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Richards MR, Whaley CM. Hospital behavior over the private equity life cycle. JOURNAL OF HEALTH ECONOMICS 2024; 97:102902. [PMID: 38861907 DOI: 10.1016/j.jhealeco.2024.102902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 05/10/2024] [Accepted: 05/28/2024] [Indexed: 06/13/2024]
Abstract
Private equity is an increasing presence in US healthcare, with unclear consequences. Leveraging unique data sources and difference-in-differences designs, we examine the largest private equity hospital takeover in history. The affected hospital chain sharply shifts its advertising strategy and pursues joint ventures with ambulatory surgery centers. Inpatient throughput is increased by allowing more patient transfers, and crucially, capturing more patients through the emergency department. The hospitals also manage shorter, less treatment-intensive stays for admitted patients. Outpatient surgical care volume declines, but remaining cases focus on higher complexity procedures. Importantly, behavior changes persist even after private equity divests.
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Affiliation(s)
- Michael R Richards
- Jeb E. Brooks School of Public Policy, Cornell University, 3301 MVR Hall, Ithaca NY 14853 and NBER.
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Zhang Z, Das S. Unveiling the patterns: exploring social and clinical characteristics of frequent mental health visits to the emergency department-a comprehensive systematic review. DISCOVER MENTAL HEALTH 2024; 4:17. [PMID: 38802580 PMCID: PMC11130112 DOI: 10.1007/s44192-024-00070-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024]
Abstract
BACKGROUND Frequent presenters (FPs) are a group of individuals who visit the hospital emergency department (ED) frequently for urgent care. Many among the group present with the main diagnosis of mental health conditions. This group of individual tend to use ED resources disproportionally and significantly affects overall healthcare outcomes. No previous reviews have examined the profiles of FPs with mental health conditions. AIMS This study aims to identify the key socio-demographic and clinical characteristics of patients who frequently present to ED with a mental health primary diagnosis by performing a comprehensive systematic review of the existing literature. METHOD PRISMA guideline was used. PubMed, PsycINFO, Scopus and Web of Science (WOS) were searched in May 2023. A manual search on the reference list of included articles was conducted at the same time. Covidence was used to perform extraction and screening, which were completed independently by two authors. Inclusion and exclusion criteria were defined. RESULTS The abstracts of 3341 non-duplicate articles were screened, with 40 full texts assessed for eligibility. 20 studies were included from 2004 to 2022 conducted in 6 countries with a total patient number of 25,688 (52% male, 48% female, mean age 40.7 years old). 27% were unemployed, 20% married, 41% homeless, and 17% had tertiary or above education. 44% had a history of substance abuse or alcohol dependence. The top 3 diagnoses are found to be anxiety disorders (44%), depressive disorders (39%) schizophrenia spectrum and other psychotic disorders (33%). CONCLUSION On average, FPs are middle-aged and equally prevalent in both genders. Current data lacks representation for gender-diverse groups. They are significantly associated with high rates of unemployment, homelessness, lower than average education level, and being single. Anxiety disorder, depressive disorder, and schizophrenia spectrum disorders are the most common clinical diagnoses associated with the group.
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Affiliation(s)
| | - Soumitra Das
- The University of Melbourne, Melbourne, Australia
- Western Health, Footscray, Australia
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Nikolla DA, Raich C, Erickson TE. Methodological limitations of the sternal brace test study. J Osteopath Med 2024; 0:jom-2024-0007. [PMID: 38742330 DOI: 10.1515/jom-2024-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2024] [Accepted: 01/17/2024] [Indexed: 05/16/2024]
Affiliation(s)
- Dhimitri A Nikolla
- Department of Emergency Medicine, Allegheny Health Network, Saint Vincent Hospital, Erie, PA, USA
| | - Cameron Raich
- Resident Physician, Department of Emergency Medicine, Allegheny Health Network, Erie, PA, USA
| | - Thomas E Erickson
- Attending Physician, Department of Emergency Medicine, Allegheny Health Network, Erie, PA, USA
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Spiegel DR. The Emergency Department and Psychiatric Boarding: A Model for the Future. Clin Neuropharmacol 2024; 47:65-66. [PMID: 38743598 DOI: 10.1097/wnf.0000000000000595] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/16/2024]
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Holzhauser L, Reza N, Edwards JJ, Birati EY, Owens AT, McLean R, Maeda K, O'Connor MJ, Rossano JW, Mondal A, Katcoff H, Edelson JB. Emergency Department Use and Hospital Mortality Among Heart Transplant Recipients in the United States. J Am Heart Assoc 2024; 13:e032676. [PMID: 38420765 PMCID: PMC10944034 DOI: 10.1161/jaha.123.032676] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2023] [Accepted: 12/19/2023] [Indexed: 03/02/2024]
Abstract
BACKGROUND Annual heart transplant (HT) volumes have increased, as have post-HT outpatient care needs. Data on HT-related emergency department (ED) visits are limited. METHODS AND RESULTS A retrospective analysis of 177 450 HT patient ED visits from the 2009 to 2018 Nationwide Emergency Department Sample was conducted. HT recipients, primary diagnoses, and comorbidities associated with ED visits were identified via International Classification of Diseases, Ninth Revision (ICD-9) and International Classification of Diseases, Tenth Revision (ICD-10) codes. Multivariable logistic regression was used to predict outcomes of hospital admission and death. HT volumes and HT-related ED visits increased from 2009 to 2018. Infection was the most common primary diagnosis (24%), and cardiac primary diagnoses represented 10% of encounters. Hospital admissions occurred in 48% of visits, but overall mortality was low (1.6%). Length of stay was 3.1 days (interquartile range, 1.6-5.9 days), and comorbidity burden was high: 42% had hypertension, 38% had diabetes, and 31% had ≥2 comorbidities. Those aged ≥65 years had significantly higher odds of admission (odds ratio [OR], 2.14 [95% CI, 1.97-2.33]) and death (OR, 2.06 [95% CI, 1.61-2.62]). Comorbidities increased odds of admission (OR, 1.62 [95% CI, 1.51-1.75]) but not death. Renal primary diagnosis had the highest risk of admission (OR, 4.1 [95% CI, 3.6-4.6]), but cardiac primary diagnosis had the highest odds of death (OR, 11.6 [95% CI, 9.1-14.8]). CONCLUSIONS HT-related ED visits increased from 2009 to 2018 with high admission rates but low in-hospital mortality, suggesting an opportunity to improve prehospital care. Older patients and those with cardiac primary diagnoses had the highest risk of death. The observed contrast between predictors of admission and mortality signals a need for further study to improve risk stratification and outpatient care strategies.
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Affiliation(s)
- Luise Holzhauser
- Division of Cardiovascular Medicine, Department of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Nosheen Reza
- Division of Cardiovascular Medicine, Department of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Jonathan J. Edwards
- Division of Cardiology, Cardiac Center, the Childrens Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Edo Y. Birati
- The Lydia and Carol Kittner, Lea and Benjamin Davidai Division of Cardiovascular Medicine and Surgery, Tzafon (Poriya) Medical Center, and Azrieli Faculty of MedicineBar‐Ilan UniversityRamat GanIsrael
| | - Anjali T. Owens
- Division of Cardiovascular Medicine, Department of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Rhondalyn McLean
- Division of Cardiovascular Medicine, Department of MedicinePerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Katsuhide Maeda
- Division of Cardiothoracic Surgery, Cardiac Center, the Children’s Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Matthew J. O'Connor
- Division of Cardiology, Cardiac Center, the Childrens Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
| | - Joseph W. Rossano
- Division of Cardiology, Cardiac Center, the Childrens Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Healthcare EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Antara Mondal
- Leonard Davis Institute for Healthcare EconomicsUniversity of PennsylvaniaPhiladelphiaPA
| | - Hannah Katcoff
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
| | - Jonathan B. Edelson
- Division of Cardiology, Cardiac Center, the Childrens Hospital of PhiladelphiaPerelman School of Medicine at the University of PennsylvaniaPhiladelphiaPA
- Cardiovascular Outcomes, Quality, and Evaluative Research CenterUniversity of PennsylvaniaPhiladelphiaPA
- Leonard Davis Institute for Healthcare EconomicsUniversity of PennsylvaniaPhiladelphiaPA
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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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Bakhribah AH, Eissa GA, Alsulami DW, Alotaibi MA, Abdulmannan HM, Khojah IM. Patients' Expectations in Emergency Department at King Abdulaziz University Hospital: A Cross-Sectional Survey-Based Study. Cureus 2024; 16:e54211. [PMID: 38496167 PMCID: PMC10943181 DOI: 10.7759/cureus.54211] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2024] [Indexed: 03/19/2024] Open
Abstract
BACKGROUND Emergency departments (EDs) are vital to the timely and necessary care that a significant percentage of patients get. Emergency medicine places a high priority on quality, and to deliver patient-centered care, it is crucial to first investigate patient expectations from ER visits. METHODOLOGY This is a cross-sectional study of all visits to the King Abdulaziz University Hospital Emergency Department in Jeddah. The study included adult patients who visited the emergency department and were willing to complete a survey and participate in an interview. Data was collected through face-to-face questionnaires. Patient's expectations during their visit to the emergency department were correlated to different parameters using univariate and bivariate analysis. RESULTS The study included 291 patients. The majority of patients believed that their medical condition required admission to the hospital and agreed that it would be easier to receive treatment if admitted to the hospital. Results showed that 65.6% (n=191) of patients reported that the most serious patients should be seen first, and 65.3% (n=190) reported that a doctor should determine the seriousness of their health problem upon arrival. There was no significant difference found between age groups in relation to other items of expectations. CONCLUSION It is clear that a sizable percentage of patients place a high value on seeing the most urgent cases first and having a doctor assess each patient's condition when they arrive. Our results show that, in order to guarantee the best patient happiness and care, healthcare practitioners must meet patients' expectations and modify their strategies accordingly.
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Affiliation(s)
| | - Ghaida A Eissa
- Medical School, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | - Dania W Alsulami
- Medical School, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
| | | | | | - Imad M Khojah
- Emergency Medicine, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
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Mostafa R, El-Atawi K. Strategies to Measure and Improve Emergency Department Performance: A Review. Cureus 2024; 16:e52879. [PMID: 38406097 PMCID: PMC10890971 DOI: 10.7759/cureus.52879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/24/2024] [Indexed: 02/27/2024] Open
Abstract
Emergency Departments (EDs) globally face escalating challenges such as overcrowding, resource limitations, and increased patient demand. This study aims to identify and analyze strategies to enhance the structural performance of EDs, with a focus on reducing overcrowding, optimizing resource allocation, and improving patient outcomes. Through a comprehensive review of the literature and observational studies, the research highlights the effectiveness of various approaches, including triage optimization, dynamic staffing, technological integration, and strategic resource management. Key findings indicate that tailored strategies, such as implementing advanced triage protocols and leveraging telemedicine, can significantly reduce wait times and enhance patient throughput. Furthermore, evidence suggests that dynamic staffing models and the integration of cutting-edge diagnostic tools contribute to operational efficiency and improved quality of care. These strategies, when combined, offer a multifaceted solution to the complex challenges faced by EDs, promising better patient care and satisfaction. The study underscores the need for a comprehensive approach, incorporating both organizational and technological innovations, to address the evolving needs of emergency healthcare.
