/2024] [Indexed: 04/26/2024] Open
Abstract
Objectives One of the most pivotal decisions an emergency physician (EP) makes is whether to admit or discharge a patient. The emergency department (ED) work-up leading to this decision involves several resource-intensive tests. Previous studies have demonstrated significant differences in EP resource utilization, measured by lab tests, advanced imaging (magnetic resonance imaging [MRI], computed tomography [CT], ultrasound), consultations, and propensity to admit a patient. However, how an EP's years of experience may impact their resource utilization and propensity to admit patients has not been well characterized. This study seeks to better understand how EPs' years of experience, post-residency, relates to their use of advanced imaging and patient disposition. Methods Ten years of ED visits were analyzed for this study from a single, academic tertiary care center in the urban Northeast United States. The primary outcomes were utilization of advanced imaging during the visit (CT, MRI, or formal ultrasound) and whether the patient was admitted. EP years of experience was categorized into 0-2 years, 3-5 years, 6-8 years, 9-11 years, and 12 or more years. Patient age, sex, Emergency Severity Index (ESI), and the attending EP's years of experience were collected. The relationship between EP years of experience and each outcome was assessed with a linear mixed model with a random effect for provider and patient age, sex, and ESI as covariates. Results A total of 460,937 visits seen by 65 EPs were included in the study. Over one-third (37.6%) of visits had an advanced imaging study ordered and nearly half (49.5%) resulted in admission. Compared to visits with EPs with 0-2 years of experience, visits with EPs with 3-5 or 6-8 years of experience had significantly lower odds of advanced imaging occurring. Visits seen by EPs with more than 2 years of experience had lower odds of admission than visits by EPs with 0-2 years of experience. Conclusion More junior EPs tend to order more advanced imaging studies and have a higher propensity to admit patients. This may be due to less comfort in decision-making without advanced imaging or a lower risk tolerance. Conversely, the additional clinical experience of the most senior EPs, with greater than 9 years of experience, likely impacts their resource utilization patterns such that their use of advanced imaging does not significantly differ from the most junior EPs.
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Affiliation(s)
- Nathan McDonald
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Peter S. Antkowiak
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Ryan Burke
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - David T. Chiu
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Bryan A. Stenson
- Department of Emergency MedicineBeth Israel Deaconess Medical CenterHarvard Medical SchoolBostonMassachusettsUSA
| | - Leon D. Sanchez
- Department of Emergency MedicineBrigham and Women's Faulkner HospitalHarvard Medical SchoolBostonMassachusettsUSA
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Howard DH, David G. Hospital ownership and admission rates from the emergency department, evidence from Florida. Health Serv Res 2024; 59:e14254. [PMID: 37875259 PMCID: PMC10915481 DOI: 10.1111/1475-6773.14254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2023] Open
Abstract
OBJECTIVE In light of Department of Justice investigations of for-profit chains for over-admitting patients, we sought to evaluate whether for-profit hospitals are more likely to admit patients from the emergency department. DATA SOURCES We used statewide visit-level inpatient and emergency department records from Florida's Agency for Healthcare Administration for 2007-2019. STUDY DESIGN We calculated differences in admission rates between for-profit and other hospitals, adjusting for patient and hospital characteristics. We also estimated instrumental variables models using differential distance to a for-profit hospital as an instrument. DATA COLLECTION/EXTRACTION METHODS Our main analysis focuses on patients ages 65 and older treated in hospitals that primarily serve adults. PRINCIPAL FINDINGS Adjusted admission rates among patients ages 65 and older were 7.1 percentage points (95% CI: 5.1-9.1) higher at for-profit hospitals in 2019 (or 18.8% of the sample mean of 37.8%). Differences in admission rates have remained constant since 2009. CONCLUSION Our results are consistent with allegations that for-profit hospitals maintain lower admission thresholds to increase occupancy levels.
