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Rappaport DI, Wilding KM, Adkins L, Bourque M, Miller JM. How Will a Shift to Value-Based Financial Models Affect Care for Hospitalized Children? Hosp Pediatr 2024; 14:e177-e180. [PMID: 38351892 DOI: 10.1542/hpeds.2023-007400] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024]
Affiliation(s)
- David I Rappaport
- Division of General Academic Pediatrics
- Utilization Management, Nemours Children's Hospital, Wilmington, Delaware
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
| | - Karen Marie Wilding
- Value-Based Services Organization, Nemours Children's Health, Wilmington, Delaware
| | - Lisa Adkins
- Utilization Management, Nemours Children's Hospital, Wilmington, Delaware
- Value-Based Services Organization, Nemours Children's Health, Wilmington, Delaware
| | - Maryanne Bourque
- Utilization Management, Nemours Children's Hospital, Wilmington, Delaware
- Value-Based Services Organization, Nemours Children's Health, Wilmington, Delaware
| | - Jonathan M Miller
- Division of General Academic Pediatrics
- Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania
- Value-Based Services Organization, Nemours Children's Health, Wilmington, Delaware
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Beckman AL, Frakt AB, Duggan C, Zheng J, Orav EJ, Tsai TC, Figueroa JF. Evaluation of Potentially Avoidable Acute Care Utilization Among Patients Insured by Medicare Advantage vs Traditional Medicare. JAMA HEALTH FORUM 2023; 4:e225530. [PMID: 36826828 PMCID: PMC9958527 DOI: 10.1001/jamahealthforum.2022.5530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/25/2023] Open
Abstract
Importance Medicare Advantage plans have strong incentives to reduce potentially wasteful health care, including costly acute care visits for ambulatory care-sensitive conditions (ACSCs). However, it remains unknown whether Medicare Advantage plans lower acute care use compared with traditional Medicare, or if it shifts patients from hospitalization to observation stays and emergency department (ED) direct discharges. Objective To determine whether Medicare Advantage is associated with differential utilization of hospitalizations, observations, and ED direct discharges for ACSCs compared with traditional Medicare. Design, Setting, and Participants Cross-sectional study of US Medicare Advantage vs traditional Medicare beneficiaries from January 1 to December 31, 2018. Poisson regression models were used to compare risk-adjusted rates of Medicare Advantage vs traditional Medicare, controlling for patient demographic characteristics and clinical risk and including county fixed-effects. Data were analyzed between April 2021 and November 2022. Main Outcomes and Measures Hospitalizations, observation stays, and ED direct discharges for ACSCs. Results The study sample comprised 2 665 340 Medicare Advantage patients (mean [SD] age, 72.7 [9.8] years; 1 504 519 [56.4%] women; 1 859 067 [69.7%] White individuals) and 7 981 547 traditional Medicare patients (mean [SD] age, 71.2 [11.8] years; 4 232 201 [53.0%] women; 6 176 239 [77.4%] White individuals). Medicare Advantage patients had lower risk of hospitalization for ACSCs compared with traditional Medicare patients (relative risk [RR], 0.94; 95% CI, 0.93-0.95), primarily owing to fewer hospitalizations for acute conditions (eg, pneumonia). Medicare Advantage patients had a higher risk of ED direct discharges (RR, 1.44; 95% CI, 1.43-1.45) and observation stays (RR, 2.38; 95% CI, 2.34-2.41) for ACSCs vs traditional Medicare patients. Overall, Medicare Advantage patients were at higher risk of needing care for an ACSC (hospitalization, ED direct discharge, or observation stay) than traditional Medicare patients (RR, 1.30; 95% CI, 1.30-1.31). Within the Medicare Advantage population, patients in health maintenance organizations (HMOs) were at lower risk of ACSC-related hospitalization compared with patients in its preferred provider organizations (RR, 0.96; 95% CI, 0.95-0.98); however, those in the HMOs had a higher risk of ED direct discharge (RR, 1.08; 95% CI, 1.07-1.09) and observation stay (overall RR, 1.10; 95% CI, 1.02-1.12). Conclusions and Relevance The findings of this cross-sectional study of Medicare Advantage and traditional Medicare patients with ACSCs indicate that apparent gains in lowering rates of potentially avoidable acute care have been associated with shifting inpatient care to settings such as ED direct discharges and observation stays.
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Affiliation(s)
- Adam L. Beckman
- Harvard Medical School, Boston, Massachusetts,Harvard Business School, Boston, Massachusetts
| | - Austin B. Frakt
- US Department of Veterans Affairs, Boston Healthcare System, Boston University School of Public Health, Boston, Massachusetts,Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Ciara Duggan
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Jie Zheng
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - E. John Orav
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
| | - Thomas C. Tsai
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Surgery, Brigham and Women’s Hospital, Boston, Massachusetts
| | - Jose F. Figueroa
- Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts,Department of Medicine, Division of General Internal Medicine, Brigham and Women’s Hospital, Boston, Massachusetts
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Maalouli W, Petersen A, Strutt J, Bergmann KR, Axelrod A, Lee G, Hester GZ. Prediction Model for Croup Admission Need. Hosp Pediatr 2022; 12:711-718. [PMID: 35788350 DOI: 10.1542/hpeds.2021-006389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVES This study aims to generate a predictive model stratifying the probability of requiring hospitalization and inpatient respiratory intervention for croup patients presenting to the emergency department (ED), and secondarily to compare the model's performance with that of ED providers. METHODS Retrospective data was collected on croup patients presenting to the EDs of 2 pediatric and 1 community hospital from 2019 to 2020, including demographics, preexisting conditions, and history of croup. The ED length of stay, previous dexamethasone administration, time to ED dexamethasone, number of ED racemic epinephrine doses, viral testing, and ED revisits were also recorded. Westley croup scores were derived at ED presentation and final disposition. For admitted patients, any respiratory interventions were recorded. Admission need was defined as either admitted and required an inpatient intervention or not admitted with ED revisit. A prediction model for admission need was fit using L1-penalized logistic regression. RESULTS We included 2951 patients in the study, 68 (2.3%) of which needed admission. The model's predictors were disposition Westley croup scores, number of ED racemic epinephrine doses, previous dexamethasone administration, and history of intubation. The model's sensitivity was 66%, specificity was 91%, positive predictive value was 15%, and negative predictive value was 99%. ED providers' performance had a sensitivity of 72%, a specificity of 94%, a positive predictive value of 23%, and a negative predictive value of 99%. CONCLUSIONS The croup admission need predictive model appears to support clinical decision making in the ED, with the potential to improve decision making when pediatric expertise is limited.
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Affiliation(s)
| | | | | | | | | | - Grace Lee
- University of Minnesota, Minneapolis, Minnesota
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Abstract
OBJECTIVE This pilot study aims to identify potential predictors of postadmission interventions of hospitalized croup patients and derive a risk model aimed at reducing hospitalizations for croup. METHODS Data were collected on all croup hospitalizations for patients aged 1 month to 17 years admitted through a community hospital's emergency department (ED) between 2012 and 2017. Potential predictors were obtained from the electronic medical records including demographics, vital signs, ED length of stay, preintervention and postintervention Westley Croup Score (WCS), number of racemic epinephrine nebulizations administered, time to dexamethasone administration, preexisting conditions, and additional interventions during hospitalization. Statistical analysis used the outcome "patient received racemic epinephrine after hospital admission (yes/no)" to identify characteristics of the child or ED visit associated with that outcome. Preliminary analyses using stepwise logistic regression, tree models, and random forests suggested predictors, interactions among predictors, and the form of their association with the outcome. A final analysis used logistic regression. RESULTS A total of 116 croup admissions were included, of which 19 (16%) received racemic epinephrine posthospitalization. These characteristics were identified as having some predictive power: sex, preexisting conditions, and preintervention and postintervention WCS, along with the interaction between sex and postintervention WCS. Logistic regression estimated an equation describing the probability of postadmission intervention, permitting the choice among admission thresholds giving different sensitivities and specificities. CONCLUSIONS There appear to be promising predictors in croup patients presenting to the ED, which might help stratify risk for interventions after the ED encounter and thus reduce the number of potentially avoidable admissions.
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Affiliation(s)
| | - James S Hodges
- Division of Biostatistics, School of Public Health, University of Minnesota, Minneapolis, MN
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Tian Y, Hall M, Ingram MCE, Hu A, Raval MV. Trends and Variation in the Use of Observation Stays at Children's Hospitals. J Hosp Med 2021; 16:645-651. [PMID: 34328847 DOI: 10.12788/jhm.3622] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/28/2020] [Accepted: 03/22/2021] [Indexed: 11/20/2022]
Abstract
BACKGROUND Observation status could improve efficiency of healthcare resource use but also might shift financial burdens to patients and hospitals. Although the use of observation stays has increased for adult patient populations, the trends are unknown among hospitalized children. OBJECTIVE The goal of this study was to describe recent trends in observation stays for pediatric populations at children's hospitals. DESIGN, SETTING, AND PARTICIPANTS Both observation and inpatient stays for all conditions were retrospectively studied using the Pediatric Health Information System database (2010 to 2019). EXPOSURE, MAIN OUTCOMES, AND MEASURES Patient type was classified as inpatient or observation status. Main outcomes included annual percentage of observation stays, annual percentage of observation stays having prolonged length of stay (>2 days), and growth rates of observation stays for the 20 most common conditions. Risk adjusted hospital-level use of observation stays was estimated using generalized linear mixed-effects models. RESULTS The percentage of observation stays increased from 23.6% in 2010 to 34.3% in 2019 (P < .001), and the percentage of observation stays with prolonged length of stay rose from 1.1% to 4.6% (P < .001). Observation status was expanded among a diverse group of clinical conditions; diabetes mellitus and surgical procedures showed the highest growth rates. Adjusted hospital-level use ranged from 0% to 67% in 2019, indicating considerable variation among hospitals. CONCLUSION Based on the increase in observation stays, future studies should explore the appropriateness of observation care related to efficient use of healthcare resources and financial implications for hospitals and patients.