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Affiliation(s)
- Reham Mostafa
- Department of Emergency Medicine, Al Zahra Hospital Dubai (AZHD), Dubai, ARE
| | - Khaled El-Atawi
- Pediatrics/ Neonatal Intensive Care Unit, Latifa Women and Children Hospital, Dubai, ARE
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9
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Heo M, Taaffe K, Ghadshi A, Teague LD, Watts J, Lopes SS, Tilkemeier P, Litwin AH. Effectiveness of Transitional Care Program among High-Risk Discharged Patients: A Quasi-Experimental Study on Saving Costs, Post-Discharge Readmissions and Emergency Department Visits. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2023; 20:7136. [PMID: 38063566 PMCID: PMC10706296 DOI: 10.3390/ijerph20237136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 11/27/2023] [Accepted: 12/01/2023] [Indexed: 12/18/2023]
Abstract
Transitional care programs (TCPs), where hospital care team members repeatedly follow up with discharged patients, aim to reduce post-discharge hospital or emergency department (ED) utilization and healthcare costs. We examined the effectiveness of TCPs at reducing healthcare costs, hospital readmissions, and ED visits. Centers for Medicare and Medicaid Services Bundled Payments for Care Improvement (BPCI) program adjudicated claims files and electronic health records from Greenville Memorial Hospital, Greenville, SC, were accessed. Data on post-discharge 30- and 90-day ED visits and readmissions, total costs, and episodes with costs over BPCI target prices were extracted from November 2017 to July 2020 and compared between the "TCP-Graduates" (N = 85) and "Did Not Graduate" (DNG) (N = 1310) groups. As compared to the DNG group, the TCP-Graduates group had significantly fewer 30-day (7.1% vs. 14.9%, p = 0.046) and 90-day (15.5% vs. 26.3%, p = 0.025) readmissions, episodes with total costs over target prices (25.9% vs. 36.6%, p = 0.031), and lower total cost/episode (USD 22,439 vs. USD 28,633, p = 0.018), but differences in 30-day (9.4% vs. 11.2%, p = 0.607) and 90-day (20.0% vs. 21.9%, p = 0.680) ED visits were not significant. TCP was associated with reduced post-discharge hospital readmissions, total care costs, and episodes exceeding target prices. Further studies with rigorous designs and individual-level data should test these findings.
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Affiliation(s)
- Moonseong Heo
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
| | - Kevin Taaffe
- Department of Industrial Engineering, Clemson University, Clemson, SC 29634, USA
| | - Ankita Ghadshi
- Department of Industrial Engineering, Clemson University, Clemson, SC 29634, USA
| | - Leigh D. Teague
- Department of Medicine, Prisma Health, Greenville, SC 29605, USA
| | - Jeffrey Watts
- Value-Based Care & Network Services, Prisma Health, Greenville, SC 29605, USA
| | - Snehal S. Lopes
- Department of Public Health Sciences, Clemson University, Clemson, SC 29634, USA
| | - Peter Tilkemeier
- Department of Medicine, Prisma Health, Greenville, SC 29605, USA
- Department of Medicine, University of South Carolina School of Medicine—Greenville, Greenville, SC 29605, USA
| | - Alain H. Litwin
- Department of Medicine, Prisma Health, Greenville, SC 29605, USA
- Department of Medicine, University of South Carolina School of Medicine—Greenville, Greenville, SC 29605, USA
- School of Health Research, Clemson University, Greenville, SC 29634, USA
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Blanes Hernández R, Rodríguez Pérez M, Fernández Navarro J, Salavert Lletí M. Current approach to skin and soft tissue infections. Thinking about continuity of care. REVISTA ESPANOLA DE QUIMIOTERAPIA : PUBLICACION OFICIAL DE LA SOCIEDAD ESPANOLA DE QUIMIOTERAPIA 2023; 36 Suppl 1:37-45. [PMID: 37997870 PMCID: PMC10793549 DOI: 10.37201/req/s01.10.2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2023]
Abstract
Skin and soft tissue infections are a common reason for patients seeking inpatient and outpatient medical care. Surgery is an essential part of managing in many episodes. Careful evaluation of antibiotic therapy could help clinicians in early identification to patients with treatment failure and to consider an alternative approach or a new surgical revision in "focus control". With the arrival of new drugs, there is a need to refine the appropriate drug's decision-making. Drugs with a long half-life (long-acting lipoglycopeptides such as dalbavancin or oritavancin), which allows weekly administration (or even greater), can reduce hospital admission and length of stay with fewer healthcare resources through outpatient management (home hospitalization or day hospitals). New anionic fluoroquinolones (e.g. delafloxacin), highly active in an acidic medium and with the possibility of switch from the intravenous to the oral route, will also make it possible to achieve these new healthcare goals and promote continuity of care. Therefore, management should rely on a collaborative multidisciplinary group with experience in this infectious syndrome.
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Affiliation(s)
| | | | | | - M Salavert Lletí
- Miguel Salavert Lletí. Unidad de Enfermedades Infecciosas (Infectious Diseases Unit). Área Clínica Médica. Hospital Universitario y Politécnico La Fe, Valencia. Av. Fernando Abril Martorell, nº 106; 46026-Valencia. (Spain). /
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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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12
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Jawade P, Khillare KM, Mangudkar S, Palange A, Dhadwad J, Deshmukh M. A Comparative Study of Ischemia-Modified Albumin: A Promising Biomarker for Early Detection of Acute Coronary Syndrome (ACS). Cureus 2023; 15:e44357. [PMID: 37779796 PMCID: PMC10539834 DOI: 10.7759/cureus.44357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/29/2023] [Indexed: 10/03/2023] Open
Abstract
Introduction The second most common cause of emergency department (ED) visits is chest pain and discomfort. Timely identification or threat stratification is crucial for identifying high-risk individuals who benefit from sophisticated diagnostic investigations (including cardiac biomarkers) and early relevant therapies. We aimed to assess the levels of ischemia-modified albumin (IMA) and also to study its sensitivity and specificity in comparison with cardiac troponin T/troponin I and electrocardiogram (ECG) (alone and in combination) in the diagnosis of acute myocardial infarction. Methods Adults (either gender) presented at the ED of a tertiary care centre with classical chest pain suggestive of angina pectoris or angina-like chest pain and ECG changes suggestive of ACS, ST-elevation myocardial infarction (STEMI), non-ST elevation myocardial MI (NSTEMI), and unstable angina, within three hours of onset were enrolled. Demographic and clinical information was recorded. ECG, haematological investigations like complete blood count, blood sugar level, lipid profile, IMA, troponin I, and creatinine kinase-MB (CK-MB), and radiological investigations like 2D-echocardiography (2D-ECHO) and coronary angiography were performed. Results A total of 100 subjects were enrolled in the study out of which 50 were cases and 50 were controls. Cases were older as compared to controls (mean age 60.5 versus 46.0 years). Of the 50 cases, 33 (66%) were males. There were equal numbers of males (33 each) and females (17 each) subjects in both the groups. Typical chest pain, risk factors, and history of coronary artery disease (CAD) were higher in cases. ECG diagnosis revealed the presence of STEMI (52%) and coronary angiography revealed the presence of double vessel CAD (60%) in cases. Among controls, gastroesophageal reflux disorder was the most common cause of chest pain followed by costochondritis and pneumonia. Glucose (fasting and postprandial), all lipid profile parameters (except high-density lipoprotein) and IMA values were significantly higher in cases as compared to controls. A combination of ECG+IMA has the highest sensitivity (90%) with 79% PPV in the diagnosis of ACS within three hours of the onset of chest pain, and ECG+IMA+2D-ECHO had similar results. However, ECG is equally sensitive. IMA alone has 64% sensitivity with 82% diagnostic accuracy which was higher than other biomarkers (CK-MB, cardiac troponin I). Conclusions As found in our study, among the biomarkers used, the diagnostic accuracy of IMA was the highest and better than that of cardiac troponin I and CK-MB. Although ECG is the preferred diagnostic tool for diagnosing ACS (STEMI, NSTEMI, and unstable angina) in patients presenting within three hours of the onset of chest pain, a confirmation can be done with the help of other diagnostic tests and investigations like serum IMA levels and further treatment can be initiated.
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Affiliation(s)
- Pranav Jawade
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Kishor M Khillare
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Sangram Mangudkar
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Amit Palange
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Jagannath Dhadwad
- General Medicine, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
| | - Madhura Deshmukh
- Central Research Facility, Dr. D.Y. Patil Medical College, Hospital and Research Centre, Pune, IND
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Bouza E, Burillo A, Muñoz P. How to manage skin and soft-tissue infections in the emergency department. Curr Opin Infect Dis 2023; 36:81-88. [PMID: 36853739 DOI: 10.1097/qco.0000000000000906] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
Abstract
PURPOSE OF REVIEW Our purpose is to review the state-of-the-art on the management of skin and soft tissue infections (SSTI) in emergency departments (ED).Although the information is scarce, SSTI may account for 3-30% of all cases presenting to an ED, of which 25-40% require hospital admission.SSTI include very different entities in aetiology, location, pathogenesis, extension, and severity. Therefore, no single management can be applied to them all. A simple approach is to classify them as non-purulent, purulent, and necrotising, to which a severity scale based on their systemic repercussions (mild, moderate, and severe) must be added.The initial approach to many SSTIs often requires no other means than anamnesis and physical examination, but imaging tests are an indispensable complement in many other circumstances (ultrasound, computerized tomography, magnetic resonance imaging…). In our opinion, an attempt at etiological filiation should be made in severe cases or where there is suspicion of a causality other than the usual one, with tests based not only on cultures of the local lesion but also molecular tests and blood cultures. RECENT FINDINGS Recent contributions of interest include the value of bedside ultrasound and the potential usefulness of biomarkers such as thrombomodulin to differentiate in early stages the presence of necrotising lesions not yet explicit.New antimicrobials will allow the treatment of many of these infections, including severe ones, with oral drugs with good bioavailability and for shorter periods. SUMMARY The ED has an essential role in managing SSTIs, in their classification, in decisions on when and where to administer antimicrobial treatment, and in the rapid convening of multidisciplinary teams that can deal with the most complex situations.
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Affiliation(s)
- Emilio Bouza
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IiSGM)
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
| | - Almudena Burillo
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IiSGM)
| | - Patricia Muñoz
- Department of Clinical Microbiology and Infectious Diseases, Hospital General Universitario Gregorio Marañón
- Medicine Department, School of Medicine, Universidad Complutense de Madrid
- Gregorio Marañón Health Research Institute (IiSGM)
- CIBER of Respiratory Diseases (CIBERES CB06/06/0058), Madrid, Spain
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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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15
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Brachmann M, Serwa P, Sauerland D. Cost-of-illness comparison between clinical judgment and molecular point-of-care testing for influenza-like illness patients in Germany. NPJ Prim Care Respir Med 2023; 33:3. [PMID: 36650143 PMCID: PMC9844933 DOI: 10.1038/s41533-022-00325-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 12/20/2022] [Indexed: 01/18/2023] Open
Abstract
A high economic burden stems from seasonal influenza as a well-known but serious public health problem. Rapid diagnostic tests have not yet been integrated into routine use in German primary care, even though they are likely to reduce overall costs in cases of suspected infection. This study aims to demonstrate that the use of point-of-care testing (POCT) produces lower costs of illness compared to the costs incurred by relying on clinical judgment alone. With the help of a decision tree model, two different diagnostic approaches for influenza-like illness (ILI) in primary care were compared: (1) clinical judgment with no technical support and (2) POCT. The costs of illness, as well as their differences, vary widely among the three age groups considered (elderly people, adults, and children). For the pathway of using clinical judgment alone, the costs of illness sum up to 155.99 € for elderly people compared to 76.31 € for adults and 74.15 € for children. With POCT, the costs of illness for the elderly amount to 115,09 €, which is 26% lower than the costs without diagnostic support. The costs for adults and children are 74.42 € and 75.66 €, respectively, which means 2.5% lower costs of illness for adults and 2% higher costs for children. The results demonstrate that the use of POCT to support detecting influenza in ILI patients may reduce the overall cost of illness. The provided data can help governments make informed decisions about potential cost savings by integrating POCT into the reimbursement scheme.
