The history of higher education in emergency management: The Emergency Management Institute, the National Science Foundation, and the William Averette Anderson Fund

As the profession of emergency management has matured, the roles and responsibilities of emergency managers  have  expanded,  new  technologies  have been deployed, and emergency management educa- tion grown and has become better connected to emer- gency management practice. This special topic cover- age (in three parts) addresses many of the changes in emergency management education over the past four decades, including the expansion of academic pro- grams for those preparing to enter the field, those transitioning from emergency response and other fields, and those moving into supervisory and man- agement positions in emergency management and related organizations. It also addresses some of the issues that academic programs have encountered as they have developed and have found their places in academic institutions. (Login to read more.)

Order policy for emergency medicine with return uncertainty in a closed-loop supply chain

Due to difficulties in accurately predicting the emergency timing and the magnitude of a disaster, operations for perishable emergency inventory planning often encounter expiration and shortage problems. In order to ease the expiration problem in emergency medicine preparation inventories, this paper investigates an emergency medicine closed-loop supply chain for returning unused items from an ERC (Emergency Reserve Center) to a hospital. To assure that the return strategy is meaningful, we propose a critical parameter that we term the latest return time, after which the remaining emergency medicine in the ERC cannot be returned to the hospital. In addition, the short lifetime of emergency products and uncertainty about demand time and demand quantity are also considered in this emergency inventory planning system. In analyzing the optimal ordering policies, we find that the two threshold values for the predefined return time, which affect the total costs, are not monotonous; rather, the direction of their effect is first down, then up, and then down again, which means that a better predefined value of the latest return time can be determined by minimizing total costs. By studying and comparing decentralized and centralized decisions, we find that the centralized decision system works better to control expiration and costs. Therefore, we design a coordination mechanism for the cooperation between the ERC and the hospital. Our analysis shows that we should not ignore the emergency uncertainty and perishability of emergency items.

Variability in Critical Care-Related Charge Markups in Medicare Patients

Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care-related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60-6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts (P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care-related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.

Areas of Potential Impact of the Patient Protection and Affordable Care Act on EMS: A Synthesis of the Literature

INTRODUCTION

This comprehensive review synthesizes the existing literature on the Patient Protection and Affordable Care Act (ACA) as it relates to emergency medical services (EMS) in order to provide guidance for navigating current and future healthcare changes.

METHODS

We conducted a comprehensive review to identify all existing literature related to the ACA and EMS and all sections within the federal law pertaining to EMS.

RESULTS

Many changes enacted by the ACA directly affect emergency care with potential indirect effects on EMS systems. New Medicaid enrollees and changes to existing coverage plans may alter EMS transport volumes. Reimbursement changes such as adjustments to the ambulance inflation factor (AIF) alter the yearly increases in EMS reimbursement by incorporating the multifactor productivity value into yearly reimbursement adjustments. New initiatives, funded by the Center for Medicare & Medicaid Innovation are exploring novel and cost-effective prehospital care delivery opportunities while EMS agencies individually explore partnerships with healthcare systems.

CONCLUSION

EMS systems should be aware of the direct and indirect impact of ACA on prehospital care due to the potential for changes in financial reimbursement, acuity and volume changes, and ongoing new care delivery initiatives.

How alternative payment models in emergency medicine can benefit physicians, payers, and patients

While there has been considerable effort devoted to developing alternative payment models (APMs) for primary care physicians and for episodes of care beginning with inpatient admissions, there has been relatively little attention by payers to developing APMs for specialty ambulatory care, and no efforts to develop APMs that explicitly focus on emergency care. In order to ensure that emergency care is appropriately integrated and valued in future payment models, emergency physicians (EPs) must engage with the stakeholders within the broader health care system. In this article, we describe a framework for the development of APMs for emergency medicine and present four examples of APMs that may be applicable in emergency medicine. A better understanding of how APMs can work in emergency medicine will help EPs develop new APMs that improve the cost and quality of care, and leverage the value that emergency care brings to the system.

Endowed Faculty Positions in Academic Emergency Medicine: One Decade Later

BACKGROUND

In 2004 and 2009, we examined the number of endowed faculty positions in academic departments of Emergency Medicine (ADEMs).

OBJECTIVE

We sought to survey ADEMs regarding the number of endowed faculty positions and compare the results to the 2004 and 2009 studies.

METHODS

A survey was e-mailed to the chairs of all ADEMs belonging to the Association of Academic Chairs of Emergency Medicine. We requested information on the following: the number of endowed chair and professorship positions; the amount required to fund; the amount allowed to be spent annually; the date established; and the source of funding.