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Affiliation(s)
- David H. Howard
- Department of Health Policy and ManagementEmory UniversityAtlantaGeorgiaUSA
| | - Guy David
- Department of Health Care ManagementUniversity of PennsylvaniaPhiladelphiaPennsylvaniaUSA
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Janke AT, Oskvarek JJ, Zocchi MS, Cai AG, Litvak O, Pines JM, Venkatesh AK. Reliability of a Measure of Admission Intensity for Emergency Physicians. Ann Emerg Med 2024:S0196-0644(24)00082-9. [PMID: 38430082 DOI: 10.1016/j.annemergmed.2024.02.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2023] [Revised: 01/18/2024] [Accepted: 02/02/2024] [Indexed: 03/03/2024]
Abstract
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.
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Affiliation(s)
- Alexander T Janke
- VA HSR&D Center for the Study of Healthcare Innovation, Implementation, & Policy/Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, MI; Department of Emergency Medicine, Yale School of Medicine, New Haven, CT.
| | - Jonathan J Oskvarek
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, Summa Health System, Akron, OH
| | - Mark S Zocchi
- US Acute Care Solutions, Canton, OH; Heller School for Social Policy and Management, Braindeis University, Waltham, MA
| | - Angela G Cai
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | | | | | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale School of Medicine, New Haven, CT
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Lane BH, Rea DJ, Gottula AL, Cathers AD, Ziegler RM, Latimer AJ, Danielson KR, Theiling BJ, Froehle CM, Hinckley WR. Association of Geographic Distance and Hospital Characteristics With Use of Interhospital Transfer by Air: A Multicenter Retrospective Study. Air Med J 2024; 43:111-115. [PMID: 38490773 DOI: 10.1016/j.amj.2023.11.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Revised: 10/21/2023] [Accepted: 11/01/2023] [Indexed: 03/17/2024]
Abstract
OBJECTIVE Interhospital transfer by air (IHTA) represents the majority of helicopter air ambulance transports in the United States, but the evaluation of what factors are associated with utilization has been limited. We aimed to assess the association of geographic distance and hospital characteristics (including patient volume) with the use of IHTA. METHODS This was a multicenter, retrospective study of helicopter flight request data from 2018 provided by a convenience sample of 4 critical care transport medicine programs in 3 US census regions. Nonfederal referring hospitals located in the home state of the associated critical care transport medicine program and within 100 miles of the primary receiving facility in the region were included if complete data were available. We fit a Poisson principal component regression model incorporating geographic distance, the number of emergency department visits, the number of hospital discharges, case mix index, the number of intensive care unit beds, and the number of general beds and tested the association of the variables with helicopter emergency medical services utilization. RESULTS A total of 106 referring hospitals were analyzed, 21 of which were hospitals identified as having a consistent request pattern. Using the hospitals with a consistent referral pattern, geographic distance had a significant positive association with flight request volume. Other variables, including emergency department visit volume, were not associated. Overall, the included variables offered poor explanatory power for the observed variation between referring facilities in the use of IHTA (r2 = 0.09). Predicted flights based on the principal component regression model for all referring hospitals suggested the majority of referring hospitals used multiple flight programs. CONCLUSION Geographic distance is associated with the use of IHTA. Unexpectedly, most basic hospital characteristics are not associated with the use of IHTA, and the degree of variation between referring facilities that is explained by patient volume is limited. The evaluation of nonhospital factors, such as the density and availability of critical care or advanced life support ground emergency medical services resources, is needed.
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Affiliation(s)
- Bennett H Lane
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; UC Health Air Care & Mobile Care, Cincinnati, Ohio.