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Affiliation(s)
- Yao Tian
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
| | - Matt Hall
- Children's Hospital Association, Lenexa, Kansas
| | - Martha-Conley E Ingram
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
| | - Andrew Hu
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
| | - Mehul V Raval
- Surgical Outcomes Quality Improvement Center, Department of Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois
- Division of Pediatric Surgery, Department of Surgery, Northwestern University Feinberg School of Medicine, Ann and Robert H Lurie Children's Hospital, Chicago, Illinois
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Wheatley M, Kapil S, Lewis A, O’Sullivan J, Armentrout J, Moran T, Osborne A, Moore B, Morse B, Rhee P, Ahmad F, Atallah H. Management of Minor Traumatic Brain Injury in an ED Observation Unit. West J Emerg Med 2021; 22:943-950. [PMID: 35354002 PMCID: PMC8328171 DOI: 10.5811/westjem.2021.4.50442] [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: 10/27/2020] [Accepted: 04/21/2021] [Indexed: 11/17/2022] Open
Abstract
Introduction Traumatic intracranial hemorrhages (TIH) have traditionally been managed in the intensive care unit (ICU) setting with neurosurgery consultation and repeat head CT (HCT) for each patient. Recent publications indicate patients with small TIH and normal neurological examinations who are not on anticoagulation do not require ICU-level care, repeat HCT, or neurosurgical consultation. It has been suggested that these patients can be safely discharged home after a short period of observation in emergency department observation units (EDOU) provided their symptoms do not progress. Methods This study is a retrospective cross-sectional evaluation of an EDOU protocol for minor traumatic brain injury (mTBI). It was conducted at a Level I trauma center. The protocol was developed by emergency medicine, neurosurgery and trauma surgery and modeled after the Brain Injury Guidelines (BIG). All patients were managed by attendings in the ED with discretionary neurosurgery and trauma surgery consultations. Patients were eligible for the mTBI protocol if they met BIG 1 or BIG 2 criteria (no intoxication, no anticoagulation, normal neurological examination, no or non-displaced skull fracture, subdural or intraparenchymal hematoma up to 7 millimeters, trace to localized subarachnoid hemorrhage), and had no other injuries or medical co-morbidities requiring admission. Protocol in the EDOU included routine neurological checks, symptom management, and repeat HCT for progression of symptoms. The EDOU group was compared with historical controls admitted with primary diagnosis of TIH over the 12 months prior to the initiation of the mTBI protocols. Primary outcome was reduction in EDOU length of stay (LOS) as compared to inpatient LOS. Secondary outcomes included rates of neurosurgical consultation, repeat HCT, conversion to inpatient admission, and need for emergent neurosurgical intervention. Results There were 169 patients placed on the mTBI protocol between September 1, 2016 and August 31, 2019. The control group consisted of 53 inpatients. Median LOS (interquartile range [IQR]) for EDOU patients was 24.8 (IQR: 18.8 – 29.9) hours compared with a median LOS for the comparison group of 60.2 (IQR: 45.1 – 85.0) hours (P < .001). In the EDOU group 47 (27.8%) patients got a repeat HCT compared with 40 (75.5%) inpatients, and 106 (62.7%) had a neurosurgical consultation compared with 53 (100%) inpatients. Subdural hematoma was the most common type of hemorrhage. It was found in 60 (35.5%) patients, and subarachnoid hemorrhage was found in 56 cases (33.1%). Eleven patients had multicompartment hemorrhage of various classifications. Twelve (7.1%) patients required hospital admission from the EDOU. None of the EDOU patients required emergent neurosurgical intervention. Conclusion Patients with minor TIH can be managed in an EDOU using an mTBI protocol and discretionary neurosurgical consults and repeat HCT. This is associated with a significant reduction in length of stay.
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Affiliation(s)
- Matthew Wheatley
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Shikha Kapil
- Georgetown University School of Medicine, Department of Emergency Medicine, Washington, District of Columbia
| | - Amanda Lewis
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Jessica O’Sullivan
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Joshua Armentrout
- Atlanta Medical Center, Department of Emergency Medicine, Atlanta, Georgia
| | - Tim Moran
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia
| | - Anwar Osborne
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Brooks Moore
- Emory University School of Medicine, Department of Emergency Medicine, Atlanta, Georgia; Grady Health Systems, Department of Emergency Medicine, Atlanta, Georgia
| | - Bryan Morse
- Maine Medical Center, Department of Surgery and Surgical Critical Care, Portland, Maine
| | - Peter Rhee
- Westchester Medical Center, Department of Surgery, Trauma Surgery, and Surgical Critical Care, Valhalla, New York
| | - Faiz Ahmad
- Emory University School of Medicine, Department of Neurosurgery, Atlanta, Georgia
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Figueroa JF, Burke LG, Horneffer KE, Zheng J, John Orav E, Jha AK. Avoidable Hospitalizations And Observation Stays: Shifts In Racial Disparities. Health Aff (Millwood) 2021; 39:1065-1071. [PMID: 32479235 DOI: 10.1377/hlthaff.2019.01019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Racial disparities in hospitalization rates for ambulatory care-sensitive conditions are concerning and may signal differential access to high-quality ambulatory care. Whether racial disparities are improving as a result of better ambulatory care versus artificially narrowing because of increased use of observation status is unclear. Using Medicare data for 2011-15, we sought to determine whether black-white disparities in avoidable hospitalizations were improving and evaluated the degree to which changes in observations for ambulatory care-sensitive conditions may be contributing to changes in these gaps. We found that while the racial gap in avoidable hospitalizations due to such conditions has decreased, that seems to be explained by a concomitant increase in the gap of avoidable observation stays. This suggests that changes from inpatient admissions to observation status seem to be driving the reduction in racial disparities in avoidable hospitalizations, rather than changes in the ambulatory setting.
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Affiliation(s)
- José F Figueroa
- José F. Figueroa is an assistant professor of health policy and management in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, and an associate physician and assistant professor of medicine in the Department of Medicine, Brigham and Women's Hospital, Harvard Medical School, both in Boston, Massachusetts
| | - Laura G Burke
- Laura G. Burke is an assistant professor of emergency medicine in the Department of Emergency Medicine, Harvard Medical School
| | - Kathryn E Horneffer
- Kathryn E. Horneffer is a research assistant in the Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, in Boston
| | - Jie Zheng
- Jie Zheng is associate director of analytics at the Harvard Global Health Institute, in Cambridge, Massachusetts
| | - E John Orav
- E. John Orav is an associate professor of biostatistics in the Department of Medicine, Brigham and Women's Hospital
| | - Ashish K Jha
- Ashish K. Jha is the director of the Harvard Global Health Institute and is dean of global strategy and the K. T. Li Professor of Global Health, Harvard T. H. Chan School of Public Health
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Practical alternative to hospitalization for emergency department patients (PATH): A feasibility study. HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION 2021; 9:100545. [PMID: 33901987 DOI: 10.1016/j.hjdsi.2021.100545] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 03/08/2021] [Accepted: 03/24/2021] [Indexed: 11/23/2022]
Abstract
OBJECTIVE We sought to determine the feasibility of the Practical Alternative to Hospitalization (PATH) program, an intervention that offers ED clinicians an outpatient care pathway for patients initially designated for inpatient admission or observation. METHODS We evaluated a novel care delivery model that was piloted at a tertiary academic medical center in December 2019. An advanced practice provider screened patients designated for inpatient admission or observation and identified eligible participants. Outpatient services were customized for each patient but primarily included care coordination and monitoring through telemedicine and home health services. The primary feasibility outcome was the proportion of eligible patients who were enrolled in the program, as well as patient outcomes after discharge including return ED visits and averted ED boarding time. RESULTS A total of 199 patients were designated for inpatient admission or observation during PATH program hours. Of 52 eligible patients, 30 (58%) were enrolled. The mean participant age was 62.5 years (SD 17.5), and 25 (83%) had non-Hispanic Black race/ethnicity. The most common disease conditions were chest pain, heart failure, and hyperglycemia. 4 (13%) enrolled patients returned to an ED within 30 days. We estimate that ED boarding time was reduced by 8.2 h (SD 8.1) per patient. CONCLUSION Emergency physicians and patients were willing to use a novel service that provided an alternative disposition to hospitalization. IMPLICATIONS alternative payment models that seek to reduce hospital utilization and cost may consider strengthening systems to monitor and coordinate care for patients after ED discharge.
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Rahman M, Meyers DJ, Wright B. Unintended Consequences of Observation Stay Use May Disproportionately Burden Medicare Beneficiaries in Disadvantaged Neighborhoods. Mayo Clin Proc 2020; 95:2589-2591. [PMID: 33276830 DOI: 10.1016/j.mayocp.2020.10.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 10/19/2020] [Indexed: 11/22/2022]
Affiliation(s)
- Momotazur Rahman
- Department of Health Services, Policy, and PracticeBrown University.
| | - David J Meyers
- Department of Health Services, Policy, and PracticeBrown University
| | - Brad Wright
- Department of Family Medicine, University of North Carolina at Chapel Hill, Chapel Hill, NC
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Cichowitz C, Loevinsohn G, Klein EY, Colantuoni E, Galiatsatos P, Rennert J, Irvin NA. Racial and ethnic disparities in hospital observation in Maryland. Am J Emerg Med 2020; 46:532-538. [PMID: 33243537 DOI: 10.1016/j.ajem.2020.11.010] [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: 06/05/2020] [Revised: 10/27/2020] [Accepted: 11/04/2020] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVES Hospital observation is a key disposition option from the emergency department (ED) and encompasses up to one third of patients requiring post-ED care. Observation has been associated with higher incidence of catastrophic financial costs and has downstream effects on post-discharge clinical services. Yet little is known about the non-clinical determinants of observation assignment. We sought to evaluate the impact of patient-level demographic factors on observation designation among Maryland patients. METHODS We conducted a retrospective analysis of all ED encounters in Maryland between July 2012 and January 2017 for four priority diagnoses (heart failure, chronic obstructive pulmonary disease [COPD], pneumonia, and acute chest pain) using multilevel logistic models allowing for heterogeneity of the effects across hospitals. The primary exposure was self-reported race and ethnicity. The primary outcome was the initial status assignment from the ED: hospital observation versus inpatient admission. RESULTS Across 46 Maryland hospitals, 259,788 patient encounters resulted in a disposition of inpatient admission (65%) or observation designation (35%). Black (adjusted odds ratio [aOR]: 1.19; 95% confidence interval [CI]: 1.16-1.23) and Hispanic (aOR: 1.11; 95% CI: 1.01-1.21) patients were significantly more likely to be placed in observation than white, non-Hispanic patients. These differences were consistent across the majority of acute-care hospitals in Maryland (27/46). CONCLUSION Black and Hispanic patients in Maryland are more likely to be treated under the observation designation than white, non-Hispanic patients independent of clinical presentation. Race agnostic, time-based status assignments may be key in eliminating these disparities.