RESULTS

Eighty-nine chairs responded (100% response rate). Nineteen chairs reported 1 endowed chair position. One chair reported 2 such positions, and 2 chairs reported 3 positions. One chair reported 4 positions. In total, 23 ADEMs (25.8%) reported 31 endowed chair positions. For endowed professorships, 8 chairs reported 1 professorship each. Four chairs replied that they had 2 positions each and 2 chairs reported 3 positions each. A total of 14 ADEMS (15.7%) reported having 22 endowed professorships. The most common amount required to fund an endowed chair position was $2 million, and $1 million for an endowed professorship. The majority of ADEMs were allowed to spend 4% to 5% of the value of the endowment annually.

CONCLUSION

Thirty ADEMs (33.7%) currently have an endowed position, compared to only 19 (26%) 5 years ago. Emergency Medicine now has a total of 53 endowed positions, compared to only 25 such positions in 2009 and just 9 endowed positions in 2004.

The Patient Protection and Affordable Care Act's Effect on Emergency Medicine: A Synthesis of the Data

This review synthesizes the existing literature to provide evidence-based predictions for the future of emergency care in the United States as a result of the Patient Protection and Affordable Care Act, with a focus on emergency department (ED) visit volume, acuity, and reimbursement. Patient behavior will likely be quite different for patients gaining Medicaid than for those gaining private insurance through the Marketplaces. Despite the threat of the individual mandate, not all uninsured patients will enroll, and those who choose to enroll will likely be a different population from those who remain uninsured. New Medicaid enrollees will be a sicker population and will likely increase their number of ED visits substantially. Their acuity will be higher at first but will then revert to the traditionally high number of low-acuity visits made by Medicaid patients. Most patients enrolling through the Marketplace are choosing high-deductible health plans, and they will initially avoid the ED because of high out-of-pocket costs but may present later and sicker after self-rationing their care. Most patients gaining health coverage through the Affordable Care Act will be shifting from uninsured to either Medicaid or private insurance, both of which reimburse more than self-pay, so ED collections should increase. Because of the differences between Medicaid and Marketplace plans, there will be a difference in ED volume, acuity, and financial outcomes, depending on states' current demographics, whether states expand Medicaid, and how aggressively states advertise new options for coverage in Medicaid or state health insurance Marketplaces.

Quantifying federal funding and scholarly output related to the academic emergency medicine consensus conferences

PURPOSE

Every year since 2000, Academic Emergency Medicine (AEM) has presented a one-day consensus conference to generate a research agenda for advancement of a scientific topic. One of the 12 annual issues of AEM is reserved for the proceedings of these conferences. The purpose of this study was to measure academic productivity of these conferences by evaluating subsequent federal research funding received by authors of conference manuscripts and calculating citation counts of conference papers.

METHOD

This was a cross-sectional study. In 2012, the NIH RePORTER system was searched to identify subsequent federal funding obtained by authors of the consensus conference issues from 2000 to 2010. Funded projects were coded as related or unrelated to conference topic. Citation counts for all conference manuscripts were quantified using Scopus and Google Scholar. Simple descriptive statistics were reported.

RESULTS

Eight hundred fifty-two individual authors contributed to 280 papers published in the 11 consensus conference issues. One hundred thirty-seven authors (16%) obtained funding for 318 projects. A median of 22 topic-related projects per conference (range 10-97) accounted for a median of $20,488,331 per conference (range $7,779,512 to $122,918,205). The average (± SD) number of citations per paper was 15.7 ± 20.5 in Scopus and 23.7 ± 32.6 in Google Scholar.

CONCLUSIONS

The authors of consensus conference manuscripts obtained significant federal grant support for follow-up research related to conference themes. In addition, the manuscripts generated by these conferences were frequently cited. Conferences devoted to research agenda development appear to be an academically worthwhile endeavor.

The Society for Academic Emergency Medicine and Association of Academic Chairs in Emergency Medicine 2009-2010 emergency medicine faculty salary and benefits survey

OBJECTIVES

he objective was to report the results of a survey conducted jointly by the Society for Academic Emergency Medicine (SAEM) and the Association of Academic Chairs in Emergency Medicine (AACEM) of faculty salaries, benefits, work hours, and department demographics for institutions sponsoring residency programs accredited by the Accreditation Council for Graduate Medical Education (ACGME) Residency Review Committee for Emergency Medicine (RRC-EM).

METHODS

Data represent information collected for the 2009-2010 academic year through an electronic survey developed by SAEM and AACEM and distributed by the Office for Survey Research at the University of Michigan to all emergency department (ED) chairs and chiefs at institutions sponsoring accredited residency programs. Information was collected regarding faculty salaries and benefits; clinical and nonclinical work hours; sources of department income and department expenses; and selected demographic information regarding faculty, EDs, and hospitals. Salary data were sorted by program geographic region and faculty characteristics such as training and board certification, academic rank, department title, and sex. Demographic data were analyzed with regard to numerous criteria, including ED staffing levels, patient volumes and length of stay, income sources, salary incentive components, research funding, and specific type and value of fringe benefits offered. Data were compared with previous SAEM studies and the most recent faculty salary survey conducted by the Association of American Medical Colleges (AAMC).