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Affiliation(s)
- M. Brachmann
- grid.412581.b0000 0000 9024 6397Witten/Herdecke University, Witten, Germany ,bcmed GmbH, Ulm, Germany
| | | | - D. Sauerland
- grid.412581.b0000 0000 9024 6397Witten/Herdecke University, Witten, Germany
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16
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Souza J, Caballero I, Vasco Santos J, Fernandes Lobo M, Pinto A, Viana J, Sáez C, Lopes F, Freitas A. Multisource and temporal variability in Portuguese hospital administrative datasets: data quality implications. J Biomed Inform 2022; 136:104242. [DOI: 10.1016/j.jbi.2022.104242] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2021] [Revised: 08/18/2022] [Accepted: 11/06/2022] [Indexed: 11/13/2022]
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17
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Kobashi Y, Cheam S, Hayashi Y, Tsubokura M, Ly V, Noun C, Kozuma T, Nit B, Okawada M. Regional Differences in Admission Rates of Emergency Patients Who Visited a Private General Hospital in the Capital City of Cambodia: A Three-Year Observational Study. Int J Health Policy Manag 2022; 11:1425-1431. [PMID: 34060276 PMCID: PMC9808335 DOI: 10.34172/ijhpm.2021.44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Accepted: 04/14/2021] [Indexed: 01/12/2023] Open
Abstract
BACKGROUND Regional disparity is an imperative component of health disparity. In particular, providing emergency care that is equally available in rural areas is an essential part of reducing the urban-rural disparity. The objective of this study was to examine the worsening admission rate among Cambodian emergency patients in a rural area and determine their background characteristics that cause this decline. METHODS To investigate the disparity among patients who visited Sunrise Japan Hospital (SJH), a major general private hospital in the capital, patient data from November 2016 to September 2019 were obtained from the electronic reception patient database. The primary outcome was defined as the proportion of admission patients as an indicator of illness severity. The patients' addresses were classified into 4 areas based on distance from the capital. RESULTS A total of 6167 patients who visited the emergency department at SJH between January 2017 and September 2019 were included in the analysis. The proportion of patients who needed to be hospitalized or transferred increased with the distance from the capital. The proportion of patients who finished consultation decreased with the distance from the capital (P<.01: Chi-square test). The results of the logistic regression analysis showed that the admission rate in rural areas was significantly higher only among males as compared to that of the capital in multivariate analyses adjusted for age, time, and season. CONCLUSION The admission rate of emergency patients who visited a private general hospital in Cambodia's capital city increased with distance from the capital city. To improve regional disparity among emergency patients, further research is necessary to identify the issues among emergency patients, especially those who are vulnerable.
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Affiliation(s)
- Yurie Kobashi
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Sophathya Cheam
- Department of Pediatrics, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Yoshifumi Hayashi
- Department of Neurosurgery, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
- Department of Neurosurgery, Kitahara International Hospital, Tokyo, Japan
| | - Masaharu Tsubokura
- Department of Internal Medicine, Soma Central Hospital, Fukushima, Japan
| | - Veyleang Ly
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Chanmakara Noun
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Takehiro Kozuma
- Department of General Internal Medicine, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
| | - Buntongyi Nit
- Department of Medicine, University of Puthisastra, Phnom Penh, Cambodia
| | - Manabu Okawada
- Department of Pediatrics, Sunrise Japan Hospital Phnom Penh, Phnom Penh, Cambodia
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Park J, Yeo Y, Ji Y, Kim B, Han K, Cha W, Son M, Jeon H, Park J, Shin D. Factors Associated with Emergency Department Visits and Consequent Hospitalization and Death in Korea Using a Population-Based National Health Database. Healthcare (Basel) 2022; 10:healthcare10071324. [PMID: 35885850 PMCID: PMC9325044 DOI: 10.3390/healthcare10071324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 07/03/2022] [Accepted: 07/14/2022] [Indexed: 12/02/2022] Open
Abstract
We aim to investigate common diagnoses and risk factors for emergency department (ED) visits as well as those for hospitalization and death after ED visits. This study describes the clinical course of ED visits by using the 2014–2015 population data retrieved from the National Health Insurance Service. Sociodemographic, medical, and behavioral factors were analyzed through multiple logistic regression. Older people were more likely to be hospitalized or to die after an ED visit, but younger people showed a higher risk for ED visits. Females were at a higher risk for ED visits, but males were at a higher risk for ED-associated hospitalization and death. Individuals in the highest quartile of income had a lower risk of ED death relative to lowest income level individuals. Disabilities, comorbidities, and medical issues, including previous ED visits or prior hospitalizations, were risk factors for all ED-related outcomes. Unhealthy behaviors, including current smoking, heavy alcohol consumption, and not engaging in regular exercise, were also significantly associated with ED visits, hospitalization, and death. Common diagnoses and risk factors for ED visits and post-visit hospitalization and death found in this study provide a perspective from which to establish health polices for the emergency medical care system.
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Affiliation(s)
- Junhee Park
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea; (J.P.); (Y.J.)
| | - Yohwan Yeo
- Department of Family Medicine, College of Medicine, Hallym University Dongtan Sacred Heart Hospital, Hwaseong 18450, Korea
- Correspondence: (Y.Y.); (D.S.)
| | - Yonghoon Ji
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea; (J.P.); (Y.J.)
| | - Bongseong Kim
- Department of Statistics and Actuarial Science, Soongsil University, Seoul 06978, Korea; (B.K.); (K.H.)
| | - Kyungdo Han
- Department of Statistics and Actuarial Science, Soongsil University, Seoul 06978, Korea; (B.K.); (K.H.)
| | - Wonchul Cha
- Department of Emergency Medicine, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea;
| | - Meonghi Son
- Department of Pediatrics, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea;
| | - Hongjin Jeon
- Department of Psychiatry, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea;
| | - Jaehyun Park
- Center for Wireless and Population Health System, University of California, La Jolla, San Diego, CA 92093, USA;
| | - Dongwook Shin
- Department of Family Medicine & Supportive Care Center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul 06351, Korea; (J.P.); (Y.J.)
- Department of Clinical Research Design & Evaluation, Samsung Advanced Institute for Health Science & Technology (SAIHST), School of Medicine, Sungkyunkwan University, Seoul 06355, Korea
- Correspondence: (Y.Y.); (D.S.)
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19
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Emergency departments: The gatekeepers of admissions in Pennsylvania's rural hospitals. Am J Emerg Med 2022; 57:138-148. [PMID: 35576794 DOI: 10.1016/j.ajem.2022.05.002] [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: 02/14/2022] [Revised: 03/25/2022] [Accepted: 05/03/2022] [Indexed: 01/02/2023] Open
Abstract
STUDY OBJECTIVE To analyze trends in admission rates and the proportion of admissions via the ED at rural hospitals in Pennsylvania and to identify factors that may impact admission rates. METHODS We use retrospective, longitudinal data on rural acute care hospitals in Pennsylvania for 2000-19 to investigate temporal patterns in admission rates and the proportion of admissions via the ED. Regression analysis is then used to identify factors that may impact admission rates. RESULTS In general admission rates, which averaged 14.5%, experienced a gradual decline (Change: -16.9%; from 15.7% to 13%) between 2000 and 2019. The proportion of hospital admissions via the ED, which averaged 64.9%, increased steadily (21%; from 57% to 69%). Critical access hospitals experienced a sharp decline in admissions via the ED (-49.1%) and admission rates (-55.3%). The fixed-effects regression model revealed several hospital- and ED-level characteristics were significantly associated with admission rate. CONCLUSIONS Emergency departments are the gatekeepers of admissions at rural acute care hospitals in Pennsylvania. Many hospitals in rural Pennsylvania, including CAHs, are admitting most of their patients through the ED, concomitant with a significant decline in admissions and admission rates. This highlights the need to strengthen primary care practices serving rural Pennsylvania as well as the need to improve rural emergency and trauma systems. In the short to medium term, policy makers should explore innovative ways to fund smaller hospitals, especially CAHs, to develop level IV trauma center capabilities.
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20
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Carrabba N, Pontone G, Andreini D, Buffa V, Cademartiri F, Carbone I, Clemente A, Guaricci AI, Guglielmo M, Indolfi C, La Grutta L, Ligabue G, Liguori C, Mercuro G, Mushtaq S, Neglia D, Palmisano A, Sciagrà R, Seitun S, Vignale D, Francone M, Esposito A. Appropriateness criteria for the use of cardiac computed tomography, SIC-SIRM part 2: acute chest pain evaluation; stent and coronary artery bypass graft patency evaluation; planning of coronary revascularization and transcatheter valve procedures; cardiomyopathies, electrophysiological applications, cardiac masses, cardio-oncology and pericardial diseases evaluation. J Cardiovasc Med (Hagerstown) 2022; 23:290-303. [PMID: 35486680 DOI: 10.2459/jcm.0000000000001303] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
In the past 20 years, cardiac computed tomography (CCT) has become a pivotal technique for the noninvasive diagnostic workup of coronary and cardiac diseases. Continuous technical and methodological improvements, combined with fast growing scientific evidence, have progressively expanded the clinical role of CCT. Randomized clinical trials documented the value of CCT in increasing the cost-effectiveness of the management of patients with acute chest pain presenting in the emergency department, also during the pandemic. Beyond the evaluation of stents and surgical graft patency, the anatomical and functional coronary imaging have the potential to guide treatment decision-making and planning for complex left main and three-vessel coronary disease. Furthermore, there has been an increasing demand to use CCT for preinterventional planning in minimally invasive procedures, such as transcatheter valve implantation and mitral valve repair. Yet, the use of CCT as a roadmap for tailored electrophysiological procedures has gained increasing importance to assure maximum success. In the meantime, innovations and advanced postprocessing tools have generated new potential applications of CCT from the simple coronary anatomy to the complete assessment of structural, functional and pathophysiological biomarkers of cardiac disease. In this complex and revolutionary scenario, it is urgently needed to provide an updated guide for the appropriate use of CCT in different clinical settings. This manuscript, endorsed by the Italian Society of Cardiology (SIC) and the Italian Society of Medical and Interventional Radiology (SIRM), represents the second of two consensus documents collecting the expert opinion of cardiologists and radiologists about current appropriate use of CCT.