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Affiliation(s)
- Cody Cichowitz
- Massachussetts General Hospital, Department of Medicine, Center for Global Health, Boston, MA, USA; Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gideon Loevinsohn
- Johns Hopkins University School of Medicine, Baltimore, MD, USA; Johns Hopkins University Bloomberg School of Public Health, Department of Epidemiology, Baltimore, MD, USA
| | - Eili Y Klein
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA; Center for Disease Dynamics, Economics & Policy, Washington, DC, USA
| | - Elizabeth Colantuoni
- Johns Hopkins University Bloomberg School of Public Health, Department of Biostatistics, Baltimore, MD, USA
| | - Panagis Galiatsatos
- Johns Hopkins University School of Medicine, Department of Medicine, Division of Pulmonary and Critical Care Medicine, Baltimore, MD, USA
| | - Jodi Rennert
- Johns Hopkins University School of Medicine, Department of Medicine, Baltimore, MD, USA
| | - Nathan A Irvin
- Johns Hopkins University School of Medicine, Department of Emergency Medicine, Baltimore, MD, USA.
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Advanced imaging and trends in hospitalizations from the emergency department. PLoS One 2020; 15:e0239059. [PMID: 32936833 PMCID: PMC7494122 DOI: 10.1371/journal.pone.0239059] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2020] [Accepted: 08/28/2020] [Indexed: 12/05/2022] Open
Abstract
Objective The proportion of US emergency department (ED) visits that lead to hospitalization has declined over time. The degree to which advanced imaging use contributed to this trend is unknown. Our objective was to examine the association between advanced imaging use during ED visits and changes in ED hospitalization rates between 2007–2008 and 2015–2016. Methods We analyzed data from the National Hospital Ambulatory Medical Care Survey. The primary outcome was ED hospitalization, including admission to inpatient and observation units and outside transfers. The primary exposure was advanced imaging during the ED visit, including computed tomography, magnetic resonance imaging, and ultrasound. We constructed a survey-weighted multivariable logistic regression with binary outcome of ED hospitalization to examine changes in adjusted hospitalization rates from 2007–2008 to 2015–2016, comparing ED visits with and without advanced imaging. Results ED patients who received advanced imaging (versus those who did not) were more likely to be 65 years or older (25.3% vs 13.0%), non-Hispanic white (65.3% vs 58.5%), female (58.4% vs 54.1%), and have Medicare (26.5% vs 16.0%). Among ED visits with advanced imaging, adjusted annual hospitalization rate declined from 22.5% in 2007–2008 to 17.3% (adjusted risk ratio [aRR] 0.77; 95% CI 0.68, 0.86) in 2015–2016. In the same periods, among ED visits without advanced imaging, adjusted annual hospitalization rate declined from 14.3% to 11.6% (aRR 0.81; 95% CI 0.73, 0.90). The aRRs between ED visits with and without advanced imaging were not significantly different. Conclusion From 2007–2016, ED visits with advanced imaging did not have a greater reduction in admission rate compared to those without advanced imaging. Our results suggest that increasing advanced imaging use likely had a limited role in the general decline in hospital admissions from EDs. Future research is needed to further validate this finding.
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Martsolf GR, Nuckols TK, Fingar KR, Barrett ML, Stocks C, Owens PL. Nonspecific chest pain and hospital revisits within 7 days of care: variation across emergency department, observation and inpatient visits. BMC Health Serv Res 2020; 20:516. [PMID: 32513147 PMCID: PMC7278151 DOI: 10.1186/s12913-020-05200-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 04/08/2020] [Indexed: 11/11/2022] Open
Affiliation(s)
- Grant R Martsolf
- University of Pittsburgh School of Nursing, 3500 Victoria St, 315B, Pittsburgh, PA, 15213, USA.,RAND Corporation, 4570 Fifth Ave #600, Pittsburgh, PA, 15213, USA
| | - Teryl K Nuckols
- RAND Corporation, 1776 Main Street, Santa Monica, CA, 90401, USA.,Cedars-Sinai Medical Center, 8700 Beverly Boulevard, Becker 113, Los Angeles, CA, 90048, USA
| | - Kathryn R Fingar
- IBM Watson Health, 5425 Hollister Ave, Suite 140, Santa Barbara, CA, 93111, USA
| | | | - Carol Stocks
- Affiliation during this investigation: Agency for Healthcare Research and Quality, Rockville, Maryland, USA.,Present address: West Virginia University, School of Public Health, 64 Medical Center Drive, PO Box 9190, Morgantown, WV, 26506-9190, USA
| | - Pamela L Owens
- Agency for Healthcare Research and Quality, 5600 Fishers Lane, Rockville, MD, 20857, USA.
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The Accuracy of Interqual Criteria in Determining the Observation versus Inpatient Status in Older Adults with Syncope. J Emerg Med 2020; 59:193-200. [PMID: 32291127 DOI: 10.1016/j.jemermed.2020.02.020] [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: 10/31/2019] [Revised: 02/06/2020] [Accepted: 02/16/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND McKesson's InterQual criteria are widely used in hospitals to determine if patients should be classified as observation or inpatient status, but the accuracy of the criteria is unknown. OBJECTIVE We sought to determine whether InterQual criteria accurately predicted length of stay (LOS) in older patients with syncope. METHODS We conducted a secondary analysis of a cohort study of adults ≥60 years of age who had syncope. We calculated InterQual criteria and classified the patient as observation or inpatient status. Outcomes were whether LOS were less than or greater than 2 midnights. RESULTS We analyzed 2361 patients; 1227 (52.0%) patients were male and 1945 (82.8%) were white, with a mean age of 73.2 ± 9.0 years. The median LOS was 32.6 h (interquartile range 24.2-71.8). The sensitivity of InterQual criteria for LOS was 60.8% (95% confidence interval 57.9-63.6%) and the specificity was 47.8% (95% confidence interval 45.0-50.5%). CONCLUSIONS In older adults with syncope, those who met InterQual criteria for inpatient status had longer LOS compared with those who did not; however, the accuracy of the criteria to predict length of stay over 2 days is poor, with a sensitivity of 60% and a specificity of 48%. Future research should identify criteria to improve LOS prediction.
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Goode AE, Owen TM, Moskal JT, Miller TK. Use of Observation Status Versus Readmission in Elective Total Knee and Hip Arthroplasty Returns to Hospital: A Single-Institution Perspective. J Arthroplasty 2019; 34:2297-2303.e3. [PMID: 31300184 DOI: 10.1016/j.arth.2019.05.013] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2019] [Revised: 05/03/2019] [Accepted: 05/07/2019] [Indexed: 02/01/2023] Open
Abstract
BACKGROUND The Affordable Care Act's Readmission Reduction Program (RRP) and ongoing transparency efforts to promote consumer-driven competition place significant institutional focus on improving 30-day readmission rates. It remains unclear whether the reduction in readmission rates subsequent to the RRP occurred due to improved quality and/or partly due to increased use of observation status in conditions that may have been classified as readmissions prior to the RRP. We hypothesize that a significant percentage of our institution's 30-day readmissions after elective total knee and hip arthroplasty (TKA/THA) overestimate the needs, duration, and complexity of the hospital-based intervention and inaccurately reflect the quality of service provided. METHODS We performed a retrospective review of prospectively collected quality control data for 30-day returns to hospital after elective TKA/THA at our institution over a 2-year period. After stratification of the readmissions to under 48-hour and over 48-hour length of stay, we calculated the financial implications to our institution if the under 48-hour length of stay admissions were reclassified as an observation by applying discharge-weighted and payment-weighted analyses to the 2017 RRP report. We then calculated the out-of-pocket expenses for the under 48-hour Medicare subpopulation. RESULTS We found that 16.7% of the 30-day readmissions after elective TKA/THA required a length of stay under 48 hours. If the short length of stay TKA/THA readmissions were reclassified as observations, our institution's 2018 RRP penalty would have been reduced to 39% or $334,512.28. However, this reclassification would result in an increase in out-of-pocket expenses by $540.25 (range $291.56-$1105.08) per patient. CONCLUSION A subpopulation of 30-day readmissions does not require a level of care consistent with inpatient admission services. Classification of this short length of stay subpopulation as an observation vs an admission per Centers for Medicare and Medicaid Services guidelines would have removed our institution from the TKA/THA-specific RRP penalty. However, this would result in the unintended consequence of shifting costs, particularly self-administered drug costs, to patients.
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Affiliation(s)
- Adam E Goode
- Virginia Tech Carilion School of Medicine, Virginia Polytechnic Institute and State University, Roanoke, VA
| | - Trevor M Owen
- Virginia Tech Carilion School of Medicine, Virginia Polytechnic Institute and State University, Roanoke, VA; Department of Orthopaedic Surgery, Carilion Clinic, Roanoke, VA
| | - Joseph T Moskal
- Virginia Tech Carilion School of Medicine, Virginia Polytechnic Institute and State University, Roanoke, VA; Department of Orthopaedic Surgery, Carilion Clinic, Roanoke, VA
| | - Thomas K Miller
- Virginia Tech Carilion School of Medicine, Virginia Polytechnic Institute and State University, Roanoke, VA; Department of Orthopaedic Surgery, Carilion Clinic, Roanoke, VA
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Sharkawi MA, McMahon S, Al Jabri D, Thompson PD. Current perspectives on location of monitoring and length of stay following PPCI for ST elevation myocardial infarction. EUROPEAN HEART JOURNAL-ACUTE CARDIOVASCULAR CARE 2019; 8:562-570. [PMID: 31264471 DOI: 10.1177/2048872619860217] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
IMPORTANCE There is marked variability in location of care and hospital length of stay after primary percutaneous coronary intervention for ST elevation myocardial infarction (STEMI). OBSERVATIONS We performed a literature review on non-critical care monitoring and early discharge following primary percutaneous coronary intervention and describe a framework for implementation in the real world. The medical literature was searched from 1 January 1988 to 31 April 2019 using PubMed and Cochrane Central Register of Controlled Trials. Randomized clinical trials, observational studies and guideline statements were included. Available data suggest that carefully selected low-risk STEMI patients identified using Zwolle or CADILLAC risk stratification scores after primary percutaneous coronary intervention may be considered for discharge after 48 hours of hospital care. There was no increase in major adverse cardiac events, medication non-compliance or hospital readmission with this treatment strategy. There are limited data on non-critical monitoring of uncomplicated STEMI patients; however, given the low adverse events rate, this strategy is likely to be safe in selected patients and may facilitate reduced length of stay and reduce resource utilization. CONCLUSIONS AND RELEVANCE Available evidence supports the safety of early discharge after 48 hours of care and omission of critical care monitoring in carefully selected patients following primary percutaneous coronary intervention. Early risk stratification and structured discharge planning are imperative. Adoption of this treatment strategy could reduce hospital costs, resource utilization and enhance patient satisfaction without affecting outcomes.