RESULTS

Ninety-four of 155 programs (61%) responded, yielding salary data on 1,644 faculty, of whom 1,515 (92%) worked full-time. The mean salary for all faculty nationwide was $237,884, with the mean ranging from $232,819 to $246,853 depending on geographic region. The mean salary for first-year faculty nationwide was $204,833. Benefits had an estimated mean value of $48,915 for all faculty, with the mean ranging from $37,813 to $55,346 depending on geographic region. The following factors are associated with higher salaries: emergency medicine (EM) residency training and board certification, fellowship training in toxicology and hyperbaric medicine, higher academic rank, male sex, and living in the western and southern regions. Full-time EM faculty work an average of 20 to 23 clinical hours and 16 to 19 nonclinical hours per week.

CONCLUSIONS

The salaries for full-time EM faculty reported in this survey were higher than those found in the AAMC survey for the same time period in the majority of categories for both academic rank and geographic region. On average, female faculty are paid 10% to 13% less than their male counterparts. Full-time EM faculty work an average of 20 to 23 clinical hours and 16 to 19 nonclinical hours per week, which is similar to the work hours reported in previous SAEM surveys.

Acute care surgery: impact on practice and economics of elective surgeons

BACKGROUND

The creation of an acute care surgery service provides a rich operative experience for acute care surgeons. Elective surgeons typically have concerns about whether their practice volume will be restored with elective cases. Acute care surgery has financial implications for both groups. The aim of this project is to examine the impact in terms of work relative value units (wRVUs), collections, and cases in both groups with creation of an acute care surgery service at our institution.

STUDY DESIGN

Work RVUs, collections, and case volume were examined from departmental records for 2 groups before and after acute care surgery service creation. The service began on September 1, 2008. Before this time, emergency surgical consults went to the general surgeon on call. After this date, all emergency consults were seen by acute care surgeons.

RESULTS

The number of operations performed by the acute care surgery group increased significantly when the mean of the 2 years after institution of acute care surgery were compared with the mean of the 2 years preceding the service creation (1,639 vs 790/year; p = 0.007). There was no change in total operations done by the elective surgery group (2,763 vs 2,496/year: p = 0.13). Elective caseload, however, did increase by 23% in the elective surgery group. In the acute care surgery group, wRVUs increased by 140% and elective surgery group wRVUs decreased by 8%. Collections increased in both groups (acute care surgery 129%, elective surgery 7%) and the combined collections of the groups increased by $2,138,00 in the year after service creation.

CONCLUSIONS

Acute care surgery service creation took emergency business from the elective surgery group, but this was almost immediately replaced with elective cases. This resulted in higher collections for both groups and a resultant significant increase in collections in aggregate.

Comparing National Institutes of Health funding of emergency medicine to four medical specialties

OBJECTIVES

The purpose of this study was to compare National Institutes of Health (NIH) funding received in 2008 by emergency medicine (EM) to the specialties of internal medicine, pediatrics, anesthesiology, and family medicine. The hypothesis was that EM would receive fewer NIH awards and less funding dollars per active physician and per medical school faculty member compared to the other four specialties.

METHODS

Research Portfolio Online Reporting Tools (RePORT) were used to identify NIH-funded grants to 125 of the 133 U.S. allopathic medical schools for fiscal year 2008 (the most recent year with all grant funding information). Eight medical schools were excluded because six were not open in 2008, one did not have a website, and one did not have funding data available by medical specialty. From RePORT, all grants awarded to EM, internal medicine, family medicine, anesthesiology, and pediatric departments of each medical school were identified for fiscal year 2008. The authors extracted the project number, project title, dollars awarded, and name of the principal investigator for each grant. Funds awarded to faculty in divisions of EM were accounted for by identifying the department of the EM division and searching for all grants awarded to EM faculty within those departments using the name of the principal investigator. The total number of active physicians per medical specialty was acquired from the Association of American Medical Colleges' 2008 Physician Specialty report. The total number of faculty per medical specialty was collected by two research assistants who independently counted the faculty listed on each medical school website. The authors compared the total number of NIH awards and total funding per 1,000 active physicians and per 1,000 faculty members by medical specialty.