| | - David J Rea
- Department of Decision and Technology Analytics, Lehigh University, Bethlehem, PA; Lehigh University College of Health, Bethlehem, PA
| | - Adam L Gottula
- Departments of Anesthesia and Emergency Medicine, University of Michigan, Ann Arbor, MI
| | - Andrew D Cathers
- Department of Emergency Medicine, University of Wisconsin, Madison, WI; UW Health Med Flight, Department of Emergency Medicine, University of Wisconsin, Madison, WI
| | - Ryan M Ziegler
- UW Health Med Flight, Department of Emergency Medicine, University of Wisconsin, Madison, WI
| | - Andrew J Latimer
- Department of Emergency Medicine, University of Washington, Seattle, WA; Airlift Northwest, Seattle, WA
| | | | - B Jason Theiling
- Division of Emergency Medicine, Department of Surgery, Duke University, Durham, NC; Emergency Services Clinical Service Unit, Duke University Hospital, Durham, NC; Duke Life Flight, Durham, NC
| | - Craig M Froehle
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; Department of Operations, Business Analytics and Information Systems, University of Cincinnati, Cincinnati, OH
| | - William R Hinckley
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, OH; UC Health Air Care & Mobile Care, Cincinnati, Ohio
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Smulowitz PB, Burke RC, Ostrovsky D, Novack V, Isbell L, Kan V, Landon BE. Clinician Risk Tolerance and Rates of Admission From the Emergency Department. JAMA Netw Open 2024; 7:e2356189. [PMID: 38363570 PMCID: PMC10873771 DOI: 10.1001/jamanetworkopen.2023.56189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 12/21/2023] [Indexed: 02/17/2024] Open
Abstract
Importance Much remains unknown about the extent of and factors that influence clinician-level variation in rates of admission from the emergency department (ED). In particular, emergency clinician risk tolerance is a potentially important attribute, but it is not well defined in terms of its association with the decision to admit. Objective To further characterize this variation in rates of admission from the ED and to determine whether clinician risk attitudes are associated with the propensity to admit. Design, Setting, and Participants In this observational cohort study, data were analyzed from the Massachusetts All Payer Claims Database to identify all ED visits from October 2015 through December 2017 with any form of commercial insurance or Medicaid. ED visits were then linked to treating clinicians and their risk tolerance scores obtained in a separate statewide survey to examine the association between risk tolerance and the decision to admit. Statistical analysis was performed from 2022 to 2023. Main Outcomes and Measures The ratio between observed and projected admission rates was computed, controlling for hospital, and then plotted against the projected admission rates to find the extent of variation. Pearson correlation coefficients were then used to examine the association between the mean projected rate of admission and the difference between actual and projected rates of admission. The consistency of clinician admission practices across a range of the most common conditions resulting in admission were then assessed to understand whether admission decisions were consistent across different conditions. Finally, an assessment was made as to whether the extent of deviation from the expected admission rates at an individual level was associated with clinician risk tolerance. Results The study sample included 392 676 ED visits seen by 691 emergency clinicians. Among patients seen for ED visits, 221 077 (56.3%) were female, and 236 783 (60.3%) were 45 years of age or older; 178 890 visits (46.5%) were for patients insured by Medicaid, 96 947 (25.2%) were for those with commercial insurance, 71 171 (18.5%) were Medicare Part B or Medicare Advantage, and the remaining 37 702 (9.8%) were other insurance category. Of the 691 clinicians, 429 (62.6%) were male; mean (SD) age was 46.5 (9.8) years; and 72 (10.4%) were Asian, 13 (1.9%) were Black, 577 (83.5%) were White, and 29 (4.2%) were other race. Admission rates across the clinicians included ranged from 36.3% at the 25th percentile to 48.0% at the 75th percentile (median, 42.1%). Overall, there was substantial variation in admission rates across clinicians; physicians were just as likely to overadmit or underadmit across the range of projected rates of admission (Pearson correlation coefficient, 0.046 [P = .23]). There also was weak consistency in admission rates across the most common clinical conditions, with intraclass correlations ranging from 0.09 (95% CI, 0.02-0.17) for genitourinary/syncope to 0.48 (95% CI, 0.42-0.53) for cardiac/syncope. Greater clinician risk tolerance (as measured by the Risk Tolerance Scale) was associated with a statistically significant tendency to admit less than the projected admission rate (coefficient, -0.09 [P = .04]). The other scales studied revealed no significant associations. Conclusions and Relevance In this cohort study of ED visits from Massachusetts, there was statistically significant variation between ED clinicians in admission rates and little consistency in admission tendencies across different conditions. Admission tendencies were minimally associated with clinician innate risk tolerance as assessed by this study's measures; further research relying on a broad range of measures of risk tolerance is needed to better understand the role of clinician attitudes toward risk in explaining practice patterns and to identify additional factors that may be associated with variation at the clinician level.