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Affiliation(s)
- Musa A Sharkawi
- Heart and Vascular Institute, Hartford HealthCare, USA.,University of Connecticut, School of Medicine, USA
| | - Sean McMahon
- Heart and Vascular Institute, Hartford HealthCare, USA.,University of Connecticut, School of Medicine, USA
| | | | - Paul D Thompson
- Heart and Vascular Institute, Hartford HealthCare, USA.,University of Connecticut, School of Medicine, USA
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Rothenberg KA, Stern JR, George EL, Trickey AW, Morris AM, Hall DE, Johanning JM, Hawn MT, Arya S. Association of Frailty and Postoperative Complications With Unplanned Readmissions After Elective Outpatient Surgery. JAMA Netw Open 2019; 2:e194330. [PMID: 31125103 PMCID: PMC6632151 DOI: 10.1001/jamanetworkopen.2019.4330] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Ambulatory surgery in geriatric populations is increasingly prevalent. Prior studies have demonstrated the association between frailty and readmissions in the inpatient setting. However, few data exist regarding the association between frailty and readmissions after outpatient procedures. OBJECTIVE To examine the association between frailty and 30-day unplanned readmissions after elective outpatient surgical procedures as well as the potential mediation of surgical complications. DESIGN, SETTING, AND PARTICIPANTS In this retrospective cohort study of elective outpatient procedures from 2012 and 2013 in the National Surgical Quality Improvement Program (NSQIP) database, 417 840 patients who underwent elective outpatient procedures were stratified into cohorts of individuals with a length of stay (LOS) of 0 days (LOS = 0) and those with a LOS of 1 or more days (LOS ≥ 1). Statistical analysis was performed from June 1, 2018, to March 31, 2019. EXPOSURE Frailty, as measured by the Risk Analysis Index. MAIN OUTCOMES AND MEASURES The main outcome was 30-day unplanned readmission. RESULTS Of the 417 840 patients in this study, 59.2% were women and unplanned readmission occurred in 2.3% of the cohort overall (LOS = 0, 2.0%; LOS ≥ 1, 3.4%). Frail patients (mean [SD] age, 64.9 [15.5] years) were more likely than nonfrail patients (mean [SD] age, 35.0 [15.8] years) to have an unplanned readmission in both LOS cohorts (LOS = 0, 8.3% vs 1.9%; LOS ≥ 1, 8.5% vs 3.2%; P < .001). Frail patients were also more likely than nonfrail patients to experience complications in both cohorts (LOS = 0, 6.9% vs 2.5%; LOS ≥ 1, 9.8% vs 4.6%; P < .001). In multivariate analysis, frailty doubled the risk of unplanned readmission (LOS = 0: adjusted relative risk [RR], 2.1; 95% CI, 2.0-2.3; LOS ≥ 1: adjusted RR, 1.8; 95% CI, 1.6-2.1). Complications occurred in 3.1% of the entire cohort, and frailty was associated with increased risk of complications (unadjusted RR, 2.6; 95% CI, 2.4-2.8). Mediation analysis confirmed that complications are a significant mediator in the association between frailty and readmissions; however, it also indicated that the association of frailty with readmission was only partially mediated by complications (LOS = 0, 22.8%; LOS ≥ 1, 29.3%). CONCLUSIONS AND RELEVANCE These findings suggest that frailty is a significant risk factor for unplanned readmission after elective outpatient surgery both independently and when partially mediated through increased complications. Screening for frailty might inform the development of interventions to decrease unplanned readmissions, including those for outpatient procedures.
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Affiliation(s)
- Kara A. Rothenberg
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Jordan R. Stern
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
- Surgical Service, Veterans Affairs Palo Alto Health System, Palo Alto, California
| | - Elizabeth L. George
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Amber W. Trickey
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Arden M. Morris
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Daniel E. Hall
- Department of Surgery, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
- Center for Health Equity Research and Promotion, Veterans Affairs Pittsburgh Healthcare System, Pittsburgh, Pennsylvania
- Wolffe Center at UPMC, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Jason M. Johanning
- Department of Surgery, University of Nebraska College of Medicine, Omaha
| | - Mary T. Hawn
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
| | - Shipra Arya
- Stanford–Surgery Policy Improvement Research and Education Center, Department of Surgery, Stanford University School of Medicine, Stanford, California
- Surgical Service, Veterans Affairs Palo Alto Health System, Palo Alto, California
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Goldstein JN, Schwartz JS, McGraw P, Hicks LS. "Implications of cost-sharing for observation care among Medicare beneficiaries: a pilot survey". BMC Health Serv Res 2019; 19:149. [PMID: 30845953 PMCID: PMC6407198 DOI: 10.1186/s12913-019-3982-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 03/01/2019] [Indexed: 11/10/2022] Open
Abstract
Background Medicare beneficiaries hospitalized under observation status have significant cost-sharing responsibilities under Medicare Part B. Prior work has demonstrated an association between increased cost-sharing and health care rationing among low-income Medicare beneficiaries. The objective of this study was to explore the potential impact of observation cost-sharing on future medical decision making of Medicare beneficiaries. Methods Single-center pilot cohort study. A convenience sample of Medicare beneficiaries hospitalized under observation status care was surveyed. Results Out of 144 respondents, low-income beneficiaries were more likely to be concerned about the cost of their observation stay than higher-income respondents (70.7% vs29.3%, p = 0.015). If hospitalized under observation status again, there was a trend among low-income beneficiaries to request completion of their workup outside of the hospital (56.3% vs 43.8%), and to consider leaving against medical advice (AMA) (100% vs 0%), though these trends were not statistically significant (p = 0.30). Conclusion The results of this pilot study suggest that low-income Medicare beneficiaries hospitalized under observation status have greater concerns about their cost-sharing obligations than their higher income peers. Cost-sharing for observation care may have unintended consequences on utilization for low-income beneficiaries. Future studies should examine this potential relationship on a larger scale. Electronic supplementary material The online version of this article (10.1186/s12913-019-3982-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2E70, Newark, DE, 19713, USA.
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, 1203 Blockley Hall, 423 Guardian Drive University, Philadelphia, PA, 19104, USA
| | - Patricia McGraw
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2E70, Newark, DE, 19713, USA
| | - LeRoi S Hicks
- Department of Medicine & The Value Institute, Christiana Care Health System, 4755 Ogletown-Stanton Rd, Ammon Education Center Suite 2C50, Newark, DE, 19713, USA
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Long B, Koyfman A, Gottlieb M. Management of Heart Failure in the Emergency Department Setting: An Evidence-Based Review of the Literature. J Emerg Med 2018; 55:635-646. [DOI: 10.1016/j.jemermed.2018.08.002] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Revised: 07/09/2018] [Accepted: 08/03/2018] [Indexed: 12/21/2022]
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Chou SC, Nagurney JM, Weiner SG, Hong AS, Wharam JF. Trends in advanced imaging and hospitalization for emergency department syncope care before and after ACEP clinical policy. Am J Emerg Med 2018; 37:1037-1043. [PMID: 30177266 DOI: 10.1016/j.ajem.2018.08.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2018] [Revised: 08/12/2018] [Accepted: 08/15/2018] [Indexed: 11/27/2022] Open
Abstract
OBJECTIVES To describe recent trends in advanced imaging and hospitalization of emergency department (ED) syncope patients, both considered "low-value", and examine trend changes before and after the publication of American College Emergency Physician (ACEP) syncope guidelines in 2007, compared to conditions that had no changes in guideline recommendations. METHODS We analyzed 2002-2015 National Hospital Ambulatory Medical Care Survey data using an interrupted-time series with comparison series design. The primary outcomes were advanced imaging among ED visits with principal diagnosis of syncope and headache and hospitalization for ED visits with principal diagnosis of syncope, chest pain, dysrhythmia, and pneumonia. We adjusted annual imaging and hospitalization rates using survey-weighted multivariable logistic regression, controlling for demographic and visit characteristics. Using adjusted outcomes as datapoints, we compared linear trends and trend changes of annual imaging and hospitalization rates before and after 2007 with aggregate-level multivariable linear regression. RESULTS From 2002 to 2007, advanced imaging rates for syncope increased from 27.2% to 42.1% but had no significant trend after 2007 (trend change: -3.1%; 95%CI -4.7, -1.6). Hospitalization rates remained at approximately 37% from 2002 to 2007 but declined to 25.7% by 2015 (trend change: -2.2%; 95%CI -3.0, -1.4). Similar trend changes occurred among control conditions versus syncope, including advanced imaging for headache (difference in trend change: -0.6%; 95%CI -2.8, 1.6) and hospitalizations for chest pain, dysrhythmia, and pneumonia (differences in trend changes: 0.1% [95%CI -1.9, 2.0]; -0.9% [95%CI -3.1, 1.3]; and -1.2% [95%CI -5.3, 2.9], respectively). CONCLUSIONS Before and after the release of 2007 ACEP syncope guidelines, trends in advanced imaging and hospitalization for ED syncope visits had similar changes compared to control conditions. Changes in syncope care may, therefore, reflect broader practice shifts rather than a direct association with the 2007 ACEP guideline. Moreover, utilization of advanced imaging remains prevalent. To reduce low-value care, policymakers should augment society guidelines with additional policy changes such as reportable quality measures.
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Affiliation(s)
- Shih-Chuan Chou
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Justine M Nagurney
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center, Boston, MA, United States of America; Institute of Aging Research, Hebrew Senior Life, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Scott G Weiner
- Department of Emergency Medicine, Brigham and Women's Hospital, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
| | - Arthur S Hong
- Department of Medicine, Department of Clinical Science, University of Texas Southwestern Medical Center, United States of America.
| | - J Frank Wharam
- Harvard Pilgrim Health Care Institute, Boston, MA, United States of America; Harvard Medical School, Boston, MA, United States of America.