RESULTS

Of the 125 medical schools included in the study, 84 had departments of EM (67%). In 2008, NIH awarded over 9,000 grants and approximately $4 billion to the five medical specialties of interest. Less than 1% of the grants and funds were awarded to EM. EM had the second-lowest number of awards and funding per active physician, and the lowest number of awards and funding per faculty member. A higher percentage of grants awarded to EM were career development awards (26%, vs. a range of 11% to 19% for the other specialties) and cooperative agreements (26%, vs. 2% to 10%). In 2008, EM was the only specialty of the five not to have a fellowship or T32 training grant. EM had the lowest proportion of research project awards (42%, vs. 58% to 73%).

CONCLUSIONS

Compared to internal medicine, pediatrics, anesthesiology, and family medicine, EM received the least amount of NIH support per active faculty member and ranked next to last for NIH support by active physician. Given the many benefits of research both for the specialty and for society, EM needs to continue to develop and support an adequate cohort of independent investigators.

Early career academic productivity among emergency physicians with R01 grant funding

OBJECTIVES

The objective was to describe the early academic career activities of emergency physician (EP) scientists with recent Research Project Grant Program (R01) grant funding from the National Institutes of Health (NIH).

METHODS

The curricula vitae of all EP scientists in the United States currently funded by the NIH were analyzed for evidence of advanced research training and frequency and type of publication and grant writing. Each investigator was surveyed for demographic features and estimation of protected time during their early career development.

RESULTS

Eighteen investigators were identified. The median length of time from completion of residency to receipt of their first R01 grant was 11 years (interquartile range [IQR] = 11 to 15 years), and the median age of investigators at the time of this award was 43 years (IQR = 39 to 47 years). At the time of their award, researchers were publishing five peer-reviewed manuscripts a year (IQR = 1 to 8 manuscripts) and had already received considerable external funding. Ninety-four percent of those studied had pursued a research fellowship, an advanced degree, or an NIH K-award following residency.

CONCLUSIONS

For EPs, receipt of an R01 from the NIH requires more than a decade of work following the completion of training. This period is characterized by pursuit of advanced research training, active and accelerating publication and collaboration, and acquisition of smaller extramural grants.

The role of the Society for Academic Emergency Medicine in the development of guidelines and performance measures

Measurement of adherence to clinical standards has become increasingly important to the practice of emergency medicine (EM). In recent years, along with a proliferation of evidence-based practice guidelines and performance measures, there has been a movement to incorporate measurement into reimbursement strategies, many of which affect EM practice. On behalf of the Society for Academic Emergency Medicine (SAEM) Guidelines Committee 2009-2010, the purposes of this document are to: 1) differentiate the processes of guideline and performance measure development, 2) describe how performance measures are currently and will be used in pay-for-performance initiatives, and 3) discuss opportunities for SAEM to affect future guideline and performance measurement development for emergency care. Specific recommendations include that SAEM should: 1) develop programs to sponsor guideline and quality measurement research; 2) increase participation in the process of guideline and quality measure development, endorsement, and maintenance; 3) increase collaboration with other EM organizations to review performance measures proposed by organizations outside of EM that affect emergency medical care; and 4) answer calls for participation in the selection and implementation of performance measures through The Joint Commission and the Centers for Medicare and Medicaid Services (CMS).

Critical care medicine in the United States 2000-2005: an analysis of bed numbers, occupancy rates, payer mix, and costs

OBJECTIVES

To analyze the evolving role, patterns of use, and costs of critical care medicine in the United States from 2000 to 2005.

DESIGN

Retrospective study of data from the Hospital Cost Report Information System (Centers for Medicare and Medicaid Services, Baltimore, Maryland).

SETTING

Nonfederal, acute care hospitals with critical care medicine beds in the United States.

SUBJECTS

None.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

We analyzed hospital and critical care medicine beds, bed types, days, occupancy rates, payer mix (Medicare and Medicaid), and costs. Critical care medicine costs were compared with national cost indexes. Between 2000 and 2005, the total number of U.S. hospitals with critical care medicine beds decreased by 12.2% (from 3,586 to 3,150). Although the number of hospital beds decreased by 4.2% (from 655,785 to 628,409), both hospital days and occupancy rates increased by 5.1% (from 145.1 to 152.5 million) and 13.7% (from 59% to 67%), respectively. Critical care medicine beds increased by 6.5% (from 88,252 to 93,955), days by 10.6% (from 21.0 to 23.2 million), and occupancy rates by 4.5% (from 65% to 68%). The majority (90%) of critical care medicine beds were classified as intensive care, premature/neonatal, and coronary care unit beds. The percentage of critical care medicine days used by Medicare decreased by 3.8% (from 37.9% to 36.5%) compared with an increase of 15.5% (from 14.5% to 16.8%) by Medicaid. From 2000 to 2005, critical care medicine costs per day increased by 30.4% (from $2698 to $3518). Although annual critical care medicine costs increased by 44.2% (from $56.6 to $81.7 billion), the proportion of hospital costs and national health expenditures allocated to critical care medicine decreased by 1.6% and 1.8%, respectively. However, the proportion of the gross domestic product used by critical care medicine increased by 13.7%. In 2005, critical care medicine costs represented 13.4% of hospital costs, 4.1% of national health expenditures, and 0.66% of the gross domestic product.