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Affiliation(s)
- Nazario Carrabba
- Department of Cardiothoracovascular Medicine, Azienda Ospedaliero-Universitaria Careggi, Florence
| | | | - Daniele Andreini
- Centro Cardiologico Monzino IRCCS.,Department of Clinical Sciences and Community Health, University of Milan, Milan
| | - Vitaliano Buffa
- Department of Radiology, Azienda Ospedaliera San Camillo Forlanini, Rome
| | | | - Iacopo Carbone
- Department of Radiological, Oncological and Pathological Sciences, 'Sapienza' University of Rome, Rome
| | - Alberto Clemente
- Department of Radiology, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Massa
| | - Andrea Igoren Guaricci
- University Cardiology Unit, Cardiothoracic Department, Policlinic University Hospital, Bari
| | | | - Ciro Indolfi
- Department of Medical and Surgical Sciences, Magna Grecia University, Catanzaro
| | - Ludovico La Grutta
- Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties-ProMISE, University of Palermo
| | - Guido Ligabue
- Department of Medical and Surgical Sciences, Modena and Raggio Emilia University.,Radiology Department, AOU of Modena, Modena
| | - Carlo Liguori
- Radiology Unit, Ospedale del Mare -A.S.L Na1- Centro, Naples
| | - Giuseppe Mercuro
- Department of Medical Sciences and Public Health, University of Cagliari, Cagliari
| | | | - Danilo Neglia
- Cardiovascular Department, CNR (National Council of Research)/Tuscany Region 'Gabriele Monasterio' Foundation (FTGM), Pisa
| | - Anna Palmisano
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| | - Roberto Sciagrà
- Nuclear Medicine Unit, Department of Experimental and Clinical Biomedical Sciences 'Mario Serio', University of Florence, Florence
| | - Sara Seitun
- Radiology Department, Ospedale Policlinico San Martino, IRCCS Per L'Oncologia e le Neuroscienze, Genoa, Italy
| | - Davide Vignale
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
| | - Marco Francone
- Department of Radiological, Oncological and Pathological Sciences, 'Sapienza' University of Rome, Rome
| | - Antonio Esposito
- Clinical and Experimental Radiology Unit, Experimental Imaging Center, IRCCS Ospedale San Raffaele.,Vita-Salute San Raffaele University, Milan
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21
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Baehr A, Fought AJ, Hsia RY, Wiler JL, Ginde AA. The association between area deprivation index and emergency department discharge rates and revisits. Acad Emerg Med 2022; 29:902-904. [PMID: 35304928 DOI: 10.1111/acem.14486] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Revised: 03/15/2022] [Accepted: 03/17/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Avi Baehr
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
- Department of Emergency Medicine Denver Health Medical Center Denver Colorado USA
| | - Angela J. Fought
- Center for Innovative Design & Analysis, Department of Biostatistics & Informatics Colorado School of Public Health, University of Colorado Aurora Colorado USA
| | - Renee Y. Hsia
- Department of Emergency Medicine University of California San Francisco San Francisco California USA
- Philip R. Lee Institute for Health Policy Studies University of California San Francisco San Francisco California USA
| | - Jennifer L. Wiler
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
| | - Adit A. Ginde
- Department of Emergency Medicine University of Colorado School of Medicine Aurora Colorado USA
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22
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Engel‐Rebitzer E, Tiako MJN, Meisel ZF, Aronowitz SV. The importance of addressing racial disparities in settings of clinical ambiguity and implications for research and patient care. Acad Emerg Med 2022; 29:808-810. [PMID: 35166415 DOI: 10.1111/acem.14461] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2022] [Revised: 02/08/2022] [Accepted: 02/10/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Eden Engel‐Rebitzer
- Center for Emergency Care Policy and Research University of Pennsylvania Philadelphia Pennsylvania USA
| | - Max Jordan Nguemeni Tiako
- Center for Emergency Care Policy and Research University of Pennsylvania Philadelphia Pennsylvania USA
- Brigham and Women's Hospital Harvard Medical School Boston Massachusetts USA
| | - Zachary F. Meisel
- Department of Emergency Medicine University of Pennsylvania Perelman School of Medicine Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Penn Injury Science Center University of Pennsylvania Philadelphia Pennsylvania USA
| | - Shoshana V. Aronowitz
- Center for Emergency Care Policy and Research University of Pennsylvania Philadelphia Pennsylvania USA
- Leonard Davis Institute of Health Economics University of Pennsylvania Philadelphia Pennsylvania USA
- Penn Injury Science Center University of Pennsylvania Philadelphia Pennsylvania USA
- School of Nursing University of Pennsylvania Philadelphia Pennsylvania USA
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23
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Mark DG, Huang J, Ballard DW, Kene MV, Sax DR, Chettipally UK, Lin JS, Bouvet SC, Cotton DM, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Reed ME. Graded Coronary Risk Stratification for Emergency Department Patients With Chest Pain: A Controlled Cohort Study. J Am Heart Assoc 2021; 10:e022539. [PMID: 34743565 PMCID: PMC8751925 DOI: 10.1161/jaha.121.022539] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Resource utilization among emergency department (ED) patients with possible coronary chest pain is highly variable. Methods and Results Controlled cohort study amongst 21 EDs of an integrated healthcare system examining the implementation of a graded coronary risk stratification algorithm (RISTRA-ACS [risk stratification for acute coronary syndrome]). Thirteen EDs had access to RISTRA-ACS within the electronic health record (RISTRA sites) beginning in month 24 of a 48-month study period (January 2016 to December 2019); the remaining 8 EDs served as contemporaneous controls. Study participants had a chief complaint of chest pain and serum troponin measurement in the ED. The primary outcome was index visit resource utilization (observation unit or hospital admission, or 7-day objective cardiac testing). Secondary outcomes were 30-day objective cardiac testing, 60-day major adverse cardiac events (MACE), and 60-day MACE-CR (MACE excluding coronary revascularization). Difference-in-differences analyses controlled for secular trends with stratification by estimated risk and adjustment for risk factors, ED physician and facility. A total of 154 914 encounters were included. Relative to control sites, 30-day objective cardiac testing decreased at RISTRA sites among patients with low (≤2%) estimated 60-day MACE risk (-2.5%, 95% CI -3.7 to -1.2%, P<0.001) and increased among patients with non-low (>2%) estimated risk (+2.8%, 95% CI +0.6 to +4.9%, P=0.014), without significant overall change (-1.0%, 95% CI -2.1 to 0.1%, P=0.079). There were no statistically significant differences in index visit resource utilization, 60-day MACE or 60-day MACE-CR. Conclusions Implementation of RISTRA-ACS was associated with better allocation of 30-day objective cardiac testing and no change in index visit resource utilization or 60-day MACE. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
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Affiliation(s)
- Dustin G Mark
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Department of Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Dustin W Ballard
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA
| | - Mamata V Kene
- Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA
| | - Dana R Sax
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Uli K Chettipally
- Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA
| | - James S Lin
- Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA
| | - Sean C Bouvet
- Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA
| | - Dale M Cotton
- Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center Sacramento CA
| | - Megan L Anderson
- Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Ian D McLachlan
- Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA
| | - Laura E Simon
- University of California San Diego School of Medicine San Diego CA
| | - Judy Shan
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | | - David R Vinson
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Mary E Reed
- Division of Research Kaiser Permanente Northern California Oakland CA
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Clinical Presentations of Adolescents Aged 16-18 Years in the Adult Emergency Department. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2021; 18:ijerph18189578. [PMID: 34574502 PMCID: PMC8470799 DOI: 10.3390/ijerph18189578] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 09/06/2021] [Accepted: 09/07/2021] [Indexed: 11/18/2022]
Abstract
Background: In many large hospitals in Switzerland, adolescents 16 years and older are treated in adult emergency departments (ED). There have been few publications about this specific patient population, especially in Switzerland. This study aims to provide an overview of emergency presentations of adolescents between 16–18 years of age when compared to adults and focuses on their principle complaints. Methods: We conducted a single-centre, retrospective, cross-sectional study of all patients aged 16 years and older presenting to the adult ED at the University Hospital (Inselspital) in Bern, Switzerland, from 2013 to 2017. This analysis gives an overview of emergency presentations of adolescents between 16–18 years of age in this time period and compares their consultation characteristics to those of adult patients. Results: Data of a total of 203,817 patients who presented to our adult ED between 2013 and 2017 were analysed. Adolescents account for 2.5% of all emergency presentations. The number of ED presentations in the reviewed time period rose for adults (+2368, 95% CI: 1695, 3041, p = 0.002 consultations more per year; +25% comparing 2013 with 2017), while adolescent presentations did not significantly increase (p = 0.420). In comparison to adult patients, adolescents presented significantly more often during the night (39.1% vs. 31.5%, p < 0.001), as walk-ins (54.2% vs. 44.9%, p < 0.001), or with less highly acute complaints at triage (21% vs. 31%, p < 0.001). They were more likely to be discharged (70.8% vs. 52.2%, p < 0.001). We found a significant association between the two age groups and principle complaints. In comparison to adults, trauma and psychiatric problems were significantly more common among adolescents. Conclusions: Our data showed that complaints in adolescent patients under 18 years of age significantly differ from those in older patients. The artificial age cut-off therefore puts this vulnerable population at risk of receiving inadequate diagnostic testing and treatment adapted only for adults. Additional studies are needed on the reasons adolescents and young adults seek ED care, as this could lead to improvements in the care processes for this vulnerable population.
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Tsai CL, Ling DA, Lu TC, Lin JCC, Huang CH, Fang CC. Inpatient Outcomes Following a Return Visit to the Emergency Department: A Nationwide Cohort Study. West J Emerg Med 2021; 22:1124-1130. [PMID: 34546889 PMCID: PMC8463058 DOI: 10.5811/westjem.2021.6.52212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 06/04/2021] [Indexed: 11/23/2022] Open
Abstract
Introduction Emergency department (ED) revisits are traditionally used to measure potential lapses in emergency care. However, recent studies on in-hospital outcomes following ED revisits have begun to challenge this notion. We aimed to examine inpatient outcomes and resource use among patients who were hospitalized following a return visit to the ED using a national database. Methods This was a retrospective cohort study using the National Health Insurance Research Database in Taiwan. One-third of ED visits from 2012–2013 were randomly selected and their subsequent hospitalizations included. We analyzed the inpatient outcomes (mortality and intensive care unit [ICU] admission) and resource use (length of stay [LOS] and costs). Comparisons were made between patients who were hospitalized after a return visit to the ED and those who were hospitalized during the index ED visit. Results Of the 3,019,416 index ED visits, 477,326 patients (16%) were directly admitted to the hospital. Among the 2,504,972 patients who were discharged during the index ED visit, 229,059 (9.1%) returned to the ED within three days. Of them, 37,118 (16%) were hospitalized. In multivariable analyses, the inpatient mortality rates and hospital LOS were similar between the two groups. Compared with the direct-admission group, the return-admission group had a lower ICU admission rate (adjusted odds ratio, 0.78; 95% confidence interval [CI], 0.72–0.84), and lower costs (adjusted difference, −5,198 New Taiwan dollars, 95% CI, −6,224 to −4,172). Conclusion Patients who were hospitalized after a return visit to the ED had a lower ICU admission rate and lower costs, compared to those who were directly admitted. Our findings suggest that ED revisits do not necessarily translate to poor initial care and that subsequent inpatient outcomes should also be considered for better assessment.
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Affiliation(s)
- Chu-Lin Tsai
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Dean-An Ling
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan
| | - Tsung-Chien Lu
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Jasper Chia-Cheng Lin
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Chien-Hua Huang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
| | - Cheng-Chung Fang
- National Taiwan University Hospital, Department of Emergency Medicine, Taipei, Taiwan.,National Taiwan University Hospital, College of Medicine, Department of Emergency Medicine, Taipei, Taiwan
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26
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Musey PI, Bellolio F, Upadhye S, Chang AM, Diercks DB, Gottlieb M, Hess EP, Kontos MC, Mumma BE, Probst MA, Stahl JH, Stopyra JP, Kline JA, Carpenter CR. Guidelines for reasonable and appropriate care in the emergency department (GRACE): Recurrent, low-risk chest pain in the emergency department. Acad Emerg Med 2021; 28:718-744. [PMID: 34228849 DOI: 10.1111/acem.14296] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2021] [Revised: 04/21/2021] [Accepted: 05/12/2021] [Indexed: 12/15/2022]
Abstract
This first Guideline for Reasonable and Appropriate Care in the Emergency Department (GRACE-1) from the Society for Academic Emergency Medicine is on the topic: Recurrent, Low-risk Chest Pain in the Emergency Department. The multidisciplinary guideline panel used The Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach to assess the certainty of evidence and strength of recommendations regarding eight priority questions for adult patients with recurrent, low-risk chest pain and have derived the following evidence based recommendations: (1) for those >3 h chest pain duration we suggest a single, high-sensitivity troponin below a validated threshold to reasonably exclude acute coronary syndrome (ACS) within 30 days; (2) for those with a normal stress test within the previous 12 months, we do not recommend repeat routine stress testing as a means to decrease rates of major adverse cardiac events at 30 days; (3) insufficient evidence to recommend hospitalization (either standard inpatient admission or observation stay) versus discharge as a strategy to mitigate major adverse cardiac events within 30 days; (4) for those with non-obstructive (<50% stenosis) coronary artery disease (CAD) on prior angiography within 5 years, we suggest referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (5) for those with no occlusive CAD (0% stenosis) on prior angiography within 5 years, we recommend referral for expedited outpatient testing as warranted rather than admission for inpatient evaluation; (6) for those with a prior coronary computed tomographic angiography within the past 2 years with no coronary stenosis, we suggest no further diagnostic testing other than a single, normal high-sensitivity troponin below a validated threshold to exclude ACS within that 2 year time frame; (7) we suggest the use of depression and anxiety screening tools as these might have an effect on healthcare use and return emergency department (ED) visits; and (8) we suggest referral for anxiety or depression management, as this might have an impact on healthcare use and return ED visits.