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Affiliation(s)
- Craig A Umscheid
- Center for Evidence-based Practice, University of Pennsylvania Health System, Philadelphia, Pennsylvania, USA
- Department of Biostatistics, Epidemiology and Informatics, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA.
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - S Ryan Greysen
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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22
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Goldstein JN, Zhang Z, Schwartz JS, Hicks LS. Observation Status, Poverty, and High Financial Liability Among Medicare Beneficiaries. Am J Med 2018; 131:101.e9-101.e15. [PMID: 28774801 PMCID: PMC5725232 DOI: 10.1016/j.amjmed.2017.07.013] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Revised: 07/11/2017] [Accepted: 07/13/2017] [Indexed: 10/19/2022]
Abstract
BACKGROUND Medicare beneficiaries hospitalized under observation status are subject to cost-sharing with no spending limit under Medicare Part B. Because low-income status is associated with increased hospital use, there is concern that such beneficiaries may be at increased risk for high use and out-of-pocket costs related to observation care. Our objective was to determine whether low-income Medicare beneficiaries are at risk for high use and high financial liability for observation care compared with higher-income beneficiaries. METHODS We performed a retrospective, observational analysis of Medicare Part B claims and US Census Bureau data from 2013. Medicare beneficiaries with Part A and B coverage for the full calendar year, with 1 or more observation stay(s), were included in the study. Beneficiaries were divided into quartiles representing poverty level. The associations between poverty quartile and high use of observation care and between poverty quartile and high financial liability for observation care were evaluated. RESULTS After multivariate adjustment, the risk of high use was higher for beneficiaries in the poor (Quartile 3) and poorest (Quartile 4) quartiles compared with those in the wealthiest quartile (Quartile 1) (adjusted odds ratio [AOR], 1.21; 95% confidence interval [CI], 1.13-1.31; AOR, 1.24; 95% CI, 1.16-1.33). The risk of high financial liability was higher in every poverty quartile compared with the wealthiest and peaked in Quartile 3, which represented the poor but not the poorest beneficiaries (AOR, 1.17; 95% CI, 1.10-1.24). CONCLUSIONS Poverty predicts high use of observation care. The poor or near poor may be at highest risk for high liability.
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Affiliation(s)
- Jennifer N Goldstein
- Department of Medicine, Christiana Care Health System, Newark Del; The Value Institute, Christiana Care Health System, Newark, Del.
| | - Zugui Zhang
- The Value Institute, Christiana Care Health System, Newark, Del
| | - J Sanford Schwartz
- Division of General Internal Medicine, University of Pennsylvania, Philadelphia
| | - LeRoi S Hicks
- Department of Medicine, Christiana Care Health System, Newark Del; The Value Institute, Christiana Care Health System, Newark, Del
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Lipitz-Snyderman A, Klotz A, Gennarelli RL, Groeger J. A Population-Based Assessment of Emergency Department Observation Status for Older Adults With Cancer. J Natl Compr Canc Netw 2017; 15:1234-1239. [PMID: 28982749 DOI: 10.6004/jnccn.2017.0160] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Accepted: 05/19/2017] [Indexed: 12/21/2022]
Abstract
Background: Hospitals' use of observation status for patients with cancer presenting to the emergency department (ED) is not well understood. This model of care delivery may be a viable alternative to inpatient admission for patients with cancer presenting with certain conditions. Our objective was to assess the use of observation status among Medicare beneficiaries with and without cancer. Methods: Population-based SEER-Medicare data were used to assess differences in the use of observation status between Medicare beneficiaries aged ≥66 years with and without cancer using a matched analysis (n=151,183 per cohort). We assessed the ratio of observation unit use to inpatient admission, between cancer and noncancer cohorts, and for patients diagnosed with breast, colon, lung, and prostate cancers. Poisson regression models were used to calculate observation rate estimates and 95% CIs while adjusting for selected patient characteristics. Results: When considering the volume of hospitalizations, observation status is used less frequently among beneficiaries with cancer than those without (43 vs 69 observation status visits per 1,000 inpatient admissions, respectively). The estimated observation rate per 1,000 inpatient admissions was higher for beneficiaries aged <75 years versus those aged ≥75 years, those with a Charlson comorbidity index of 0 vs 1 or ≥2, and those without a prior hospitalization versus those with ≥1 prior hospitalizations. Patients with breast and prostate cancers had higher adjusted and unadjusted observation rates per 1,000 inpatient admissions compared with those with colon and lung cancers. Conclusions: Observation status is used proportionately less for beneficiaries with cancer than those without. There may be opportunities to develop standards for ED staff to manage certain conditions for patients with cancer in observation status, and to reserve hospital resources for those who need it most.
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Narang AK, Nicholas LH. Out-of-Pocket Spending and Financial Burden Among Medicare Beneficiaries With Cancer. JAMA Oncol 2017; 3:757-765. [PMID: 27893028 DOI: 10.1001/jamaoncol.2016.4865] [Citation(s) in RCA: 150] [Impact Index Per Article: 21.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Importance Medicare beneficiaries with cancer are at risk for financial hardship given increasingly expensive cancer care and significant cost sharing by beneficiaries. Objectives To measure out-of-pocket (OOP) costs incurred by Medicare beneficiaries with cancer and identify which factors and services contribute to high OOP costs. Design, Setting, and Participants We prospectively collected survey data from 18 166 community-dwelling Medicare beneficiaries, including 1409 individuals who were diagnosed with cancer during the study period, who participated in the January 1, 2002, to December 31, 2012, waves of the Health and Retirement Study, a nationally representative panel study of US residents older than 50 years. Data analysis was performed from July 1, 2014, to June 30, 2015. Main Outcomes and Measures Out-of-pocket medical spending and financial burden (OOP expenditures divided by total household income). Results Among the 1409 participants (median age, 73 years [interquartile range, 69-79 years]; 46.4% female and 53.6% male) diagnosed with cancer during the study period, the type of supplementary insurance was significantly associated with mean annual OOP costs incurred after a cancer diagnosis ($2116 among those insured by Medicaid, $2367 among those insured by the Veterans Health Administration, $5976 among those insured by a Medicare health maintenance organization, $5492 among those with employer-sponsored insurance, $5670 among those with Medigap insurance coverage, and $8115 among those insured by traditional fee-for-service Medicare but without supplemental insurance coverage). A new diagnosis of cancer or common chronic noncancer condition was associated with increased odds of incurring costs in the highest decile of OOP expenditures (cancer: adjusted odds ratio, 1.86; 95% CI, 1.55-2.23; P < .001; chronic noncancer condition: adjusted odds ratio, 1.82; 95% CI, 1.69-1.97; P < .001). Beneficiaries with a new cancer diagnosis and Medicare alone incurred OOP expenditures that were a mean of 23.7% of their household income; 10% of these beneficiaries incurred OOP expenditures that were 63.1% of their household income. Among the 10% of beneficiaries with cancer who incurred the highest OOP costs, hospitalization contributed to 41.6% of total OOP costs. Conclusions and Relevance Medicare beneficiaries without supplemental insurance incur significant OOP costs following a diagnosis of cancer. Costs associated with hospitalization may be a primary contributor to these high OOP costs. Medicare reform proposals that restructure the benefit design for hospital-based services and incorporate an OOP maximum may help alleviate financial burden, as can interventions that reduce hospitalization in this population.
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Affiliation(s)
- Amol K Narang
- Department of Radiation Oncology and Molecular Radiation Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland
| | - Lauren Hersch Nicholas
- Department of Health Policy and Management, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland3Department of Surgery, Johns Hopkins School of Medicine, Baltimore, Maryland4Sidney Kimmel Comprehensive Cancer Center, Cancer Prevention and Control Program, Johns Hopkins School of Medicine, Baltimore, Maryland
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Sánchez Y, Yun BJ, Prabhakar AM, Glover M, White BA, Benzer TI, Raja AS. Magnetic Resonance Imaging Utilization in an Emergency Department Observation Unit. West J Emerg Med 2017; 18:780-784. [PMID: 28874928 PMCID: PMC5576612 DOI: 10.5811/westjem.2017.6.33992] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2017] [Revised: 02/17/2017] [Accepted: 06/22/2017] [Indexed: 11/11/2022] Open
Abstract
Introduction Emergency department observation units (EDOUs) are a valuable alternative to inpatient admissions for ED patients needing extended care. However, while the use of advanced imaging is becoming more common in the ED, there are no studies characterizing the use of magnetic resonance imaging (MRI) examinations in the EDOU. Methods This institutional review board-approved, retrospective study was performed at a 999-bed quaternary care academic Level I adult and pediatric trauma center, with approximately 114,000 ED visits annually and a 32-bed adult EDOU. We retrospectively reviewed the EDOU patient database for all MRI examinations done from October 1, 2013, to September 30, 2015. We sought to describe the most frequent uses for MRI during EDOU admissions and reviewed EDOU length of stay (LOS) to determine whether the use of MRI was associated with any change in LOS. Results A total of 22,840 EDOU admissions were recorded during the two-year study period, and 4,437 (19%) of these patients had a least one MRI examination during their stay; 2,730 (62%) of these studies were of the brain, head, or neck, and an additional 1,392 (31%) were of the spine. There was no significant difference between the median LOS of admissions in which an MRI study was performed (17.5 hours) and the median LOS (17.7 hours) of admissions in which an MRI study was not performed [p=0.33]. Conclusion Neuroimaging makes up the clear majority of MRI examinations from our EDOU, and the use of MRI does not appear to prolong EDOU LOS. Future work should focus on the appropriateness of these MRI examinations to determine potential resource and cost savings.