CONCLUSIONS

Critical care medicine continues to grow in a shrinking U.S. hospital system. The critical care medicine payer mix is evolving, with Medicaid increasing in its percentage of critical care medicine use. Critical care medicine is more cost controlled than other healthcare indexes, but is still using an increasing percentage of the gross domestic product. Our updated and comprehensive critical care medicine use and cost analysis provides a contemporary benchmark for the strategic planning of critical care medicine services within the U.S. healthcare system.

Emergency medicine public health research funded by federal agencies: progress and priorities

The emergency department (ED) visit provides an opportunity to impact the health of the public throughout the entire spectrum of care, from prevention to treatment. As the federal government has a vested interest in funding research and providing programmatic opportunities that promote the health of the public, emergency medicine (EM) is prime to develop a research agenda to advance the field. EM researchers need to be aware of federal funding opportunities, which entails an understanding of the organizational structure of the federal agencies that fund medical research, and the rules and regulations governing applications for grants. Additionally, there are numerous funding streams outside of the National Institutes of Health (NIH; the primary federal health research agency). EM researchers should seek funding from agencies according to each agency's mission and aims. Finally, while funds from the Department of Health and Human Services (HHS) are an important source of support for EM research, we need to look beyond traditional sources and appeal to other agencies with a vested interest in promoting public health in EDs. EM requires a broad skill set from a multitude of medical disciplines, and conducting research in the field will require looking for funding opportunities in a variety of traditional and not so traditional places within and without the federal government. The following is the discussion of a moderated session at the 2009 Academic Emergency Medicine consensus conference that included panel discussants from the National Institutes of Mental Health, Drug Abuse, and Alcoholism and Alcohol Abuse and the Centers for Disease Control and Prevention (CDC). Further information is also provided to discuss those agencies and centers not represented.

[E-health in emergency medicine - the research project Med-on-@ix]

There is a need for new strategies to face current and future problems in German Emergency Medical Services (EMS). Lack of quality management and increasing costs in the presence of a deficit of EMS physicians are typical challenges, resulting in an increasing deficit in medical care. In addition, information and communication technology used in German EMS is out of date. The physician-powered EMS has to be modernized to increase quality and show measurable evidence of its effectiveness. Otherwise its future existence is at serious risk. Therefore, the project Med-on-@ix was created by the Department of Anaesthesiology at the University Hospital Aachen, Germany. The aim was to develop a new emergency telemedicine service system and to implement it clinically in order to advance medical care and effectiveness in the EMS by process optimization of each scene call. This system offers EMS physicians and paramedics an additional consultation by a specialised centre of competence, thus assuring medical therapy according to evidence-based guidelines. Several prospective studies are conducted to analyse this system in comparison to the conventional EMS.

RVU ready? Preparing emergency medicine resident physicians in documentation for an incentive-based work environment

OBJECTIVES

The emergency medicine (EM) job market is increasingly focused on incentive-based reimbursement, which is largely based on relative value units (RVUs) and is directly related to documentation of patient care. Previous studies have shown a need to improve resident education in documentation. The authors created a focused educational intervention on billing and documentation practices to meet this identified need. The hypothesis of this study was that this educational intervention would result in an increase in RVUs generated by EM resident physicians and the average amount billed per patient.

METHODS

The authors used a quasi-experimental study design. An educational intervention included a 1-hour lecture on documentation and billing, biweekly newsletters, and case-specific feedback from the billing department for EM resident physicians. RVUs and charges generated per patient were recorded for all second- and third-year resident physicians for a 3-month period prior to the educational intervention and for a 3-month period following the intervention. Pre- and postintervention data were compared using Student's t-test and repeated-measures analysis of variance, as appropriate.

RESULTS

The evaluation and management (E/M) chart levels billed during each phase of the study were significantly different (p < 0.0001). The total number of RVUs generated per hour increased from 3.17 in the first phase to 3.71 in the second phase (p = 0.0001). During the initial 3-month phase, the average amount billed per patient seen by a second- or third-year resident was 282.82 USD, which increased to 301.94 USD in the second phase (p = 0.0004).

CONCLUSIONS

The educational intervention positively affected resident documentation resulting in greater RVUs/hour and greater billing performance in the study emergency department (ED).