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Affiliation(s)
- Paul I. Musey
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | | | - Suneel Upadhye
- Division of Emergency Medicine McMaster University Hamilton Canada
| | - Anna Marie Chang
- Department of Emergency Medicine Thomas Jefferson University Philadelphia PA USA
| | - Deborah B. Diercks
- Department of Emergency Medicine UT Southwestern Medical Center Dallas TX USA
| | - Michael Gottlieb
- Department of Emergency Medicine Rush Medical Center Chicago IL USA
| | - Erik P. Hess
- Department of Emergency Medicine Vanderbilt University Medical Center Nashville TN USA
| | - Michael C. Kontos
- Department of Internal Medicine Virginia Commonwealth University Richmond VA USA
| | - Bryn E. Mumma
- Department of Emergency Medicine UC Davis School of Medicine Sacramento CA USA
| | - Marc A. Probst
- Department of Emergency Medicine Icahn School of Medicine at Mount Sinai New York NY USA
| | | | - Jason P. Stopyra
- Department of Emergency Medicine Wake Forest School of Medicine Winston‐SalemNC USA
| | - Jeffrey A. Kline
- Department of Emergency Medicine Indiana University School of Medicine Indianapolis IN USA
| | - Christopher R. Carpenter
- Department of Emergency Medicine and Emergency Care Research Core Washington University School of Medicine St. Louis MO USA
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Chou SC, Hong AS, Weiner SG, Wharam JF. Impact of High-Deductible Health Plans on Emergency Department Patients With Nonspecific Chest Pain and Their Subsequent Care. Circulation 2021; 144:336-349. [PMID: 34176279 PMCID: PMC8323713 DOI: 10.1161/circulationaha.120.052501] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
Supplemental Digital Content is available in the text. Timely evaluation of acute chest pain is necessary, although most evaluations will not find significant coronary disease. With employers increasingly adopting high-deductible health plans (HDHP), how HDHPs impact subsequent care after an emergency department (ED) diagnosis of nonspecific chest pain is unclear.
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Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA (S.-C.C., S.G.W.)
| | - Arthur S Hong
- Departments of Internal Medicine and Population and Data Sciences, University of Texas Southwestern Medical Center, Dallas (A.S.H.)
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA (S.-C.C., S.G.W.)
| | - J Frank Wharam
- Department of Population Medicine, Harvard Medical School, Boston, MA (J.F.W.).,Harvard Pilgrim Health Care Institute, Boston, MA (J.F.W.)
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28
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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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29
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Dalton MK, Andriotti T, Matsas B, Chaudhary MA, Tilley L, Lipsitz S, Learn PA, Schoenfeld AJ, Jarman MP, Goralnick E. Emergency Department Utilization in the U.S. Military Health System. Mil Med 2021; 186:606-612. [PMID: 33331640 DOI: 10.1093/milmed/usaa547] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/16/2020] [Accepted: 12/02/2020] [Indexed: 12/28/2022] Open
Abstract
INTRODUCTION Emergency department (ED) utilization represents an expensive and growing means of accessing care for a variety of conditions. Prior studies have characterized ED utilization in the general population. We aim to identify the clinical conditions that drive ED utilization in a universally insured population and the impacts of care setting on ED use and admissions in the U.S. Military Health System. METHODS We queried TRICARE claims data from October 1, 2012, to September 30, 2015, to identify all ED visits for adult patients (age 18-64). The primary presenting diagnoses of all ED visits and those leading to admission are presented with descriptive statistics. Logistic regression was used to identify clinical and sociodemographic factors associated with admission from the ED. RESULTS A total of 4,687,205 ED visits were identified, of which 46% took place in the DoD healthcare facilities (direct care). The most common diagnoses across all ED visits were abdominal pain, chest pain, headache, nausea and vomiting, and urinary tract infection. A total of 270,127 (5.8%) ED visits led to inpatient admission. The most common diagnoses leading to admission were chest pain, abdominal pain, depression, conditions relating to acute psychological stress, and pneumonia. For patients presenting with 1 of the 10 most common ED diagnoses, those who were seen at a civilian ED were significantly less likely to be admitted (3.4%) compared to direct care facilities (4.1%) in an adjusted logistic regression model (Adjusted Odds Ratio 0.40 [95% CI: 0.40-0.41], P < .001). CONCLUSIONS Ultimately, we show that abdominal pain and chest pain are the most common reasons for presentation to the ED in the Military Health System and the most common presenting diagnoses for admission from the ED. Among patients presenting with the most common ED conditions, direct care EDs were significantly more likely to admit patients than civilian facilities.
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Affiliation(s)
- Michael K Dalton
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA
| | - Tomas Andriotti
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA
| | | | - Muhammad Ali Chaudhary
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA
| | - Laura Tilley
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Stuart Lipsitz
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA.,Division of General Internal Medicine, Brigham and Women's Hospital and Harvard Medical School, Boston, MA 02115, USA
| | - Peter A Learn
- F. Edward Hébert School of Medicine, Uniformed Services University of the Health Sciences, Bethesda, MD 20814, USA
| | - Andrew J Schoenfeld
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA
| | - Molly P Jarman
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA
| | - Eric Goralnick
- Center for Surgery and Public Health, Harvard Medical School, Harvard T. H. Chan School of Public Health, Department of Surgery, Brigham and Women's Hospital, Boston, MA 02120, USA.,Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA 02115, USA
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30
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Ding Z, Patel A, Izanec J, Pericone CD, Lin JH, Baugh CW. Trends in US emergency department visits and subsequent hospital admission among patients with inflammatory bowel disease presenting with abdominal pain: a real-world study from a national emergency department sample database. JOURNAL OF MARKET ACCESS & HEALTH POLICY 2021; 9:1912924. [PMID: 33968334 PMCID: PMC8079064 DOI: 10.1080/20016689.2021.1912924] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/16/2021] [Accepted: 03/31/2021] [Indexed: 06/12/2023]
Abstract
Background/Objective: This study evaluated emergency department (ED) visit trends, subsequent inpatient admissions for patients with inflammatory bowel disease (IBD) diagnosis and IBD-related abdominal pain (AP), and hospital-level variation in inpatient admission rates in the USA (US). Methods: This population-based, cross-sectional study included data from Nationwide Emergency Department Sample (NEDS, 2006─2013) database. Patients ≥18 years of age with primary ED diagnosis of IBD/IBD-related AP were included. Variables included demographics, insurance information, household income, Quan-Charlson comorbidity score, ED discharge disposition, and length of hospital stay (2006, 2010, and 2013). Variation between hospitals using risk-adjusted admission ratio was estimated. Results: Annual ED visits for IBD/100,000 US population increased (30 in 2006 vs 42 in 2013, p = 0.09), subsequent admissions remained stable (20 in 2006 vs 23 in 2013, p = 0.52). ED visits for IBD-related AP increased by 71% (7 in 2006 vs 12 in 2013; p = 0.12), subsequent admissions were stable (0.50 in 2006 vs 0.58 in 2013; p = 0.88). Proportion of patients with subsequent hospitalization decreased (IBD: 65.7% to 55.7%; IBD-related AP: 6.9% to 4.9%). Variation in subsequent inpatient admissions was 1.42 (IBD) and 1.96 (IBD-related AP). Conclusions: An increase in annual ED visits was observed for patients with IBD and IBD-related AP; however, subsequent inpatient admission rate remained stable.
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Affiliation(s)
- Zhijie Ding
- Janssen Scientific Affairs, Janssen Pharmaceuticals, Horsham, PA, USA
| | - Aarti Patel
- Janssen Scientific Affairs, Janssen Pharmaceuticals, Titusville, NJ, USA
| | - James Izanec
- Janssen Scientific Affairs, Janssen Pharmaceuticals, Horsham, PA, USA
| | | | - Jennifer H. Lin
- Janssen Scientific Affairs, Janssen Pharmaceuticals, Titusville, NJ, USA
| | - Christopher W. Baugh
- Department of Emergency Medicine, Brigham and Women’s Hospital, Harvard Medical School, Boston, MA, USA
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Mark DG, Huang J, Kene MV, Sax DR, Cotton DM, Lin JS, Bouvet SC, Chettipally UK, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Ballard DW, Reed ME. Prospective Validation and Comparative Analysis of Coronary Risk Stratification Strategies Among Emergency Department Patients With Chest Pain. J Am Heart Assoc 2021; 10:e020082. [PMID: 33787290 PMCID: PMC8174350 DOI: 10.1161/jaha.120.020082] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Background Coronary risk stratification is recommended for emergency department patients with chest pain. Many protocols are designed as “rule‐out” binary classification strategies, while others use graded‐risk stratification. The comparative performance of competing approaches at varying levels of risk tolerance has not been widely reported. Methods and Results This is a prospective cohort study of adult patients with chest pain presenting between January 2018 and December 2019 to 13 medical center emergency departments within an integrated healthcare delivery system. Using an electronic clinical decision support interface, we externally validated and assessed the net benefit (at varying risk thresholds) of several coronary risk scores (History, ECG, Age, Risk Factors, and Troponin [HEART] score, HEART pathway, Emergency Department Assessment of Chest Pain Score Accelerated Diagnostic Protocol), troponin‐only strategies (fourth‐generation assay), unstructured physician gestalt, and a novel risk algorithm (RISTRA‐ACS). The primary outcome was 60‐day major adverse cardiac event defined as myocardial infarction, cardiac arrest, cardiogenic shock, coronary revascularization, or all‐cause mortality. There were 13 192 patient encounters included with a 60‐day major adverse cardiac event incidence of 3.7%. RISTRA‐ACS and HEART pathway had the lowest negative likelihood ratios (0.06, 95% CI, 0.03–0.10 and 0.07, 95% CI, 0.04–0.11, respectively) and the greatest net benefit across a range of low‐risk thresholds. RISTRA‐ACS demonstrated the highest discrimination for 60‐day major adverse cardiac event (area under the receiver operating characteristic curve 0.92, 95% CI, 0.91–0.94, P<0.0001). Conclusions RISTRA‐ACS and HEART pathway were the optimal rule‐out approaches, while RISTRA‐ACS was the best‐performing graded‐risk approach. RISTRA‐ACS offers promise as a versatile single approach to emergency department coronary risk stratification. Registration URL: https://www.clinicaltrials.gov; Unique identifier: NCT03286179.
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Affiliation(s)
- Dustin G Mark
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Department of Critical Care Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Jie Huang
- Division of Research Kaiser Permanente Northern California Oakland CA
| | - Mamata V Kene
- Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA
| | - Dana R Sax
- Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA.,Division of Research Kaiser Permanente Northern California Oakland CA
| | - Dale M Cotton
- Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center Sacramento CA
| | - James S Lin
- Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA
| | - Sean C Bouvet
- Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA
| | - Uli K Chettipally
- Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA
| | - Megan L Anderson
- Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Ian D McLachlan
- Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA
| | - Laura E Simon
- University of California San Diego School of Medicine San Diego CA
| | - Judy Shan
- Division of Research Kaiser Permanente Northern California Oakland CA
| | | | - David R Vinson
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA
| | - Dustin W Ballard
- Division of Research Kaiser Permanente Northern California Oakland CA.,Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA
| | - Mary E Reed
- Division of Research Kaiser Permanente Northern California Oakland CA
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Natsui S, Sun BC, Shen E, Redberg RF, Ferencik M, Lee MS, Musigdilok V, Wu YL, Zheng C, Kawatkar AA, Sharp AL. Higher Emergency Physician Chest Pain Hospitalization Rates Do Not Lead to Improved Patient Outcomes. Circ Cardiovasc Qual Outcomes 2021; 14:e006297. [PMID: 33430609 DOI: 10.1161/circoutcomes.119.006297] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Wide variation exists for hospital admission rates for the evaluation of possible acute coronary syndrome, but there are limited data on physician-level variation. Our aim is to describe physicians' rates of admission for suspected acute coronary syndrome and associated 30-day major adverse events. METHODS We conducted a retrospective analysis of adult emergency department chest pain encounters from January 2016 to December 2017 across 15 community emergency departments within an integrated health system in Southern California. The unit of analysis was the Emergency physician. The primary outcome was the proportion of patients admitted/observed in the hospital. Secondary analysis described the 30-day incidence of death or acute myocardial infarction. RESULTS Thirty-eight thousand seven hundred seventy-eight patients encounters were included among 327 managing physicians. The median number of encounters per physician was 123 (interquartile range, 82-157) with an overall admission/observation rate of 14.0%. Wide variation in individual physician admission rates were observed (unadjusted, 1.5%-68.9%) and persisted after case-mix adjustments (adjusted, 5.5%-27.8%). More clinical experience was associated with a higher likelihood of hospital care. There was no difference in 30-day death or acute myocardial infarction between high- and low-admitting physician quartiles (unadjusted, 1.70% versus 0.82% and adjusted, 1.33% versus 1.29%). CONCLUSIONS Wide variation persists in physician-level admission rates for emergency department chest pain evaluation, even in a well-integrated health system. There was no associated benefit in 30-day death or acute myocardial infarction for patients evaluated by high-admitting physicians. This suggests an additional opportunity to investigate the safe reduction of physician-level variation in the use of hospital care.