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Affiliation(s)
- Yadiel Sánchez
- Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Brian J Yun
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Anand M Prabhakar
- Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Division of Emergency Imaging, Boston, Massachusetts
| | - McKinley Glover
- Harvard Medical School, Massachusetts General Hospital, Department of Radiology, Boston, Massachusetts.,Massachusetts General Physicians Organization, Massachusetts General Hospital, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Benjamin A White
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Theodore I Benzer
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
| | - Ali S Raja
- Harvard Medical School, Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts.,Center for Research in Emergency Department Operations (CREDO), Massachusetts General Hospital, Department of Emergency Medicine, Boston, Massachusetts
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Hospital Use of Observation Stays: Cross-sectional Study of the Impact on Readmission Rates. Med Care 2017; 54:1070-1077. [PMID: 27579906 DOI: 10.1097/mlr.0000000000000601] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND The Centers for Medicare and Medicaid Services publicly reports hospital risk-standardized readmission rates (RSRRs) as a measure of quality and performance; mischaracterizations may occur because observation stays are not captured by current measures. OBJECTIVES To describe variation in hospital use of observation stays, the relationship between hospitals observation stay use and RSRRs. MATERIALS AND METHODS Cross-sectional analysis of Medicare fee-for-service beneficiaries discharged after acute myocardial infarction (AMI), heart failure, or pneumonia between July 2011 and June 2012. We calculated 3 hospital-specific 30-day outcomes: (1) observation rate, the proportion of all discharges followed by an observation stay without a readmission; (2) observation proportion, the proportion of observation stays among all patients with an observation stay or readmission; and (3) RSRR. RESULTS For all 3 conditions, hospitals' observation rates were <2.5% and observation proportions were <12%, although there was variation across hospitals, including 28% of hospital with no observation stay use for AMI, 31% for heart failure, and 43% for pneumonia. There were statistically significant, but minimal, correlations between hospital observation rates and RSRRs: AMI (r=-0.02), heart failure (r=-0.11), and pneumonia (r=-0.02) (P<0.001). There were modest inverse correlations between hospital observation proportion and RSRR: AMI (r=-0.34), heart failure (r=-0.26), and pneumonia (r=-0.21) (P<0.001). If observation stays were included in readmission measures, <4% of top performing hospitals would be recategorized as having average performance. CONCLUSIONS Hospitals' observation stay use in the postdischarge period is low, but varies widely. Despite modest correlation between the observation proportion and RSRR, counting observation stays in readmission measures would minimally impact public reporting of performance.
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Use or Abuse? A Qualitative Study of Emergency Physicians' Views on Use of Observation Stays at Three Hospitals in the United States and England. Ann Emerg Med 2017; 69:284-292.e2. [DOI: 10.1016/j.annemergmed.2016.08.458] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2016] [Revised: 08/19/2016] [Accepted: 08/25/2016] [Indexed: 11/22/2022]
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Wheatley M, Baugh C, Osborne A, Clark C, Shayne P, Ross M. A Model Longitudinal Observation Medicine Curriculum for an Emergency Medicine Residency. Acad Emerg Med 2016; 23:482-92. [PMID: 26806664 DOI: 10.1111/acem.12909] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Revised: 10/20/2015] [Accepted: 10/30/2015] [Indexed: 11/29/2022]
Abstract
The role of observation services for emergency department patients has increased in recent years. Driven by changing health care practices and evolving payer policies, many hospitals in the United States currently have or are developing an observation unit (OU) and emergency physicians are most often expected to manage patients in this setting. Yet, few residency programs dedicate a portion of their clinical curriculum to observation medicine. This knowledge set should be integrated into the core training curriculum of emergency physicians. Presented here is a model observation medicine longitudinal training curriculum, which can be integrated into an emergency medicine (EM) residency. It was developed by a consensus of content experts representing the observation medicine interest group and observation medicine section, respectively, from EM's two major specialty societies: the Society for Academic Emergency Medicine (SAEM) and the American College of Emergency Physicians (ACEP). The curriculum consists of didactic, clinical, and self-directed elements. It is longitudinal, with learning objectives for each year of training, focusing initially on the basic principles of observation medicine and appropriate observation patient selection; moving to the management of various observation appropriate conditions; and then incorporating further concepts of OU management, billing, and administration. This curriculum is flexible and designed to be used in both academic and community EM training programs within the United States. Additionally, scholarly opportunities, such as elective rotations and fellowship training, are explored.
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Affiliation(s)
| | | | - Anwar Osborne
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Carol Clark
- Department of Emergency Medicine; William Beaumont Health System; Troy MI
| | - Philip Shayne
- Department of Emergency Medicine; Emory University; Atlanta GA
| | - Michael Ross
- Department of Emergency Medicine; Emory University; Atlanta GA
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Ali NJ, Jesus J, Smulowitz PB. Observation Care: Ethical and Legal Considerations for the Emergency Physician. J Emerg Med 2016; 50:527-33.e1. [DOI: 10.1016/j.jemermed.2015.11.019] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2015] [Revised: 11/10/2015] [Accepted: 11/17/2015] [Indexed: 10/22/2022]
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Kangovi S, Cafardi SG, Smith RA, Kulkarni R, Grande D. Patient financial responsibility for observation care. J Hosp Med 2015; 10:718-23. [PMID: 26292192 DOI: 10.1002/jhm.2436] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2015] [Revised: 06/16/2015] [Accepted: 06/22/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND As observation care grows, Medicare beneficiaries are increasingly likely to revisit observation care instead of being readmitted. This trend has potential financial implications for Medicare beneficiaries because observation care-although typically hospital based-is classified as an outpatient service. Beneficiaries who are readmitted pay the inpatient deductible only once per benefit period. In contrast, beneficiaries who have multiple care episodes under observations status are subject to coinsurance at every stay and could accrue higher cumulative costs. OBJECTIVES We were interested in answering the question: Do Medicare beneficiaries who revisit observation care pay more than they would have had they been readmitted? DESIGN We used a 20% sample of the Medicare Outpatient Standard Analytic File (2010-2012) to determine the total cumulative financial liability for Medicare beneficiaries who revisit observation care multiple times within a 60-day period. PARTICIPANTS Participants were fee-for-service Medicare beneficiaries who had Part A and Part B coverage for a full calendar year (or until death) during the study period. MEASUREMENTS Our primary measure was beneficiary financial responsibility for facilities fees. RESULTS On average, beneficiaries with multiple observation stays in a 60-day period had a cumulative financial liability of $947.40 (803.62), which is significantly lower than the $1100 inpatient deductible (P < 0.01). However, 26.6% of these beneficiaries had a cumulative financial liability that exceeded the inpatient deductible. CONCLUSIONS More than a quarter of Medicare beneficiaries with multiple observation stays in a 60-day time period have a higher financial liability than they would have had under Part A benefits.
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Affiliation(s)
- Shreya Kangovi
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
- Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | | | - Robyn A Smith
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | - Raina Kulkarni
- Penn Center for Community Health Workers, Philadelphia, Pennsylvania
| | - David Grande
- Department of Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania
- Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania
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Wright B, O’Shea AMJ, Ayyagari P, Ugwi PG, Kaboli P, Vaughan Sarrazin M. Observation Rates At Veterans’ Hospitals More Than Doubled During 2005–13, Similar To Medicare Trends. Health Aff (Millwood) 2015; 34:1730-7. [DOI: 10.1377/hlthaff.2014.1474] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Brad Wright
- Brad Wright ( ) is an assistant professor in the Department of Health Management and Policy and at the Public Policy Center, both at the University of Iowa, in Iowa City
| | - Amy M. J. O’Shea
- Amy M. J. O’Shea is a research health specialist at the Iowa City Veterans Affairs Healthcare System and a research associate in the Department of Internal Medicine, Carver College of Medicine, at the University of Iowa
| | - Padmaja Ayyagari
- Padmaja Ayyagari is an assistant professor in the Department of Health Management and Policy at the University of Iowa
| | - Patience G. Ugwi
- Patience G. Ugwi is a doctoral student in the Department of Health Management and Policy at the University of Iowa
| | - Peter Kaboli
- Peter Kaboli is an investigator at the Iowa City Veterans Affairs Healthcare System and a professor in the Department of Internal Medicine, Carver College of Medicine, at the University of Iowa
| | - Mary Vaughan Sarrazin
- Mary Vaughan Sarrazin is an investigator at the Iowa City Veterans Affairs Healthcare System and an associate professor in the Department of Internal Medicine, Carver College of Medicine, at the University of Iowa
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Cafardi SG, Pines JM, Deb P, Powers CA, Shrank WH. Increased observation services in Medicare beneficiaries with chest pain. Am J Emerg Med 2015; 34:16-9. [PMID: 26490388 DOI: 10.1016/j.ajem.2015.08.049] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2015] [Revised: 08/26/2015] [Accepted: 08/31/2015] [Indexed: 10/23/2022] Open
Abstract
INTRODUCTION We examined trends in the use of observation services and the relationship between index service type (observation services, emergency department [ED] visits, inpatient stays) and both clinical outcomes and Medicare payments. METHODS We created a yearly cohort panel of Medicare beneficiaries with chest pain. We evaluate the relationships between index service type and 30-day clinical outcomes using a multinomial logit model and between index service type and Medicare payments using generalized linear models. RESULTS In 2009, 24% of patients with chest pain received observation services; this rose to 29% in 2011. Conversely, 20% were treated as hospital inpatients in 2009; this fell to 16% in 2011. In the adjusted analysis, the risk of 30-day return to the hospital was 7% less (95% confidence interval, 5%-8%) for those receiving observation services as compared with inpatients. Average Medicare payments ranged from $3032 for beneficiaries initially treated in the ED to $3885 for those initially treated in observation to $6545 for those initially treated as inpatients. DISCUSSION Patients treated in observation are less likely than those treated in the ED or as inpatients to have an adverse event within 30 days. Adjusted Medicare payments, including the index stay and the subsequent 30 days, were substantially less for those treated in observation as compared with those treated as inpatients, but more than for those treated and released from the ED. Higher rates of observation service use do not appear to be negatively affecting patient outcomes and may lower costs relative to inpatient treatment.