Alignment of emergency medicine research efforts with Clinical and Translational Science Awards

The Clinical and Translational Science Awards (CTSA) represent a major new funding pathway for health science investigators seeking National Institutes of Health (NIH) funds. This new pathway provides institutional-level support for clinical and translational research and is not tied to one organ system or disease process, fitting well with emergency medicine (EM) research needs. These awards open unique opportunities for advancing EM research. The CTSA mechanism provides institutional support from the NIH to promote both clinical and translational science. Of the 60 expected awards, 38 sites are currently funded. EM investigators can benefit the institutions applying for these awards and simultaneously gain from involvement. Some opportunities for participation provided by the CTSA include research training programs, joining multidisciplinary research teams, seed grant funding, and use of the CTSA-developed research infrastructure. Involvement of EM can benefit institutions by enhancing acute care research collaboration both within and among institutions. Emergency medicine researchers at institutions either planning to submit a CTSA application or with funded CTSA grants are encouraged to become actively involved in CTSA-related research programs.

Payment by results: a guide for emergency physicians

Payment by results is a new funding mechanism being introduced into the National Health Service. It is a key part of current health reforms and will impact significantly on the way emergency departments are financed and run. This paper aims to describe the basics of payment by results, examines how it relates to and impacts upon emergency medicine, and considers how emergency physicians can set about integrating this new system into current practice and thinking.

Equipment, supplies, and pharmaceuticals: how much might it cost to achieve basic surge capacity?

The ability to deliver optimal medical care in the setting of a disaster event, regardless of its cause, will in large part be contingent on an immediately available supply of key medical equipment, supplies, and pharmaceuticals. Although the Department of Health and Human Services Strategic National Stockpile program makes these available through its 12-hour "push packs" and vendor-managed inventory, every local community should be funded to create a local cache for these items. This report explores the funding requirements for this suggested approach. Furthermore, the response to a surge in demand for care will be contingent on keeping available staff close to the hospitals for a sustained period. A proposal for accomplishing this, with associated costs, is discussed as well.

The economic role of the Emergency Department in the health care continuum: applying Michael Porter's five forces model to Emergency Medicine

Emergency Medicine plays a vital role in the health care continuum in the United States. Michael Porters' five forces model of industry analysis provides an insight into the economics of emergency care by showing how the forces of supplier power, buyer power, threat of substitution, barriers to entry, and internal rivalry affect Emergency Medicine. Illustrating these relationships provides a view into the complexities of the emergency care industry and offers opportunities for Emergency Departments, groups of physicians, and the individual emergency physician to maximize the relationship with other market players.

High fidelity medical simulation in the difficult environment of a helicopter: feasibility, self-efficacy and cost

BACKGROUND

This study assessed the feasibility, self-efficacy and cost of providing a high fidelity medical simulation experience in the difficult environment of an air ambulance helicopter.

METHODS

Seven of 12 EM residents in their first postgraduate year participated in an EMS flight simulation as the flight physician. The simulation used the Laerdal SimMantrade mark to present a cardiac and a trauma case in an EMS helicopter while running at flight idle. Before and after the simulation, subjects completed visual analog scales and a semi-structured interview to measure their self-efficacy, i.e. comfort with their ability to treat patients in the helicopter, and recognition of obstacles to care in the helicopter environment. After all 12 residents had completed their first non-simulated flight as the flight physician; they were surveyed about self-assessed comfort and perceived value of the simulation. Continuous data were compared between pre- and post-simulation using a paired samples t-test, and between residents participating in the simulation and those who did not using an independent samples t-test. Categorical data were compared using Fisher's exact test. Cost data for the simulation experience were estimated by the investigators.

RESULTS

The simulations functioned correctly 5 out of 7 times; suggesting some refinement is necessary. Cost data indicated a monetary cost of 440 dollars and a time cost of 22 hours of skilled instructor time. The simulation and non-simulation groups were similar in their demographics and pre-hospital experiences. The simulation did not improve residents' self-assessed comfort prior to their first flight (p > 0.234), but did improve understanding of the obstacles to patient care in the helicopter (p = 0.029). Every resident undertaking the simulation agreed it was educational and it should be included in their training. Qualitative data suggested residents would benefit from high fidelity simulation in other environments, including ground transport and for running codes in hospital.

CONCLUSION

It is feasible to provide a high fidelity medical simulation experience in the difficult environment of the air ambulance helicopter, although further experience is necessary to eliminate practical problems. Simulation improves recognition of the challenges present and provides an important opportunity for training in challenging environments. However, use of simulation technology is expensive both in terms of monetary outlay and of personnel involvement. The benefits of this technology must be weighed against the cost for each institution.