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Affiliation(s)
- Shaw Natsui
- National Clinician Scholars Program, University of California, Los Angeles (S.N.).,Department of Emergency Medicine. Los Angeles, CA (S.N.)
| | - Benjamin C Sun
- Department of Emergency Medicine, University of Pennsylvania, Philadelphia (B.C.S.)
| | - Ernest Shen
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Rita F Redberg
- Division of Cardiology, University of California, San Francisco (R.F.R.)
| | - Maros Ferencik
- Oregon Health and Science University, Knight Cardiovascular Institute, Portland (M.F.)
| | - Ming-Sum Lee
- Division of Cardiology, Kaiser Permanente Southern California, Los Angeles Medical Center (M.-S.L.)
| | - Visanee Musigdilok
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Yi-Lin Wu
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Chengyi Zheng
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Aniket A Kawatkar
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
| | - Adam L Sharp
- Kaiser Permanente Southern California, Research and Evaluation Department. Pasadena (E.S., V.M., Y.-L.W., C.Z., A.A.K., A.L.S.)
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Kocher KE. From Evidence to Action for Emergency Department Chest Pain Hospitalization Practices. Circ Cardiovasc Qual Outcomes 2021; 14:e007572. [PMID: 33430611 DOI: 10.1161/circoutcomes.120.007572] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Affiliation(s)
- Keith E Kocher
- Departments of Emergency Medicine and Learning Health Sciences, Medical School and Institute for Healthcare Policy and Innovation (IHPI), University of Michigan, Ann Arbor
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Jang H, Ozkaynak M, Ayer T, Sills MR. Factors Associated With First Medication Time for Children Treated in the Emergency Department for Asthma. Pediatr Emerg Care 2021; 37:e42-e47. [PMID: 30281550 DOI: 10.1097/pec.0000000000001609] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES Acute asthma exacerbations are among the most common reasons for childhood emergency department (ED) visits and hospitalizations. Although early ED administration of asthma medication has been shown to decrease hospitalizations, studies of factors associated with early ED asthma medication delivery have been limited. The objective of our study was to identify patient- and ED-related factors associated with early medication delivery among children treated in the ED for asthma exacerbations. METHODS This retrospective study used electronic health record data from all encounters for a primary diagnosis of asthma in an academic children's hospital ED during the study period 2009 to 2013. Using multivariate logistic regression, we identified the association between patient- and ED-related factors and the time to first medication defined as a binary outcome using a threshold of 1 hour from ED arrival. We then stratified our analysis by triage level (Emergency Severity Index [ESI]). RESULTS Of the 4846 encounters during the study period, 62% were male, mean age was 7.30 years, 76% had public insurance, and 57% had an ESI level of 3. Medication was administered within 1 hour of arrival in 2236 encounters (46%). After adjusting for covariates, multivariate logistic regression revealed that patients were less likely to have medications within 1 hour when they had less severe ESI (ESI 2 vs ESI 4: odds ratio [OR], 0.139; confidence interval [CI], 0.114-0.170), arrived via non-emergency medical services (OR, 0.525; CI, 0.413-0.665), or arrived to a crowded ED (OR, 0.574; CI, 0.505-0.652). Age, sex, and insurance type were not associated with timeliness of initial medication administration. Stratified analyses demonstrated that the crowding effect was larger for less severely ill patients. CONCLUSIONS Our study found that patient severity (acuity level, arrival mode) and level of ED crowing-but not demographic factors-are associated with the administration of medication in the first hour to pediatric patients with asthma. Our findings may be helpful in redesigning asthma care management strategies.
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Affiliation(s)
- Hoon Jang
- From the Science and Technology Policy Institute, Sejong, South Korea
| | - Mustafa Ozkaynak
- School of Nursing, University of Colorado-Anschutz Medical Campus, Aurora, CO
| | - Turgay Ayer
- Georgia Institute of Technology, Atlanta, GA
| | - Marion R Sills
- School of Medicine, University of Colorado-Anschutz Medical Campus, Aurora, CO
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Dhaliwal JS, Goss F, Whittington MD, Bookman K, Ho PM, Zane R, Wiler J. Reduced admission rates and resource utilization for chest pain patients using an electronic health record-embedded clinical pathway in the emergency department. J Am Coll Emerg Physicians Open 2020; 1:1602-1613. [PMID: 33392569 PMCID: PMC7771814 DOI: 10.1002/emp2.12308] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2020] [Revised: 10/12/2020] [Accepted: 10/13/2020] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Assess the impact of an electronic health record (EHR)-embedded clinical pathway (ePATH) as compared to a paper-based clinical decision support tool on outcomes for patients presenting to the emergency department (ED) with suspected acute coronary syndrome (ACS). METHODS A retrospective, quasi-experimental study using difference-in-differences and interrupted time series specifications to evaluate the impact of an EHR-embedded clinical pathway between April 2013 and July 2017. The intervention was implemented in February 2016 at a large academic tertiary hospital and compared to a local community hospital without the intervention. Eligible patients included adults (>18 years) presenting to the ED with chest pain who had a troponin ordered within 2 hours of arrival and a chest pain-related diagnosis. Patients with initial evidence of acute myocardial infarction were excluded. Primary outcomes included rates of admission and stress testing, hospital length of stay, and occurrence of major adverse cardiac events. RESULTS On average, there were 170 chest pain visits per month at the intervention site. The frequency of hospital admission (unadjusted 28.2% to 20.9%, P < 0.001) and stress testing (unadjusted 15.8% to 12.7%, P < 0.001) significantly declined after ePATH implementation. After comparison with the comparator site, ePATH was still associated with a significant reduction in hospital admissions (-10.79%, P < 0.001) and stress testing (-6.05%, P < 0.001). Hospital length of stay and rates of major adverse cardiac events did not significantly change. CONCLUSIONS Implementation of ePATH for patients presenting to the ED with chest pain was associated with safe reductions in hospital admission and stress testing. ePATH appears to be an effective tool for implementing evidence-based guidelines for ED patients with chest pain.
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Affiliation(s)
- Jasmeet S. Dhaliwal
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Foster Goss
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Melanie D. Whittington
- Skaggs School of Pharmacy and Pharmaceutical SciencesUniversity of Colorado Anschutz Medical CampusAuroraColoradoUSA
- Data Science to Patient Value ProgramUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Kelly Bookman
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - P. Michael Ho
- Data Science to Patient Value ProgramUniversity of Colorado School of MedicineAuroraColoradoUSA
- Division of CardiologyDepartment of MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
| | - Richard Zane
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- UCHealth CARE Innovation CenterAuroraColoradoUSA
| | - Jennifer Wiler
- Department of Emergency MedicineUniversity of Colorado School of MedicineAuroraColoradoUSA
- UCHealth CARE Innovation CenterAuroraColoradoUSA
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Patients with pulmonary hypertension presenting to the emergency department. Am J Emerg Med 2020; 38:2313-2317. [DOI: 10.1016/j.ajem.2019.10.031] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Revised: 10/17/2019] [Accepted: 10/20/2019] [Indexed: 11/20/2022] Open
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Mark DG, Huang J, Kene MV, Sax DR, Cotton DM, Lin JS, Bouvet SC, Chettipally UK, Anderson ML, McLachlan ID, Simon LE, Shan J, Rauchwerger AS, Vinson DR, Ballard DW, Reed ME. Automated Retrospective Calculation of the EDACS and HEART Scores in a Multicenter Prospective Cohort of Emergency Department Chest Pain Patients. Acad Emerg Med 2020; 27:1028-1038. [PMID: 32596953 DOI: 10.1111/acem.14068] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2020] [Revised: 06/18/2020] [Accepted: 06/23/2020] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Coronary risk scores are commonly applied to emergency department patients with undifferentiated chest pain. Two prominent risk score-based protocols are the Emergency Department Assessment of Chest pain Score Accelerated Diagnostic Protocol (EDACS-ADP) and the History, ECG, Age, Risk factors, and Troponin (HEART) pathway. Since prospective documentation of these risk determinations can be challenging to obtain, quality improvement projects could benefit from automated retrospective risk score classification methodologies. METHODS EDACS-ADP and HEART pathway data elements were prospectively collected using a Web-based electronic clinical decision support (eCDS) tool over a 24-month period (2018-2019) among patients presenting with chest pain to 13 EDs within an integrated health system. Data elements were also extracted and processed electronically (retrospectively) from the electronic health record (EHR) for the same patients. The primary outcome was agreement between the prospective/eCDS and retrospective/EHR data sets on dichotomous risk protocol classification, as assessed by kappa statistics (ĸ). RESULTS There were 12,110 eligible eCDS uses during the study period, of which 66 and 47% were low-risk encounters by EDACS-ADP and HEART pathway, respectively. Agreement on low-risk status was acceptable for EDACS-ADP (ĸ = 0.73, 95% confidence interval [CI] = 0.72 to 0.75) and HEART pathway (ĸ = 0.69, 95% CI = 0.68 to 0.70) and for the continuous scores (interclass correlation coefficients = 0.87 and 0.84 for EDACS and HEART, respectively). CONCLUSIONS Automated retrospective determination of low risk status by either the EDACS-ADP or the HEART pathway provides acceptable agreement compared to prospective score calculations, providing a feasible risk adjustment option for use in large data set analyses.