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Affiliation(s)
- Susannah G Cafardi
- Research and Rapid-Cycle Evaluation Group, Centers for Medicare & Medicaid Innovation, Centers for Medicare & Medicaid Services, Baltimore, MD.
| | - Jesse M Pines
- Department of Emergency Medicine, The George Washington University, Washington, DC; Department of Health Policy, The George Washington University, Washington, DC
| | - Partha Deb
- Department of Economics, Hunter College, New York, NY; Centers for Medicare & Medicaid Services, Center for Medicare & Medicaid Innovation, Baltimore, MD
| | - Christopher A Powers
- Office of Information Products and Data Analytics, Center for Medicare & Medicaid Services, Baltimore, MD
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Shanley LA, Hronek C, Hall M, Alpern ER, Fieldston ES, Hain PD, Shah SS, Macy ML. Structure and Function of Observation Units in Children's Hospitals: A Mixed-Methods Study. Acad Pediatr 2015; 15:518-25. [PMID: 26344718 DOI: 10.1016/j.acap.2014.12.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2014] [Revised: 12/08/2014] [Accepted: 12/10/2014] [Indexed: 11/27/2022]
Abstract
OBJECTIVE Observation unit (OU) use has been promoted recently to decrease resource utilization and costs for select patients, but little is known about the operations of pediatric OUs. This study aimed to characterize the infrastructure and function of OUs within freestanding children's hospitals and to compare characteristics between hospitals with and without OUs. METHODS All 43 freestanding children's hospitals that submit data to the Pediatric Health Information System were contacted in 2013 to identify OUs that admitted unscheduled patients from their emergency department (ED) in 2011. Semistructured interviews were conducted with representatives at hospitals with these OUs. Characteristics of hospitals with and without OUs were compared. RESULTS Fourteen (33%) of 43 hospitals had an OU during 2011. Hospitals with OUs had more beds and more annual ED visits compared to those without OUs. Most OUs (65%) were located in the ED and had <12 beds (65%). Staffing models and patient populations differed between OUs. Nearly 60% were hybrid OUs, providing scheduled services. OUs lacked uniform outcome measures. Themes included: admissions were intuition based, certain patients were not well suited for OUs, OUs had rapid-turnover cultures, and the designation of observation status was arbitrary. Challenges included patient discontent with copayments and payer-driven utilization reviews. CONCLUSIONS OUs were located in higher volume hospitals and varied by location, size, and staffing. Most functioned as hybrid OUs. OUs based admissions on intuition, had staffing cultures centered on rapid turnover of patient care, lacked consistent outcome measures, and faced challenges regarding utilization review and patient copayments.
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Affiliation(s)
- Leticia A Shanley
- Department of Pediatrics, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Tex.
| | - Carla Hronek
- Children's Hospital Association, Overland Park, Kans
| | - Matthew Hall
- Children's Hospital Association, Overland Park, Kans
| | - Elizabeth R Alpern
- Department of Pediatrics, Lurie Children's Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Ill
| | - Evan S Fieldston
- Department of Pediatrics, The Children's Hospital of Philadelphia, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pa
| | - Paul D Hain
- Department of Pediatrics, Children's Medical Center of Dallas, University of Texas Southwestern Medical Center, Dallas, Tex
| | - Samir S Shah
- Department of Pediatrics, Cincinnati Children's Hospital and Medical Center, University of Cincinnati School of Medicine, Cincinnati, Ohio
| | - Michelle L Macy
- Departments of Emergency Medicine and Pediatrics, Child Health Evaluation and Research (CHEAR) Unit, University of Michigan Medical School, Ann Arbor, Mich
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Baugh CW, Liang LJ, Probst MA, Sun BC. National cost savings from observation unit management of syncope. Acad Emerg Med 2015. [PMID: 26204970 DOI: 10.1111/acem.12720] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Syncope is a frequent emergency department (ED) presenting complaint and results in a disproportionate rate of hospitalization with variable management strategies. The objective was to estimate the annual national cost savings, reduction in inpatient hospitalizations, and reduction in hospital bed hours from implementation of protocolized care in an observation unit. METHODS We created a Monte Carlo simulation by building a model that reflects current clinical practice in the United States and uses inputs gathered from the most recent available peer-reviewed literature and national survey data. ED visit volume was adjusted to reflect observation unit availability and the portion of observation visits requiring subsequent inpatient care. A recent multicenter randomized controlled study informed the cost savings and length of stay reduction per observation unit visit model inputs. The study population included patients aged 50 years and older with syncope deemed at intermediate risk for serious 30-day cardiovascular outcomes. RESULTS The mean (±SD) annual cost savings was estimated to be $108 million (±$89 million) from avoiding 235,000 (±13,900) inpatient admissions, resulting in 4,297,000 (±1,242,000) fewer hospital bed hours. CONCLUSIONS The potential national cost savings for managing selected patients with syncope in a dedicated observation unit is substantial. Syncope is one of many conditions suitable for care in an observation unit as an alternative to an inpatient setting. As pressure to decrease hospital length of stay and bill short-stay hospitalizations as observation increases, syncope illustrates the value of observation unit care.
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Affiliation(s)
| | - Li-Jung Liang
- Division of General Internal Medicine and Health Services Research; David Geffen School of Medicine at UCLA; Los Angeles CA
| | - Marc A. Probst
- Department of Emergency Medicine; Ichan School of Medicine at Mount Sinai; New York NY
| | - Benjamin C. Sun
- Department of Emergency Medicine; Oregon Health & Science University; Portland OR
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Prabhakar AM, Misono AS, Harvey HB, Yun BJ, Saini S, Oklu R. Imaging utilization from the ED: no difference between observation and admitted patients. Am J Emerg Med 2015; 33:1076-9. [PMID: 25957145 DOI: 10.1016/j.ajem.2015.04.025] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2015] [Revised: 04/11/2015] [Accepted: 04/15/2015] [Indexed: 11/30/2022] Open
Abstract
OBJECTIVES This study aims to determine the use of diagnostic imaging in emergency department (ED) observation units, particularly relative to inpatients admitted from the ED. STUDY DESIGN Retrospective, descriptive analysis. METHODS Our database of ED patients was retrospectively reviewed to identify patients managed in the observation unit or admitted to inpatient services. In February 2014, we randomly selected 105 ED observation patients and 108 patients admitted to inpatient services from the ED. Electronic medical records were reviewed to assess diagnosis as well as type and quantity of imaging tests obtained. RESULTS Eighty (76%) ED observation patients underwent imaging tests (radiographs, 39%; computed tomography, 25%; magnetic resonance imaging (MRI), 24%; ultrasound, 8%; other, 4%); 85 inpatients (79%) underwent imaging tests while in the ED (radiographs, 52%; computed tomography, 30%; MRI, 8%; ultrasound, 9%; other, 1%). There was no significant difference in overall imaging use between ED observation patients and inpatients, but ED observation patients were more likely to undergo MRI (P=.0243). The most common presenting diagnoses to the ED observation unit were neurologic complaints (25%), abdominal pain (17%), and cardiac symptoms (16%). CONCLUSION There is no difference in the overall use of imaging in patients transferred to the ED observation unit vs those directly admitted from the ED. However, because ED observation unit patients tend to be accountable for a higher proportion of their health care bill, the impact of imaging in these patients is likely substantive.
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Affiliation(s)
- Anand M Prabhakar
- Division of Cardiovascular Imaging and Emergency Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA.
| | - Alexander S Misono
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - H Benjamin Harvey
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Brian J Yun
- Department of Emergency Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Sanjay Saini
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Rahmi Oklu
- Division of Vascular Imaging and Intervention, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
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Lipitz-Snyderman A, Klotz A, Atoria CL, Martin S, Groeger J. Impact of observation status on hospital use for patients with cancer. J Oncol Pract 2015; 11:73-7. [PMID: 25628386 DOI: 10.1200/jop.2014.001248] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE For patients with cancer, the impact of observation status on hospital and patient outcomes is not well understood. Our objective was to assess the impact that an observation unit had on hospital use for patients with cancer who presented to the Urgent Care Center at a comprehensive cancer center. METHODS We assessed the proportion of Urgent Care Center visits that resulted in an admission to the hospital at a comprehensive cancer center, before (July 9, 2012-December 31, 2012) versus after (July 9, 2013-December 31, 2013) implementation of the observation unit. We also assessed differences in length of stay and stratified the data by presenting complaint. RESULTS During each 6-month study interval, there were more than 10,000 patient visits to the Urgent Care Center, representing approximately 6,000 unique patients. Fewer visits resulted in an inpatient admission postimplementation (47%) compared with preimplementation (50%). The duration of hospital stay for admitted patients was higher in the post period (median 108 hours) than in the pre period (median 96 hours). Alternatively, the proportion of hospital admissions with a length of stay less than 24 hours was lower in the post period (pre: 7%; post: 5%). Lower admission rates postimplementation were observed for patients who presented with fluid and electrolyte disorders, nausea and vomiting, syncope, and chest pain. CONCLUSION We observed reductions in hospital use for patients with cancer related to an observation unit in a comprehensive cancer center. Adoption of this approach for this patient population has the potential to reduce hospital use, which is of interest to hospitals, payers, and patients.
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Affiliation(s)
| | - Adam Klotz
- Memorial Sloan Kettering Cancer Center, New York NY
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Waxman DA, Greenberg MD, Ridgely MS, Kellermann AL, Heaton P. The effect of malpractice reform on emergency department care. N Engl J Med 2014; 371:1518-25. [PMID: 25317871 DOI: 10.1056/nejmsa1313308] [Citation(s) in RCA: 66] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Many believe that fear of malpractice lawsuits drives physicians to order otherwise unnecessary care and that legal reforms could reduce such wasteful spending. Emergency physicians practice in an information-poor, resource-rich environment that may lend itself to costly defensive practice. Three states, Texas (in 2003), Georgia (in 2005), and South Carolina (in 2005), enacted legislation that changed the malpractice standard for emergency care to gross negligence. We investigated whether these substantial reforms changed practice. METHODS Using a 5% random sample of Medicare fee-for-service beneficiaries, we identified all emergency department visits to hospitals in the three reform states and in neighboring (control) states from 1997 through 2011. Using a quasi-experimental design, we compared patient-level outcomes, before and after legislation, in reform states and control states. We controlled for characteristics of the patients, time-invariant hospital characteristics, and temporal trends. Outcomes were policy-attributable changes in the use of computed tomography (CT) or magnetic resonance imaging (MRI), per-visit emergency department charges, and the rate of hospital admissions. RESULTS For eight of the nine state-outcome combinations tested, no policy-attributable reduction in the intensity of care was detected. We found no reduction in the rates of CT or MRI utilization or hospital admission in any of the three reform states and no reduction in charges in Texas or South Carolina. In Georgia, reform was associated with a 3.6% reduction (95% confidence interval, 0.9 to 6.2) in per-visit emergency department charges. CONCLUSIONS Legislation that substantially changed the malpractice standard for emergency physicians in three states had little effect on the intensity of practice, as measured by imaging rates, average charges, or hospital admission rates. (Funded by the Veterans Affairs Office of Academic Affiliations and others.).
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Affiliation(s)
- Daniel A Waxman
- From RAND Health (D.A.W., M.D.G., M.S.R.) and RAND Institute for Civil Justice (P.H.), Santa Monica, CA; the Department of Emergency Medicine, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles (D.A.W.); and Uniformed Services University of the Health Sciences, Bethesda, MD (A.L.K.)