Nonprescription Availability of Emergency Contraception in the United States: Current Status, Controversies, and Impact on Emergency Medicine Practice

In October 2004, the American College of Emergency Physicians Council joined more than 60 other health professional organizations in supporting the nonprescription availability of emergency contraception. This article reviews the history, efficacy, and safety of emergency contraception; the efforts toward making emergency contraception available without a prescription in the United States; the arguments for and against nonprescription availability of emergency contraception; and the potential impact nonprescription availability could have on the practice of emergency medicine in the United States.

Cost-Effectiveness of Hair Apposition Technique Compared With Standard Suturing in Scalp Lacerations

STUDY OBJECTIVE

We have previously described a prospective, randomized, multicenter, clinical trial comparing the hair apposition technique, a new technique of treating scalp lacerations with tissue adhesives, with standard suturing. We found the hair apposition technique to be a better technique for closing suitable scalp lacerations. In this study, we aim to compare the cost-effectiveness of the hair apposition technique and standard suturing.

METHODS

All costs related to each method were calculated, including equipment and staff time. On the basis of the previous randomized controlled trial, differential costs caused by complications were also calculated. The incremental effectiveness of the hair apposition technique was assessed in terms of complications avoided. Expected values of costs and outcomes were obtained through Monte Carlo simulation.

RESULTS

The hair apposition technique was dominant over standard suturing in that it was more effective and resulted in a cost savings of USD 28.50 (95% confidence interval USD 16.30 to USD 43.40) per patient compared with standard suturing because of reduced equipment needs, shorter medical staff time required, no need for another visit to remove sutures, and lower complication rates. The probability of the hair apposition technique being both cost saving and more effective was 98.9%.

CONCLUSION

The hair apposition technique is more cost-effective compared with standard suturing and could lead to large cost savings, given the common occurrence of scalp lacerations in most health systems.

Defensive medicine among high-risk specialist physicians in a volatile malpractice environment

CONTEXT

How often physicians alter their clinical behavior because of the threat of malpractice liability, termed defensive medicine, and the consequences of those changes, are central questions in the ongoing medical malpractice reform debate.

OBJECTIVE

To study the prevalence and characteristics of defensive medicine among physicians practicing in high-liability specialties during a period of substantial instability in the malpractice environment.

DESIGN, SETTING, AND PARTICIPANTS

Mail survey of physicians in 6 specialties at high risk of litigation (emergency medicine, general surgery, orthopedic surgery, neurosurgery, obstetrics/gynecology, and radiology) in Pennsylvania in May 2003.

MAIN OUTCOME MEASURES

Number of physicians in each specialty reporting defensive medicine or changes in scope of practice and characteristics of defensive medicine (assurance and avoidance behavior).

RESULTS

A total of 824 physicians (65%) completed the survey. Nearly all (93%) reported practicing defensive medicine. "Assurance behavior" such as ordering tests, performing diagnostic procedures, and referring patients for consultation, was very common (92%). Among practitioners of defensive medicine who detailed their most recent defensive act, 43% reported using imaging technology in clinically unnecessary circumstances. Avoidance of procedures and patients that were perceived to elevate the probability of litigation was also widespread. Forty-two percent of respondents reported that they had taken steps to restrict their practice in the previous 3 years, including eliminating procedures prone to complications, such as trauma surgery, and avoiding patients who had complex medical problems or were perceived as litigious. Defensive practice correlated strongly with respondents' lack of confidence in their liability insurance and perceived burden of insurance premiums.

CONCLUSION

Defensive medicine is highly prevalent among physicians in Pennsylvania who pay the most for liability insurance, with potentially serious implications for cost, access, and both technical and interpersonal quality of care.

Reimbursement challenges for emergency physicians

Emergency physicians are under growing fiscal pressures on multiple fronts. Federal and state laws require that emergency care be provided to all those presenting at an emergency department, yet in nearly all cases there is no comparable mandate for reimbursement. The growing number of uninsured and underinsured, as well as downward pressure on reimbursement from managed care organizations and social assistance programs such as Medicaid and Medicare, also contributes to the difficulty of emergency physicians to be compensated. It may be time for the public to address more fundamental questions about the right to care and who pays for that care.

Funding emergency medicine development in low- and middle-income countries

The specialty of EM is developing rapidly throughout the world. This growth is relatively lacking in the LICs, however. The lack of resources and financing capabilities in these regions may hinder specialty development. Further growth of the specialty in these countries requires an understanding of their health priorities and the global health and development agencies that often assist these countries in supporting the health sector. Identifying health priorities in these regions that intersect with EM is crucial and may form the basis for further expansion of EM. Many potential funding opportunities exist within the governmental and private sector, but all require some familiarity with application mechanisms and project cycles. Building relationships with personnel within these agencies and countries of interest is often fundamental to successful programmatic funding.