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Affiliation(s)
- Peter B. Smulowitz
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester
- Milford Regional Medical Center, Milford, Massachusetts
| | - Ryan C. Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Daniel Ostrovsky
- Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
| | - Victor Novack
- Soroka University Medical Center, Ben-Gurion University of the Negev, Be’er-Sheva, Israel
| | - Linda Isbell
- Department of Psychological and Brain Sciences, University of Massachusetts, Amherst
| | - Vincent Kan
- Department of Emergency Medicine, University of Massachusetts Medical School, Worcester
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School and Division of General Internal Medicine, Beth Israel Deaconess Medical Center, Boston
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Riedel HB, Espejo T, Bingisser R, Kellett J, Nickel CH. A fast emergency department triage score based on mobility, mental status and oxygen saturation compared with the emergency severity index: a prospective cohort study. QJM 2023; 116:774-780. [PMID: 37399089 PMCID: PMC10559338 DOI: 10.1093/qjmed/hcad160] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 06/27/2023] [Indexed: 07/05/2023] Open
Abstract
BACKGROUND Waiting for triage in overburdened emergency departments (ED) has become an increasing problem, which endangers patients. A fast triage system to rapidly identify low-acuity patients should divert care and resources to more urgent cases. AIM The objective of this study was to compare the performance of the Kitovu Hospital fast triage (KFT) score with the Emergency Severity Index (ESI), using mortality and hospital admission as proxies for the patients' acuity. DESIGN This is a prospective observational study of consecutive patients presenting to a Swiss academic ED. METHODS Patients were prospectively triaged into one of five ESI strata and retrospectively assessed by the KFT score, which awards one point each for altered mental status, impaired mobility and oxygen saturation <94%. RESULTS The KFT score had a lower discrimination than the ESI for hospital admission, but a higher discrimination for mortality from 24 h to 1 year after ED presentation. A total of 5544 (67%) patients were assigned to the lowest acuity by the KFT score compared with 2374 (28.7%) by the ESI; there was no significant difference in the 24-h mortality of patients who were deemed low acuity by either score. CONCLUSION Compared to the ESI, the KFT score identifies more than twice as many patients at low risk of early death. Therefore, this score might help to identify patients who could be managed through alternative pathways. This may be particularly helpful in situations of ED crowding and access block.
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Affiliation(s)
- H B Riedel
- Emergency Department, University Hospital Basel, Petersgraben 2, 4031 Basel, Schweiz
| | - T Espejo
- Emergency Department, University Hospital Basel, Petersgraben 2, 4031 Basel, Schweiz
| | - R Bingisser
- Emergency Department, University Hospital Basel, Petersgraben 2, 4031 Basel, Schweiz
| | - J Kellett
- Department of Emergency Medicine, Odense University Hospital, J. B. Winsløws Vej 4, 5000 Odense, Denmark
| | - C H Nickel
- Emergency Department, University Hospital Basel, Petersgraben 2, 4031 Basel, Schweiz
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Oskvarek JJ, Zocchi MS, Cai A, Venkat A, Janke AT, Venkatesh A, Pines JM. Development and Internal Validation of an Emergency Department Admission Intensity Measure Using Data From a National Group. Ann Emerg Med 2023; 82:316-325. [PMID: 36669915 DOI: 10.1016/j.annemergmed.2022.12.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Revised: 11/01/2022] [Accepted: 12/02/2022] [Indexed: 01/20/2023]
Abstract
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.