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Affiliation(s)
- Dustin G. Mark
- From the Departments of Emergency Medicine and Critical Care Kaiser Permanente Oakland Medical Center Oakland CA USA
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
| | - Jie Huang
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
| | - Mamata V. Kene
- the Department of Emergency Medicine Kaiser Permanente San Leandro Medical Center San Leandro CA USA
| | - Dana R. Sax
- the Department of Emergency Medicine Kaiser Permanente Oakland Medical Center Oakland CA USA
| | - Dale M. Cotton
- the Department of Emergency Medicine Kaiser Permanente South Sacramento Medical Center South Sacramento CA USA
| | - James S. Lin
- the Department of Emergency Medicine Kaiser Permanente Santa Clara Medical Center Santa Clara CA USA
| | - Sean C. Bouvet
- the Department of Emergency Medicine Kaiser Permanente Walnut Creek Medical Center Walnut Creek CA USA
| | - Uli K. Chettipally
- the Department of Emergency Medicine Kaiser Permanente South San Francisco Medical Center South San Francisco CA USA
| | - Megan L. Anderson
- the Department of Emergency Medicine Kaiser Permanente Roseville Medical Center Roseville CA USA
| | - Ian D. McLachlan
- the Department of Emergency Medicine Kaiser Permanente San Francisco Medical Center San Francisco CA USA
| | - Laura E. Simon
- the University of California San Diego School of Medicine San Diego CA USA
| | - Judy Shan
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
| | | | - David R. Vinson
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
- the Department of Emergency Medicine Kaiser Permanente Sacramento Medical Center Sacramento CA USA
| | - Dustin W. Ballard
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
- and the Department of Emergency Medicine Kaiser Permanente San Rafael Medical Center San Rafael CA USA
| | - Mary E. Reed
- the Division of Research Kaiser Permanente Northern California Oakland CA USA
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Eichelberger C, Patel A, Ding Z, Pericone CD, Lin JH, Baugh CW. Emergency Department Visits and Subsequent Hospital Admission Trends for Patients with Chest Pain and a History of Coronary Artery Disease. Cardiol Ther 2020; 9:153-165. [PMID: 32124423 PMCID: PMC7237631 DOI: 10.1007/s40119-020-00168-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2020] [Indexed: 12/25/2022] Open
Abstract
INTRODUCTION Hospitalization is the largest component of health care spending in the United States. Most hospitalized patients first visit the emergency department (ED), where hospitalization decisions are made. Optimal utilization of hospital resources is critical for all stakeholders. METHODS We performed a population-based, cross-sectional study evaluating ED visits and subsequent inpatient admissions for patients with coronary artery disease (CAD) and chest pain (CP) suggestive of CAD from 2006 to 2013 using the Nationwide Emergency Department Sample database weighted for national estimates. We analyzed trends using a generalized linear regression model with a Poisson distribution and Wald test. RESULTS From 2006 to 2013, there was a 15% decrease in ED visits for CAD (p < 0.01), while ED visit rates for CP increased 31% (p < 0.01). Subsequent inpatient admission rates decreased 18% for CAD (p < 0.01) and 33% for CP (p < 0.01). Trends were not modified by patient and hospital strata. CONCLUSION ED visits and subsequent inpatient admissions resulting from CAD decreased from 2006 to 2013. Patients with CP had a substantially higher number of ED visits, with a significant decline in inpatient admissions.
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Affiliation(s)
- Christine Eichelberger
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Aarti Patel
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Zhijie Ding
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Christopher D Pericone
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Jennifer H Lin
- Janssen Scientific Affairs, LLC, 1125 Trenton-Harbourton Road, Titusville, NJ, 08560, USA
| | - Christopher W Baugh
- Department of Emergency Medicine, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Neville House Second Floor, Boston, MA, 02115, USA.
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Baehr A, Nedza S, Bettinger J, Marshall Vaskas H, Pilgrim R, Wiler J. Enhancing Appropriate Admissions: An Advanced Alternative Payment Model for Emergency Physicians. Ann Emerg Med 2020; 75:612-614. [DOI: 10.1016/j.annemergmed.2019.09.008] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2019] [Indexed: 11/27/2022]
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Hsuan C, Carr BG, Hsia RY, Hoffman GJ. Assessment of Hospital Readmissions From the Emergency Department After Implementation of Medicare's Hospital Readmissions Reduction Program. JAMA Netw Open 2020; 3:e203857. [PMID: 32356883 PMCID: PMC7195622 DOI: 10.1001/jamanetworkopen.2020.3857] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
IMPORTANCE The Medicare Hospital Readmissions Reduction Program (HRRP) is associated with reduced readmission rates, but it is unknown how this decrease occurred. OBJECTIVE To examine whether the HRRP was associated with changes in the probability of readmission at emergency department (ED) visits after hospital discharge (ED revisits) overall and depending on whether admission is typically indicated for the patient's condition at the ED revisit. DESIGN, SETTING, AND PARTICIPANTS This retrospective cohort study used hospital and ED discharge data from California, Florida, and New York from January 1, 2010, to December 31, 2014. A difference-in-differences analysis examined change in readmission probability at ED revisits for recently discharged patients; ED revisits with clinical presentations for which admission is typically indicated vs those for which admission is more variable (ie, discretionary) were examined separately. Inclusion criteria were Medicare patients 65 years and older who revisited an ED within 30 days of inpatient discharge. Data were analyzed from December 18, 2018, to September 11, 2019. EXPOSURES Before and after HRRP implementation among patients initially hospitalized for targeted vs nontargeted conditions. MAIN OUTCOMES AND MEASURES Thirty-day unplanned hospital readmissions at the ED revisit. RESULTS A total of 9 914 068 index hospitalizations were identified in California, Florida, and New York from 2010 to 2014. Of 2 052 096 discharges in 2010, 1 168 126 (56.9%) discharges were women and 566 957 discharges (27.6%) were among patients older than 85 years. Among 1 421 407 patients with an unplanned readmission within 30 days of discharge, 1 266 107 patients (89.1%) were admitted through the ED. A total of 1 906 498 ED revisits were identified. After adjusting for patient demographic and clinical characteristics from the index hospitalization, HRRP implementation was associated with fewer readmissions from the ED, with a difference-in-difference estimate of -0.9 (95% CI, -1.4 to -0.4) percentage points (P < .001), or a 1.4% relative decrease from the 65.8% pre-HRRP readmission rates. Implementation of the HRRP was associated with fewer readmissions at the ED revisit involving clinical presentations for which admission is typically indicated (difference-in-differences estimate, -1.1 [95% CI, -1.6 to -0.6] percentage points; P < .001), or a 1.2% relative decrease from the 93.6% pre-HRRP rate. These results appear to be associated with patients presenting at the ED revisit with congestive heart failure (difference-in-difference estimate, -1.2 [95% CI, -2.0 to -0.4] percentage points; P = .003). CONCLUSIONS AND RELEVANCE These findings suggest that implementation of the HRRP was associated with a lower likelihood of readmission for recently discharged patients presenting to the ED, specifically for congestive heart failure. This highlights the critical role of the ED in readmission reduction under the HRRP and suggests that patient outcomes after HRRP implementation should be further studied.
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Affiliation(s)
- Charleen Hsuan
- Department of Health Policy and Administration, Pennsylvania State University, University Park
| | - Brendan G. Carr
- Department of Emergency Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Renee Y. Hsia
- Department of Emergency Medicine, University of California, San Francisco
| | - Geoffrey J. Hoffman
- Department of Systems, Populations and Leadership, University of Michigan School of Nursing, Ann Arbor
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Michel JB. Thinking fast and slow in medicine. Proc AMIA Symp 2020; 33:123-125. [PMID: 32063797 DOI: 10.1080/08998280.2019.1674043] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2019] [Accepted: 09/23/2019] [Indexed: 10/25/2022] Open
Affiliation(s)
- Jeffrey B Michel
- Division of Cardiology, Baylor Scott and White Memorial HospitalTempleTexas
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Janke AT, Danagoulian S, Venkatesh AK, Levy PD. Medicaid expansion and resource utilization in the emergency department. Am J Emerg Med 2020; 38:2586-2590. [PMID: 31982222 DOI: 10.1016/j.ajem.2019.12.050] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2019] [Revised: 11/25/2019] [Accepted: 12/24/2019] [Indexed: 10/25/2022] Open
Abstract
BACKGROUND The Affordable Care Act (ACA) has impacted the insurance mix of emergency department (ED) visits, yet the degree to which this has influenced provider behavior is not clear. METHODS This was a difference-in-differences (DID) analysis of ED-visit data from five states in 2013 and 2014. Sample states included 3 expanding Medicaid under the ACA, 1 rejecting ACA funding and delaying an eligibility expansion, and 1 with no eligibility change. We included self-pay and Medicaid patients aged 27 to 64 years. A subsample analysis was done for chest pain visits. DID logistic models were estimated for likelihood of admission for given Medicaid-paid ED visits in expansion states as compared to non-expansion states. Among chest pain visits we assessed likelihood given visits resulted in admission or advanced cardiac imaging, where clinician discretion may be more significant. RESULTS A total of 8,157,748 ED visits with primary payer Medicaid and self-pay were included, of which 331,422 were for chest pain. The proportion of visits paid for by Medicaid rose in expansion states by between 15.8% and 38.9%. Medicaid eligibility expansion was associated with increased odds of admission (OR 1.070 [95% CI 1.051-1.089]). Among chest pain visits, expansion was associated with increased odds of admission (OR 1.294 [95% CI 1.144-1.464]), but not advanced cardiac imaging (OR 1.099 [95% CI 0.983-1.229]). CONCLUSION Medicaid expansion was associated with small increases in ED visit admissions across the board and among the subgroup of patients presenting with chest pain.
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Affiliation(s)
- Alexander T Janke
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress, New Haven, CT 06510, USA.
| | - Shooshan Danagoulian
- Department of Economics, Wayne State University, 656 W Kirby St 2074, FAB, Detroit, MI 48202, USA
| | - Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, 464 Congress, New Haven, CT 06510, USA
| | - Phillip D Levy
- Department of Emergency Medicine, Wayne State University School of Medicine, 6135 Woodward Ave, Detroit, MI 48202, USA
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Blinkenberg J, Pahlavanyali S, Hetlevik Ø, Sandvik H, Hunskaar S. General practitioners' and out-of-hours doctors' role as gatekeeper in emergency admissions to somatic hospitals in Norway: registry-based observational study. BMC Health Serv Res 2019; 19:568. [PMID: 31412931 PMCID: PMC6693245 DOI: 10.1186/s12913-019-4419-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Accepted: 08/09/2019] [Indexed: 12/11/2022] Open
Abstract
Background Primary care doctors have a gatekeeper function in many healthcare systems, and strategies to reduce emergency hospital admissions often focus on general practitioners’ (GPs’) and out-of-hours (OOH) doctors’ role. The aim of the present study was to investigate these doctors’ role in emergency admissions to somatic hospitals in the Norwegian public healthcare system, where GPs and OOH doctors have a distinct gatekeeper function. Methods A cross-sectional analysis was performed by linking data from the Norwegian Patient Registry (NPR) and the physicians’ claims database. The referring doctor was defined as the physician who had sent a claim for a consultation with the patient within 24 h prior to an emergency admission. If there was no claim registered prior to hospital arrival, the admission was defined as direct, representing admissions from ambulance services, referrals from nursing home doctors, and admissions initiated by in-hospital doctors. Results In 2014 there were 497,587 emergency admissions to somatic hospitals in Norway after excluding birth related conditions. Direct admissions were most frequent (43%), 31% were referred by OOH doctors, 25% were referred by GPs, whereas only 2% were referred from outpatient clinics or private specialists with public contract. Direct admissions were more common in central areas (52%), here GPs’ referrals constituted only 16%. The prehospital paths varied with the hospital discharge diagnosis. For anaemias, 46–49% were referred by GPs, for acute appendicitis and mental/alcohol related disorders 52 and 49% were referred by OOH doctors, respectively. For both malignant neoplasms and cardiac arrest 63% were direct admissions. Conclusions GPs or OOH doctors referred many emergencies to somatic hospitals, and for some clinical conditions GPs’ and OOH doctors’ gatekeeping role was substantial. However, a significant proportion of the emergency admissions was direct, and this reduces the impact of the GPs’ and OOH doctors’ gatekeeper roles, even in a strict gatekeeping system.
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Affiliation(s)
- Jesper Blinkenberg
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway. .,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway.
| | - Sahar Pahlavanyali
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Øystein Hetlevik
- Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
| | - Hogne Sandvik
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway
| | - Steinar Hunskaar
- National Centre for Emergency Primary Health Care, NORCE Norwegian Research Centre, Kalfarveien 31, 5018, Bergen, Norway.,Department of Global Public Health and Primary Care, University of Bergen, Kalfarveien 31, 5018, Bergen, Norway
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Treatment failure definitions for non-purulent skin and soft tissue infections: a systematic review. Infection 2019; 48:75-83. [PMID: 31378847 DOI: 10.1007/s15010-019-01347-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 07/30/2019] [Indexed: 10/26/2022]
Abstract
OBJECTIVE There is currently no uniform definition for antimicrobial treatment failure for adults with non-purulent skin and soft tissue infections (SSTIs). The objective of this systematic review was to identify treatment failure definitions and their common components in the literature. METHODS Five electronic databases were searched from inception to March 2019. Two independent reviewers identified studies involving adults (age ≥ 18 years) with non-purulent SSTIs in which antimicrobial treatment failure was a defined outcome. There were no language restrictions. Only randomized trials or observational studies were included. RESULTS After screening 4953 abstracts, 26 studies (N = 6629 patients) met full inclusion criteria. Reported treatment failure ranged from 0 to 29.5%. The most common definition components were hospital admission (78.9%), change in antibiotics (65.4%), and persistent or worsening signs and symptoms of infection (34.6%). Only one study listed specific criteria for persistent or worsening signs and symptoms of infection. CONCLUSIONS For studies involving non-purulent SSTIs, the outcome of treatment failure is inconsistently defined and reported failure rates are highly variable. This systematic review has highlighted the need for more robust treatment failure definitions for non-purulent SSTIs. Research should focus on the development of a uniform treatment failure definition that should be used in future studies.