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Abstract
BACKGROUND Growing use of hospital observation care continues unabated despite growing concerns from Medicare beneficiaries, patient advocacy groups, providers, and policy makers. Unlike inpatient stays, outpatient observation stays are subject to 20% coinsurance and do not count toward the 3-day stay required for Medicare coverage of skilled nursing facility (SNF) care. Despite the policy relevance, we know little about where patients originate or their discharge disposition following observation stays, making it difficult to understand the scope of unintended consequences for beneficiaries, particularly those needing postacute care in a SNF. OBJECTIVE To determine Medicare beneficiaries' location immediately preceding and following an observation stay. RESEARCH DESIGN We linked 100% Medicare Inpatient and Outpatient claims data with the Minimum Data Set for nursing home resident assessments. We then flagged observation stays and conducted a descriptive claims-based analysis of where beneficiaries were immediately before and after their observation stay. RESULTS Most patients came from (92%) and were discharged to (90%) the community. Of >1 million total observation stays in 2009, just 7537 (0.75%) were at risk for high out-of-pocket expenses related to postobservation SNF care. Beneficiaries with longer observation stays were more likely to be discharged to SNF. CONCLUSIONS With few at risk for being denied Medicare SNF coverage due to observation care, high out-of-pocket costs resulting from Medicare outpatient coinsurance requirements for observation stays seem to be of greater concern than limitations on Medicare coverage of postacute care. However, future research should explore how observation stay policy might decrease appropriate SNF use.
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Venkatesh AK, Suter LG. Observation "services" and observation "care"--one word can mean a world of difference. Health Serv Res 2014; 49:1083-7. [PMID: 25055717 PMCID: PMC4239839 DOI: 10.1111/1475-6773.12210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Emergency Departments, Acute Heart Failure, and Admissions. JACC-HEART FAILURE 2014; 2:278-80. [DOI: 10.1016/j.jchf.2014.03.003] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/25/2014] [Accepted: 03/25/2014] [Indexed: 01/08/2023]
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Overman RA, Freburger JK, Assimon MM, Li X, Brookhart MA. Observation stays in administrative claims databases: underestimation of hospitalized cases. Pharmacoepidemiol Drug Saf 2014; 23:902-10. [PMID: 24866538 DOI: 10.1002/pds.3647] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2014] [Revised: 04/02/2014] [Accepted: 04/22/2014] [Indexed: 11/07/2022]
Abstract
PURPOSE Recent policy changes in the USA have led to an increasing number of patients being placed into observation units rather than admitted directly to the hospital. Studies of administrative data that use inpatient diagnosis codes to identify cohorts, outcomes, or covariates may be affected by this change in practice. To understand the potential impact of observation stays on research using administrative healthcare data, we examine the trends of observation stays, short (≤2 days) inpatient admissions, and all inpatient admissions. METHODS We examined a large administrative claims database of commercially insured individuals in the USA between 2002 and 2011. Observation stays were defined on the basis of the procedure codes reimbursable by Medicare or commercial insurers. We report monthly rates of observation stays and short inpatient admissions overall and by patient demographics. RESULTS We identified 5 355 752 observation stays from 2002 to 2011. Over the course of study, the rate of observation stays increased, whereas the rate of short inpatient stays declined. The most common reason for observation stays was nonspecific chest pain, also the third most common reason for short inpatient stays. The increasing trend of observation stays related to circulatory diseases mirrors the decreasing trend of short inpatient stays. CONCLUSIONS The use of observation stays has increased in patients with commercial insurance. Failure to account for observation stays may lead to an under-ascertainment of hospitalizations in contemporary administrative healthcare data from the USA.
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Affiliation(s)
- Robert A Overman
- Division of Pharmaceutical Outcomes and Policy, UNC Eshelman School of Pharmacy, University of North Carolina, Chapel Hill, NC, USA
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Komindr A, Baugh CW, Grossman SA, Bohan JS. Key operational characteristics in emergency department observation units: a comparative study between sites in the United States and Asia. Int J Emerg Med 2014; 7:6. [PMID: 24499641 PMCID: PMC3922480 DOI: 10.1186/1865-1380-7-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2013] [Accepted: 01/11/2014] [Indexed: 11/22/2022] Open
Abstract
Background To improve efficiency, emergency departments (EDs) use dedicated observation units (OUs) to manage patients who are unable to be discharged home, yet do not clearly require inpatient hospitalization. However, operational metrics and their ideal targets have not been created for this setting and patient population. Variation in these metrics across different countries has not previously been reported. This study aims to define and compare key operational characteristics between three ED OUs in the United States (US) and three ED OUs in Asia. Methods This is a descriptive study of six tertiary-care hospitals, all of which are level 1 trauma centers and have OUs managed by ED staff. We collected data via various methods, including a standardized survey, direct observation, and interviews with unit leadership, and compared these data across continents. Results We define multiple key operational characteristics to compare between sites, including OU length of stay (LOS), OU discharge rate, and bed turnover rate. OU LOS in the US and Asian sites averaged 12.9 hours (95% CI, 8.3 to 17.5) and 20.5 hours (95% CI, -49.4 to 90.4), respectively (P = 0.39). OU discharge rates in the US and Asia averaged 84.3% (95% CI, 81.5 to 87.2) and 88.7% (95% CI, 81.5 to 95.8), respectively (P = 0.11), and the bed turnover rates in the US and Asian sites averaged 1.6 patients/bed/day (95% CI, -0.1 to 3.3) and 0.9 patient/bed/day (95% CI, -0.6 to 2.4), respectively (P = 0.27). Conclusions Prior research has shown that the OU is a resource that can mitigate many of problems in the ED and hospital, while simultaneously improving patient care and satisfaction. We describe key operational characteristics that are relevant to all OUs, regardless of geography or healthcare system to monitor and maximize efficiency. Although measures of LOS and bed turnover varied widely between US and Asian sites, we did not find a statistically significant difference. Use of these metrics may enable hospitals to establish or revise an ED OU and reduce OU LOS, increase bed turnover, and discharge rates while simultaneously improving patient satisfaction and quality of care.
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Affiliation(s)
- Atthasit Komindr
- Emergency Unit, King Chulalongkorn Memorial Hospital, 1873 Rama 4 Road, Pathumwan, Bangkok 10330, Thailand.
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Yoo JW, Kim SJ, Geng Y, Shin HP, Nakagawa S. Quality and innovations for caring hospitalized older persons in the unites States. Aging Dis 2014; 5:41-51. [PMID: 24490116 PMCID: PMC3901613 DOI: 10.14366/ad.2014.050041] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2013] [Revised: 10/09/2013] [Accepted: 10/14/2013] [Indexed: 01/22/2023] Open
Abstract
Older persons are occasionally acutely ill and their hospitalizations frequently end up with complications and adverse outcomes. Medicare from U.S. federal government's payment resource for older persons is facing financial strain. Medicare highlights both cost-saving and high quality of care while older persons are hospitalized. Several health policy changes were initiated to achieve Medicare's goals. In response to Medicare's health policy changes, U.S. hospital environments have been changed and these resulted in hospital quality measurements' improvement. American seniors are facing the challenges during and around their hospital care. Several innovative measures are suggested to overcome these challenges.
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Affiliation(s)
- Ji Won Yoo
- Center for Senior Health and Longevity, Aurora Health Care, Milwaukee, WI, USA
- Department of Medicine, School of Medicine and Public Health, University of Wisconsin, Madison, WI, USA
| | - Sun Jung Kim
- Department of Public Health, College of Medicine, Yonsei University Seoul, Korea
- Institute of Health Services Research, College of Medicine, Yonsei University Seoul, Korea
| | - Yan Geng
- Center for Senior Health and Longevity, Aurora Health Care, Milwaukee, WI, USA
| | - Hyun Phil Shin
- Department of Internal Medicine, College of Medicine, Kyung Hee University, Seoul, Korea
| | - Shunichi Nakagawa
- Department of Medicine, College of Physicians and Surgeons, Columbia University, New York, NY. USA
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Observation Units: Definition, History, Data, Financial Considerations, and Metrics. CURRENT EMERGENCY AND HOSPITAL MEDICINE REPORTS 2014. [DOI: 10.1007/s40138-013-0038-y] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
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Madan S. Education program during residency to improve documentation. Am J Med 2014; 127:e5. [PMID: 24384111 DOI: 10.1016/j.amjmed.2013.08.029] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2013] [Accepted: 08/26/2013] [Indexed: 11/25/2022]
Affiliation(s)
- Shivank Madan
- Department of Internal Medicine, Drexel University College of Medicine/Saint Peters University Hospital, New Brunswick, NJ
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Hockenberry JM, Mutter R, Barrett M, Parlato J, Ross MA. Factors associated with prolonged observation services stays and the impact of long stays on patient cost. Health Serv Res 2013; 49:893-909. [PMID: 24344860 DOI: 10.1111/1475-6773.12143] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND Patients are treated using observation services (OS) when their care needs exceed standard outpatient care (i.e., clinic or emergency department) but do not qualify for admission. Medicare and other private payers seek to limit this care setting to 48 hours. DATA SOURCE/STUDY SETTING Healthcare Cost and Utilization Project data from 10 states and data collected from two additional states for 2009. STUDY DESIGN Bivariate analyses and hierarchical linear modeling were used to examine patient- and hospital-level predictors of OS stays exceeding 48 (and 72) hours (prolonged OS). Hierarchical models were used to examine the additional cost associated with longer OS stays. PRINCIPAL FINDINGS Of the 696,732 patient OS stays, 8.8 percent were for visits exceeding 48 hours. Having Medicaid or no insurance, a condition associated with no OS treatment protocol, and being discharged to skilled nursing were associated with having a prolonged OS stay. Among Medicare patients, the mean charge for OS stays was $10,373. OS visits of 48-72 hours were associated with a 42 percent increase in costs; visits exceeding 72 hours were associated with a 61 percent increase in costs. CONCLUSION Patient cost sharing for most OS stays of less than 24 hours is lower than the Medicare inpatient deductible. However, prolonged OS stays potentially increase this cost sharing.
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Affiliation(s)
- Jason M Hockenberry
- Department of Health Policy and Management, Rollins School of Public Health, Emory University, Atlanta, GA; Center for Comprehensive Access Delivery Research and Evaluation, Iowa City Veterans Health Care System, Atlanta, GA
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