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Affiliation(s)
- Jonathan J Oskvarek
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, Summa Health System, Akron, OH.
| | - Mark S Zocchi
- The Heller School for Social Policy and Management, Brandeis University, Waltham, MA
| | - Angela Cai
- Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Arvind Venkat
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
| | - Alexander T Janke
- National Clinician Scholars Program, Institute for Healthcare Policy and Innovation, VA Ann Arbor/University of Michigan, Ann Arbor, MI
| | - Arjun Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, CT
| | - Jesse M Pines
- US Acute Care Solutions, Canton, OH; Department of Emergency Medicine, Allegheny Health Network, Pittsburgh, PA
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8
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Miyawaki A, Jena AB, Burke LG, Figueroa JF, Tsugawa Y. Association Between Emergency Physician's Age and Mortality of Medicare Patients Aged 65 to 89 Years After Emergency Department Visit. Ann Emerg Med 2023; 82:301-312. [PMID: 36964007 DOI: 10.1016/j.annemergmed.2023.02.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Revised: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 03/26/2023]
Abstract
STUDY OBJECTIVE To determine the association between emergency physicians' ages and patient mortality after emergency department visits. METHODS This observational study used a 20% random sample of Medicare fee-for-service beneficiaries aged 65 to 89 years treated by emergency physicians at EDs from 2016 to 2017. We investigated whether 7-day mortality after ED visits differed by the age of the emergency physician, adjusting for patient and physician characteristics and hospital fixed effects. RESULTS We observed 2,629,464 ED visits treated by 32,570 emergency physicians (mean age 43.5). We found that patients treated by younger emergency physicians had lower mortality rates compared with those treated by older physicians. Adjusted 7-day mortality was 1.33% for patients treated by emergency physicians aged less than 40 years, 1.36% (adjusted difference, 0.03%; 95% confidence interval [CI], -0.001% to 0.06%) for physicians ages 40 to 49, 1.40% (0.08%; 95% CI 0.04% to 0.12%) for physicians ages 50 to 59, and 1.43% (0.11%; 95% CI 0.06% to 0.16%) for those with a physician age of 60 years and more. Similar patterns were observed when stratified by the patient's disposition (discharged vs admitted), and the association was more pronounced for patients with higher severity of illness. CONCLUSIONS Medicare patients aged 65 to 89 years treated by emergency physicians aged under 40 years had lower 7-day mortality rates than those treated by physicians aged 50 to 59 years and 60 years or older within the same hospital. Potential mechanisms explaining the association between emergency physician age and patient mortality (eg, differences in training received and other unobservable patient/physician characteristics) are uncertain and require further study.
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Affiliation(s)
- Atsushi Miyawaki
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Public Health, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
| | - Anupam B Jena
- Department of Health Care Policy, Harvard Medical School, Boston, MA; Department of Medicine, Massachusetts General Hospital, Boston, MA; National Bureau of Economic Research, Cambridge, MA
| | - Laura G Burke
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA; Harvard Medical School, Boston, MA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Jose F Figueroa
- Harvard Medical School, Boston, MA; Department of Health Policy and Management, Harvard T.H. Chan School of Public Health, Boston, MA; Division of General Internal Medicine, Brigham and Women's Hospital, Boston, MA
| | - Yusuke Tsugawa
- Division of General Internal Medicine and Health Services Research, David Geffen School of Medicine at UCLA, Los Angeles, CA; Department of Health Policy and Management, UCLA Fielding School of Public Health, Los Angeles, CA
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Kilaru AS, Friedman AB, Delgado MK. Considering the Whole Person in Hospital Admission Decisions for Older Adults in the Emergency Department. JAMA Intern Med 2023; 183:793-794. [PMID: 37307011 DOI: 10.1001/jamainternmed.2023.2155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/13/2023]