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Performance of Coronary Risk Scores Among Patients With Chest Pain in the Emergency Department. J Am Coll Cardiol 2019; 71:606-616. [PMID: 29420956 DOI: 10.1016/j.jacc.2017.11.064] [Citation(s) in RCA: 45] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2017] [Revised: 10/30/2017] [Accepted: 11/27/2017] [Indexed: 12/22/2022]
Abstract
BACKGROUND Both the modified History, Electrocardiogram, Age, Risk factors and Troponin (HEART) score and the Emergency Department Assessment of Chest pain Score (EDACS) can identify patients with possible acute coronary syndrome (ACS) at low risk (<1%) for major adverse cardiac events (MACE). OBJECTIVES The authors sought to assess the comparative accuracy of the EDACS (original and simplified) and modified HEART risk scores when using cardiac troponin I (cTnI) cutoffs below the 99th percentile, and obtain precise MACE risk estimates. METHODS The authors conducted a retrospective study of adult emergency department (ED) patients evaluated for possible ACS in an integrated health care system between 2013 and 2015. Negative predictive values for MACE (composite of myocardial infarction, cardiogenic shock, cardiac arrest, and all-cause mortality) were determined at 60 days. Reclassification analyses were used to assess the comparative accuracy of risk scores and lower cTnI cutoffs. RESULTS A total of 118,822 patients with possible ACS were included. The 3 risk scores' accuracies were optimized using the lower limit of cTnI quantitation (<0.02 ng/ml) to define low risk for 60-day MACE, with reclassification yields ranging between 3.4% and 3.9%, while maintaining similar negative predictive values (range 99.49% to 99.55%; p = 0.27). The original EDACS identified the largest proportion of patients as low risk (60.6%; p < 0.0001). CONCLUSIONS Among ED patients with possible ACS, the modified HEART score, original EDACS, and simplified EDACS all predicted a low risk of 60-day MACE with improved accuracy using a cTnI cutoff below the 99th percentile. The original EDACS identified the most low-risk patients, and thus may be the preferred risk score.
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Zikos D, Shrestha A, Fegaras L. Estimation of the Mismatch between Admission and Discharge Diagnosis for Respiratory Patients, and Implications on the Length of Stay and Hospital Charges. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE PROCEEDINGS. AMIA JOINT SUMMITS ON TRANSLATIONAL SCIENCE 2019; 2019:192-201. [PMID: 31258971 PMCID: PMC6568083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/09/2023]
Abstract
Admission and discharge diagnoses in hospitals are often in discord, and this has significant implications for the cost of care and patient safety. In this paper we used medical claims data to examine these differences for beneficiaries with respiratory conditions and quantified the degree to which specific respiratory conditions are mistaken for other ones, on admission. Since respiratory problems have seasonality, we performed two separate analyses, for summer and for winter admissions. The length of stay and hospital charges were compared between matching and non-matching {admission, discharge Dx} pairs, using independent samples t-test analysis. Results were integrated into a standalone application where physicians can select an admission diagnosis to see (i) the probability for this diagnosis to be correct (matching the discharge Dx), (ii) the probabilities for mismatch and (iii) pair-specific differential diagnosis criteria to consider reassessing the patient before confirming the admission diagnosis.
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Venkatesh AK, Chou SC, Li SX, Choi J, Ross JS, D'Onofrio G, Krumholz HM, Dharmarajan K. Association Between Insurance Status and Access to Hospital Care in Emergency Department Disposition. JAMA Intern Med 2019; 179:686-693. [PMID: 30933243 PMCID: PMC6503571 DOI: 10.1001/jamainternmed.2019.0037] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
IMPORTANCE Studies of public hospitals have reported increasing incidence of emergency department (ED) transfers of uninsured patients for hospitalization, which is perceived to be associated with financial incentives. OBJECTIVE To examine the differences in risk-adjusted transfer and discharge rates by patient insurance status among hospitals capable of providing critical care. DESIGN, SETTING, AND PARTICIPANTS A cross-sectional analysis of the 2015 National Emergency Department Sample was conducted, including visits between January 2015 and December 2015. Adult ED visits throughout 2015 (n = 215 028) for the 3 common medical conditions of pneumonia, chronic obstructive pulmonary disease, and asthma, at hospitals with intensive care capabilities were included. Only hospitals with advanced critical care capabilities for pulmonary care were included. MAIN OUTCOMES AND MEASURES The primary outcomes were patient-level and hospital-level risk-adjusted ED discharges, ED transfers, and hospital admissions. Adjusted odds of discharge or transfer compared with admission among uninsured patients, Medicaid and Medicare beneficiaries, and privately insured patients are reported. Hospital ownership status was used for the secondary analysis. RESULTS Of the 30 542 691 ED visits to 953 hospitals included in the 2015 National Emergency Department Sample, 215 028 visits (0.7%) were for acute pulmonary diseases to 160 intensive care-capable hospitals. These visits were made by patients with a median (interquartile range [IQR]) age of 55 (40-71) years and who were predominantly female (124 931 [58.1%]). Substantial variation in unadjusted and risk-standardized ED discharge, ED transfer, and hospital admission rates was found across EDs. Compared with privately insured patients, uninsured patients were more likely to be discharged (odds ratio [OR], 1.66; 95% CI, 1.57-1.76) and transferred (adjusted OR [aOR], 2.41; 95% CI, 2.08-2.79). Medicaid beneficiaries had comparable odds of discharge (aOR, 1.00; 95% CI, 0.97-1.04) but higher odds of transfer (aOR, 1.19; 95% CI, 1.05-1.33). CONCLUSIONS AND RELEVANCE After accounting for hospital critical care capability and patient case mix, the study found that uninsured patients and Medicaid beneficiaries with common medical conditions appeared to have higher odds of interhospital transfer.
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Affiliation(s)
- Arjun K Venkatesh
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut.,Yale New Haven Hospital-Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, Massachusetts
| | - Shu-Xia Li
- Yale New Haven Hospital-Center for Outcomes Research and Evaluation, New Haven, Connecticut
| | - Jennie Choi
- Yale University School of Medicine, New Haven, Connecticut
| | - Joseph S Ross
- Yale New Haven Hospital-Center for Outcomes Research and Evaluation, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.,Section of General Medicine, Department of Internal Medicine, Yale School of Medicine, New Haven, Connecticut
| | - Gail D'Onofrio
- Department of Emergency Medicine, Yale University School of Medicine, New Haven, Connecticut
| | - Harlan M Krumholz
- Yale New Haven Hospital-Center for Outcomes Research and Evaluation, New Haven, Connecticut.,Department of Health Policy and Management, Yale School of Public Health, New Haven, Connecticut.,Division of Cardiology, Department of Internal Medicine, Yale University School of Medicine, New Haven, Connecticut
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Schechtman M, Kocher KE, Nypaver MM, Ham JJ, Zochowski MK, Macy ML. Michigan Emergency Department Leader Attitudes Toward and Experiences With Clinical Pathways to Guide Admission Decisions: A Mixed-methods Study. Acad Emerg Med 2019; 26:384-393. [PMID: 30112831 DOI: 10.1111/acem.13555] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Revised: 08/04/2018] [Accepted: 08/11/2018] [Indexed: 12/19/2022]
Abstract
OBJECTIVES The objective was to characterize emergency department (ED) leader's attitudes toward potentially avoidable admissions and experiences with the use of clinical pathways to guide admission decisions, including the challenges and successes with implementation of these pathways. METHODS A mixed-methods study of Michigan ED leaders was conducted. First, a cross-sectional Web-based survey was distributed via e-mail to all 135 hospital-based EDs in the state. Descriptive statistics were calculated. Survey participants who provided contact information were considered eligible for follow-up. Semistructured interviews were conducted by telephone until thematic saturation was reached. Interviews were recorded, transcribed verbatim, reviewed for accuracy, and thematically coded. Representative quotes were extracted for reporting. RESULTS Survey responses were received from 64 ED leaders (48% eligible response rate). Semistructured interviews were conducted with a purposeful sample of 11 of the 29 representatives willing to be contacted. Eight sites implemented clinical care pathways as a strategy to reduce avoidable admissions. Pathways were developed for high-frequency conditions. Many pathways were multidisciplinary, incorporating case managers and outpatient care providers, which was thought to improve acceptability. Five models of care emerged 1) standardized care, 2) observation medicine, 3) enhanced follow-up, 4) care coordination, and 5) comprehensive programs. We identified barriers to and facilitators of discharging a patient from the ED when an admission otherwise could be avoided. Barriers included limited access to follow-up, lack of care coordination, and lack of trust in patient's ability to provide self-care or navigate the system. Facilitators included strong relationships with outpatient providers, care coordination, and shared decision making. CONCLUSIONS Potential solutions to help avoid hospitalization from the ED include multidisciplinary clinical care pathways. Successful pathways emerged from bringing stakeholders from the ED, hospital, and health care community together. Additionally, emergency providers need systems and supports in place to help their patients navigate follow-up care in a timely fashion.
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Affiliation(s)
- Megan Schechtman
- University of Michigan Medical School Michigan Medicine Ann Arbor MI
| | - Keith E Kocher
- Department of Emergency Medicine Michigan Medicine Ann Arbor MI
- Institute for Health Policy and Innovation University of Michigan Ann Arbor MI
| | - Michele M. Nypaver
- Departments of Emergency Medicine and Pediatrics Michigan Medicine Ann Arbor MI
| | - Jason J. Ham
- Department of Internal Medicine Michigan Medicine Ann Arbor MI
| | | | - Michelle L. Macy
- Departments of Emergency Medicine and Pediatrics Michigan Medicine Ann Arbor MI
- Child Health Evaluation and Research (CHEAR) Center University of Michigan Ann Arbor MI
- Institute for Health Policy and Innovation University of Michigan Ann Arbor MI
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Sex-Specific Cut-Offs for High-Sensitivity Cardiac Troponin: Is Less More? Cardiovasc Ther 2019; 2019:9546931. [PMID: 31772621 PMCID: PMC6739766 DOI: 10.1155/2019/9546931] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2018] [Revised: 01/08/2019] [Accepted: 01/16/2019] [Indexed: 12/25/2022] Open
Abstract
Management of patients presenting to the Emergency Department with chest pain is continuously evolving. In the setting of acute coronary syndrome, the availability of high-sensitivity cardiac troponin assays (hs-cTn) has allowed for the development of algorithms aimed at rapidly assessing the risk of an ongoing myocardial infarction. However, concerns were raised about the massive application of such a simplified approach to heterogeneous real-world populations. As a result, there is a potential risk of underdiagnosis in several clusters of patients, including women, for whom a lower threshold for hs-cTn was suggested to be more appropriate. Implementation in clinical practice of sex-tailored cut-off values for hs-cTn represents a hot topic due to the need to reduce inequality and improve diagnostic performance in females. The aim of this review is to summarize current evidence on sex-specific cut-off values of hs-cTn and their application and usefulness in clinical practice. We also offer an extensive overview of thresholds reported in literature and of the mechanisms underlying such differences among sexes, suggesting possible explanations about debated issues.
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