Survey of emergency medicine resident debt status and financial planning preparedness

OBJECTIVES

Most resident physicians accrue significant financial debt throughout their medical and graduate medical education. The objective of this study was to analyze emergency medicine resident debt status, financial planning actions, and educational experiences for financial planning and debt management.

METHODS

A 22-item questionnaire was sent to all 123 Accreditation Council on Graduate Medical Education-accredited emergency medicine residency programs in July 2001. Two follow-up mailings were made to increase the response rate. The survey addressed four areas of resident debt and financial planning: 1) accrued debt, 2) moonlighting activity, 3) financial planning/debt management education, and 4) financial planning actions. Descriptive statistics were used to analyze the data.

RESULTS

Survey responses were obtained from 67.4% (1,707/2,532) of emergency medicine residents in 89 of 123 (72.4%) residency programs. Nearly one half (768/1,707) of respondents have accrued more than 100,000 dollars of debt. Fifty-eight percent (990/1,707) of all residents reported that moonlighting would be necessary to meet their financial needs, and more than 33% (640/1,707) presently moonlight to supplement their income. Nearly one half (832/1,707) of residents actively invested money, of which online trading was the most common method (23.3%). Most residents reported that they received no debt management education during residency (82.1%) or medical school (63.7%). Furthermore, 79.1% (1,351/1,707) of residents reported that they received no financial planning lectures during residency, although 84.2% (1,438/1,707) reported that debt management and financial planning education should be available during residency.

CONCLUSIONS

Most emergency medicine residency programs do not provide their residents with financial planning education. Most residents have accrued significant debt and believe that more financial planning and debt management education is needed during residency.

Enoxaparin versus Heparin

The SYNERGY (Superior Yield of the New strategy of Enoxaparin, Revascularisation, and GlYcoprotein inhibitors) trial, involving almost 10,000 patients, is a landmark cardiology study published in 2004. The study compared two anticoagulants used as part of a modern early invasive strategy involving angiographic triage of high-risk non-ST-elevation acute coronary syndrome patients. The trial as a whole showed similar efficacy between unfractionated heparin and enoxaparin. Regarding safety, two of the three in-hospital bleeding endpoints reported were similar between the two anticoagulants. Importantly, because of the high rate of pre-enrolment anticoagulant administration, many study participants required an anticoagulant change after randomisation. Thus, close attention is warranted to a prespecified subanalysis of >6000 patients who received 'consistent therapy'; that is, the same anticoagulant was administered pre- and post-enrolment based on intention to treat. In this large 'consistent therapy' cohort, the efficacy endpoint favoured enoxaparin and, as in the overall study population, two of the three reported bleeding endpoints were similar between the two anticoagulants. Finally, the rate of peri-procedural thrombotic complications that occurred during percutaneous coronary intervention was equal for both anticoagulants. Thus, since both anticoagulants have a similar efficacy and safety profile, then the simplicity of the enoxaparin regimen (i.e. no monitoring of activated partial thromboplastin time and easy dose calculation of 1 mg/kg subcutaneously) provides an important and desirable feature relevant to a busy emergency medicine practitioner.

Current political issues facing emergency medicine in Canada

Health care in Canada is universal, accessible, transferable and publicly funded. Each of Canada's provinces has the responsibility for health care funding and delivery through its ministry of health, controlled by the governing provincial party and overseen by a Minister of Health. The Federal Government is responsible for ensuring the provinces conform to the spirit and regulations within the Canada Health Act and for broad programme funding, through the federal Minister of Health. As such, access to emergency health services is available to all Canadians free of direct charge. Some aspects of health care are the direct responsibility of citizens, such as ambulance services, medications (for those who can afford them), and 'non-essential' services. For most Canadians, however, care for acute illness and injury is provided without barriers in EDs while generalists such as family physicians and paediatricians provide primary care.

Political issues in emergency medicine: The United States

The format of the paper is to allow three authors to discuss what they believe are the most significant political issues facing emergency medicine (EM) in their country or region. Each author writes independently and does not see any other contributing author's work, therefore potential overlap of subject matter is inevitable. However, we were soliciting their individual opinions about the serious issues confronting us today, rather than a consensus. An additional author, well familiar with the topics being discussed, wrote the Commentary from an overview perspective on the writings of the other authors. This supplemental opinion was offered as a method for enhanced cohesiveness in describing the political situations impacting the specialty of emergency medicine. The three authors for the United States are James Hoekstra, Professor and Chair, Wake Forest University Health Sciences; Robert McNamara, Professor and Chair, Temple University School of Medicine, and Robert Schafermeyer, Associate Chair, Department of Emergency Medicine, North Carolina School of Medicine. Between them, they represent more than 50 years experience in clinical and academic emergency medicine. They write from a personal perspective. Their views are their own, and do not represent any organization(s) with which they may have or had affiliations.