Affiliation(s)
- Austin S Kilaru
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Ari B Friedman
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
| | - Mucio Kit Delgado
- Center for Emergency Care Policy and Research, Department of Emergency Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
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10
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Smulowitz PB, Weinreb G, McWilliams JM, O’Malley AJ, Landon BE. Association of Functional Status, Cognition, Social Support, and Geriatric Syndrome With Admission From the Emergency Department. JAMA Intern Med 2023; 183:784-792. [PMID: 37307004 PMCID: PMC10262058 DOI: 10.1001/jamainternmed.2023.2149] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 04/13/2023] [Indexed: 06/13/2023]
Abstract
Importance The role of patient-level factors that are unrelated to the specific clinical condition leading to an emergency department (ED) visit, such as functional status, cognitive status, social supports, and geriatric syndromes, in admission decisions is not well understood, partly because these data are not available in administrative databases. Objective To determine the extent to which patient-level factors are associated with rates of hospital admission from the ED. Design, Setting, and Participants This cohort study analyzed survey data collected from participants (or their proxies, such as family members) enrolled in the Health and Retirement Study (HRS) from January 1, 2000, to December 31, 2018. These HRS data were linked to Medicare fee-for-service claims data from January 1, 1999, to December 31, 2018. Information on functional status, cognitive status, social supports, and geriatric syndromes was obtained from the HRS data, whereas ED visits, subsequent hospital admission or ED discharge, and other claims-derived comorbidities and sociodemographic characteristics were obtained from Medicare data. Data were analyzed from September 2021 to April 2023. Main Outcomes and Measures The primary outcome measure was hospital admission after an ED visit. A baseline logistic regression model was estimated, with a binary indicator of admission as the dependent variable of interest. For each primary variable of interest derived from the HRS data, the model was reestimated, including the HRS variable of interest as an independent variable. For each of these models, the odds ratio (OR) and average marginal effect (AME) of changing the value of the variable of interest were calculated. Results A total of 42 392 ED visits by 11 783 unique patients were included. At the time of the ED visit, patients had a mean (SD) age of 77.4 (9.6) years, and visits were predominantly for female (25 719 visits [60.7%]) and White (32 148 visits [75.8%]) individuals. The overall percentage of patients admitted was 42.5%. After controlling for ED diagnosis and demographic characteristics, functional status, cognition status, and social supports all were associated with the likelihood of admission. For instance, difficulty performing 5 activities of daily living was associated with an 8.5-percentage point (OR, 1.47; 95% CI, 1.29-1.66) AME increase in the likelihood of admission. Having dementia was associated with an AME increase in the likelihood of admission of 4.6 percentage points (OR, 1.23; 95% CI, 1.14-1.33). Living with a spouse was associated with an AME decrease in the likelihood of admission of 3.9 percentage points (OR, 0.84; 95% CI, 0.79-0.89), and having children living within 10 miles was associated with an AME decrease in the likelihood of admission of 5.0 percentage points (OR, 0.80; 95% CI, 0.71-0.89). Other common geriatric syndromes, including trouble falling asleep, waking early, trouble with vision, glaucoma or cataract, use of hearing aids or trouble with hearing, falls in past 2 years, incontinence, depression, and polypharmacy, were not meaningfully associated with the likelihood of admission. Conclusion and Relevance Results of this cohort study suggest that the key patient-level characteristics, including social supports, cognitive status, and functional status, were associated with the decision to admit older patients to the hospital from the ED. These factors are critical to consider when devising strategies to reduce low-value admissions among older adult patients from the ED.
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Affiliation(s)
| | - Gabe Weinreb
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
| | | | - A. James O’Malley
- Department of Biomedical Data Science, The Dartmouth Institute for Health Policy and Clinical Practice, Geisel School of Medicine at Dartmouth, Lebanon, New Hampshire
| | - Bruce E. Landon
- Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
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Cutter CM, Tran LD, Wu S, Urech TH, Seidenfeld J, Kocher KE, Vashi AA. Hospital-level variation in risk-standardized admission rates for emergency care-sensitive conditions among older and younger Veterans. Acad Emerg Med 2023; 30:299-309. [PMID: 36762877 DOI: 10.1111/acem.14691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Revised: 01/30/2023] [Accepted: 02/02/2023] [Indexed: 02/11/2023]
Abstract
OBJECTIVES Research examining emergency department (ED) admission practices within the Department of Veterans Affairs (VA) is limited. This study investigates facility-level variation in risk-standardized admission rates (RSARs) for emergency care-sensitive conditions (ECSCs) among older (≥65 years) and younger (<65 years) Veterans across VA EDs. METHODS Veterans presenting to a VA ED for an ECSC between October 1, 2016 and September 30, 2019 were identified and the 10 most common ECSCs established. ECSC-specific RSARs were calculated using hierarchical generalized linear models, adjusting for Veteran and encounter characteristics. The interquartile range ratio (IQR ratio) and coefficient of variation were measures of dispersion for each condition and were stratified by age group. Associations with facility characteristics were also examined in condition-specific multivariable models. RESULTS The overall cohort included 651,336 ED visits across 110 VA facilities for the 10 most common ECSCs-chronic obstructive pulmonary disease (COPD), heart failure, pneumonia, volume depletion, tachyarrhythmias, acute diabetes mellitus, gastrointestinal (GI) bleeding, asthma, sepsis, and myocardial infarction (MI). After adjusting for case mix, the ECSCs with the greatest variation (IQR ratio, coefficient of variation) in RSARs were asthma (1.43, 32.12), COPD (1.39, 24.64), volume depletion (1.38, 23.67), and acute diabetes mellitus (1.28, 17.52), whereas those with the least variation were MI (1.01, 0.87) and sepsis (1.02, 2.41). Condition-specific RSARs were not qualitatively different between age subgroups. Association with facility characteristics varied across ECSCs and within condition-specific age subgroups. CONCLUSIONS We identified unexplained facility-level variation in RSARs for Veterans presenting with the 10 most common ECSCs to VA EDs. The magnitude of variation did not appear to be qualitatively different between older and younger Veteran subgroups. Variation in RSARs for ECSCs may be an important target for systems-based levers to improve value in VA emergency care.
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Affiliation(s)
- Christina M Cutter
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
| | - Linda D Tran
- Health Economics Resource Center, VA Palo Alto Health Care System, Palo Alto, California, USA
- Stanford Surgery Policy Improvement Research and Education Center, Stanford University, Stanford, California, USA
| | - Siqi Wu
- Stanford Primary Care and Population Health, Stanford University, Stanford, California, USA
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, California, USA
| | - Tracy H Urech
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, California, USA
| | - Justine Seidenfeld
- Division of Emergency Medicine, Department of Surgery, Duke University School of Medicine, Durham, North Carolina, USA
- Center of Innovation to Accelerate Discovery and Practice Transformation (ADAPT), Durham VA Health Care System, Durham, North Carolina, USA
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, Ann Arbor, Michigan, USA
- Department of Veterans Affairs, VA Ann Arbor Healthcare System, Ann Arbor, Michigan, USA
- Institute for Healthcare Policy and Innovation, University of Michigan, Ann Arbor, Michigan, USA
- Department of Learning Health Sciences, University of Michigan, Ann Arbor, Michigan, USA
- Department of Veterans Affairs Health Services Research & Development, VA Center for Clinical Management Research, Ann Arbor, Michigan, USA
| | - Anita A Vashi
- Center for Innovation to Implementation, Palo Alto Veterans Affairs Health Care System, Menlo Park, California, USA
- Department of Emergency Medicine, University of California San Francisco, San Francisco, California, USA
- Department of Emergency Medicine (Affiliated), Stanford University, Stanford, California, USA
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Patel K, Diaz MJ, Taneja K, Batchu S, Zhang A, Mohamed A, Wolfe J, Patel UK. Predictors of inpatient admission likelihood and prolonged length of stay among cerebrovascular disease patients: A nationwide emergency department sample analysis. J Stroke Cerebrovasc Dis 2023; 32:106983. [PMID: 36641949 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Revised: 12/20/2022] [Accepted: 01/09/2023] [Indexed: 01/15/2023] Open
Abstract
PURPOSE To examine the hospital- and patient-related factors associated with increased likelihood of inpatient admission and extended hospitalization. METHODS We applied multivariate logistic regression to a subset of ED hospital and patient characteristics linearly extrapolated from the 2019 National Emergency Department Sample database (n=626,508). Patient characteristics with 10 or fewer ED visits after national extrapolation were not reported in the current study to maintain patient confidentiality, in accordance with the HCUP Data Use Agreement. All selected ED visits represented a primary diagnosis of CVD (ICD-10 codes 160-168). All reported hospital and patient characteristics were subject to adjustment for covariates. P-values < 0.05 were considered statistically significant. MAIN FINDINGS Medicare beneficiaries report higher inpatient admission rates than uninsured OR 0.81 (0.73-0.91) and privately insured OR 0.86 (0.79-0.94) individuals. Black and Native-American patients were 37% and 55% more likely to be hospitalized long (>75th percentile) (OR 1.37 [1.25-1.50], OR 1.55 [1.14-2.10]). Northeast emergency departments reported an increased odds of admission compared to the Midwest OR (0.40-0.62), South OR 0.79 (0.63-0.98) and West OR 0.52 (0.39-0.69). Patients with multiple comorbidities (mCCI = 3+) were 226% more likely to have a longer stay OR 3.26 (3.09-3.45) than patients presenting with zero or few comorbidities. Level I, II, and III trauma centers report distinctly high odds of inpatient admission (OR 3.54 [2.84-4.42], OR 2.68 [2.14-3.35], OR 1.51 [1.25-1.84]). PRINCIPAL CONCLUSIONS Likelihoods of inpatient admission and long hospital stays were observably stratified through multiple, independently acting hospital and patient characteristics. Significant associations were stratified by race/ethnicity, location, and clinical presentation, among others. Attention to the factors reported here may serve well to mitigate emergency department crowding and its sobering impact on United States healthcare systems and patients.
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Affiliation(s)
- Karan Patel
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States.
| | | | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, 100 Nicolls Rd, Stony Brook, NY, 11794, United States
| | | | - Alex Zhang
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Aleem Mohamed
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Jared Wolfe
- Cooper Medical School of Rowan University, 401 South Broadway, Camden, NJ, 08103, United States
| | - Urvish K Patel
- Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Pl, New York, NY, 10029, United States
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Utilizing an emergency medicine stabilization team to provide critical care in a rural health system. Am J Emerg Med 2023; 63:113-119. [PMID: 36356488 DOI: 10.1016/j.ajem.2022.10.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 09/23/2022] [Accepted: 10/21/2022] [Indexed: 11/09/2022] Open
Abstract
INTRODUCTION Over the past decade, Emergency Department (ED) patient volumes have increased more than available hospital ICU capacity. This has led to increased boarding and crowding in EDs, requiring new methods of providing intensive care. Many hospitals nationwide have developed ICU boarding mitigation strategies at the hospital and ED level or implemented ED-based resuscitative care units to improve patient care and disposition. However, these have been described in the setting of larger medical centers without broader application to rural, community ED environments. The authors herein have created an ED model utilizing a physician and nurse on-call team to provide improved care to critically ill patients requiring resuscitation when an ICU bed is not immediately available. GOALS The goal of this paper is to describe a novel approach to providing critical care in a rural health system. A community health system-based resuscitation team named Emergency Medicine Stabilization Team, or EMSTAT, was developed as a mobile team consisting of one emergency physician and one emergency or critical care nurse. The authors present data from the first 12 months of the program including diagnoses, procedures, temporal trends, and lengths of stay. RESULTS Over the course of twelve months, EMSTAT was contacted for 195 patients and ultimately traveled to bedside for 131 cases. The three most common diagnoses seen were sepsis, respiratory failure, and diabetic emergencies. 99 documented procedures were performed; the most common were central venous catheters, arterial lines, and intubations. 104 patients were admitted to the intensive care unit, while the other 27 were either downgraded to a lower level of care, discharged, transitioned to palliative care, or died. DISCUSSION Over a twelve-month period, the authors describe a novel rural community-based mobile critical care team. This team demonstrated the ability to quickly arrive at bedside, continue resuscitation, acquire a disposition, and provide individualized critical are. This model serves as a roadmap for developing similar community based-resuscitation programs.
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The Central Importance of Emergency Department Admission Rate Variation in Value-Based Care. Ann Emerg Med 2021; 78:484-486. [PMID: 34140160 DOI: 10.1016/j.annemergmed.2021.04.034] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2021] [Indexed: 11/23/2022]
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