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Scholarly Works (6 results)

  • Article
  • Peer Reviewed
Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 24, Issue 3 (2023)

Introduction: Recent reports suggest rising intensity of emergency department (ED) billing practices, sparking concerns that this may represent up-coding. However, it may reflect increasing severity and complexity of care in the ED population. We hypothesize that this in part may be reflected in more severe manifestations of illness as indicated by vital sign abnormalities.

Methods: Using 18 years of data from the National Hospital Ambulatory Medical Care Survey, we conducted a retrospective secondary analysis of adults (>18 years). We assessed standard vital signs using weighted descriptive statistics (heart rate, oxygen saturation, temperature, and systolic blood pressure [SBP]), as well as hypotension and tachycardia. Finally, we evaluated for differing effects stratifying by subpopulations of interest, including age (<65 vs ≥65), payer type, arrival by ambulance, and high-risk diagnoses.

Results: In total there were 418,849 observations representing 1,745,368,303 ED visits. We found only minimal variations in vital signs over the study period: heart rate (median 85, interquartile range [IQR] 74-97); oxygen saturation (median 98, IQR 97-99); temperature (median 98.1, IQR 97.6-98.6); and SBP (median 134, IQR 120-149). Similar results were found among the subpopulations tested. The proportion of visits with hypotension decreased (first/last year difference 0.5% [95% CI 0.2%-0.7%]) while there was no difference in the proportion of patients with tachycardia.

Conclusions: Arrival vital signs in the ED have largely remained unchanged or improved over the most recent 18 years of nationally representative data, even for key subpopulations. Greater intensity in ED billing practices is not explained by changes in arrival vital signs.

  • 1 supplemental ZIP
Cover page: National Trends in Vital Sign Abnormalities at Arrival to the Emergency DepartmentCreative Commons 'BY' version 4.0 license
  • Article
Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 23, Issue 5.1 (2022)

Objectives: The objective of this study was to determine if an ED-based electronic health record (EHR) Best Practice Alert (BPA) increased the ordering of expedited partner therapy (EPT) for sexually transmitted infections (STI) in adult patients.

Background: US EDs have reported increases in STI visits and positivity rates, mirroring record level increases in STI incidence in the general population. EPT is an evidence-based practice recommended by public health experts for treating sexual partners of STI patients. EDs typically evaluate patients for STIs without their sexual partner present, thereby providing opportunities for EPT. However, EPT is infrequently used in US EDs.

Methods: This pilot study was part of a quality improvement initiative conducted between August and October 2021 in an academic tertiary care ED located in the Midwest. An EPT BPA was randomly displayed in the EHR to clinicians when they empirically treated adult ED patients for STIs with antibiotics. Differences in proportions of EPT ordering were calculated for STI visits between BPA exposed vs. unexposed, ED clinician type, and testing-confirmed vs. not confirmed STI status.

Results: Of the 52 adult ED patients empirically treated for STIs during the study period, their mean age was 30 years old, 56% were female, 48% White and 40% Black, and 31% had Medicaid. Testing-confirmed STI prevalence was 27%. EPT was ordered less often during BPA unexposed (8%; 95% CI 1-25) than BPA exposed (42%; 95% CI 23-63) STI visits, for a mean difference of 35% (95% CI 13-56). EPT was ordered during 41% of STI visits involving residents, as compared to 7% of physician assistant visits (p=0.07). EPT was not ordered more often for testing-confirmed vs. not confirmed STI visits (21% vs. 26%; p=0.7).

Conclusion: Displaying an EHR BPA greatly increased EPT ordering for patients empirically treated for STIs, although not consistently across all clinician types. Because suspected cases of STIs may be less common in some EDs depending on the populations they serve, BPAs may be a useful tool to bolster the implementation of EPT practices.

    Cover page: Impact of a Best Practice Alert on the Implementation of Expedited Partner TherapyCreative Commons 'BY' version 4.0 license
    • Article
    • Peer Reviewed
    UC San Francisco Previously Published Works (2016)

    Importance

    Unscheduled short-term return visits to the emergency department (ED) are increasingly monitored as a hospital performance measure and have been proposed as a measure of the quality of emergency care.

    Objective

    To examine in-hospital clinical outcomes and resource use among patients who are hospitalized during an unscheduled return visit to the ED.

    Design, setting, and participants

    Retrospective analysis of adult ED visits to acute care hospitals in Florida and New York in 2013 using data from the Healthcare Cost and Utilization Project. Patients with index ED visits were identified and followed up for return visits to the ED within 7, 14, and 30 days.

    Exposures

    Hospital admission occurring during an initial visit to the ED vs during a return visit to the ED.

    Main outcomes and measures

    In-hospital mortality, intensive care unit (ICU) admission, length of stay, and inpatient costs.

    Results

    Among the 9,036,483 index ED visits to 424 hospitals in the study sample, 1,758,359 patients were admitted to the hospital during the index ED visit. Of these patients, 149,214 (8.5%) had a return visit to the ED within 7 days of the index ED visit, 228,370 (13.0%) within 14 days, and 349,335 (19.9%) within 30 days, and 76,151 (51.0%), 122,040 (53.4%), and 190,768 (54.6%), respectively, were readmitted to the hospital. Among the 7,278,124 patients who were discharged during the index ED visit, 598,404 (8.2%) had a return visit to the ED within 7 days, 839,386 (11.5%) within 14 days, and 1,205,865 (16.6%) within 30 days. Of these patients, 86,012 (14.4%) were admitted to the hospital within 7 days, 121,587 (14.5%) within 14 days, and 173,279 (14.4%) within 30 days. The 86,012 patients discharged from the ED and admitted to the hospital during a return ED visit within 7 days had significantly lower rates of in-hospital mortality (1.85%) compared with the 1,609,145 patients who were admitted during the index ED visit without a return ED visit (2.48%) (odds ratio, 0.73 [95% CI, 0.69-0.78]), lower rates of ICU admission (23.3% vs 29.0%, respectively; odds ratio, 0.73 [95% CI, 0.71-0.76]), lower mean costs ($10,169 vs $10,799; difference, $629 [95% CI, $479-$781]), and longer lengths of stay (5.16 days vs 4.97 days; IRR, 1.04 [95% CI, 1.03-1.05]). Similar outcomes were observed for patients returning to the ED within 14 and 30 days of the index ED visit. In contrast, patients who returned to the ED after hospital discharge and were readmitted had higher rates of in-hospital mortality and ICU admission, longer lengths of stay, and higher costs during the repeat hospital admission compared with those admitted to the hospital during the index ED visit without a return ED visit.

    Conclusions and relevance

    Compared with adult patients who were hospitalized during the index ED visit and did not have a return visit to the ED, patients who were initially discharged during an ED visit and admitted during a return visit to the ED had lower in-hospital mortality, ICU admission rates, and in-hospital costs and longer lengths of stay. These findings suggest that hospital admissions associated with return visits to the ED may not adequately capture deficits in the quality of care delivered during an ED visit.
      Cover page: In-Hospital Outcomes and Costs Among Patients Hospitalized During a Return Visit to the Emergency Department
      • Article
      • Peer Reviewed
      Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 20, Issue 3 (2019)

      Introduction: Attempts to reduce low-value hospital care often focus on emergency department (ED) hospitalizations. We compared rural and urban EDs in Michigan on resources designed to reduce avoidable admissions.

      Methods: A cross-sectional, web-based survey was emailed to medical directors and/or nurse managers of the 135 hospital-based EDs in Michigan. Questions included presence of clinical pathways, services to reduce admissions, and barriers to connecting patients to outpatient services. We performed chi-squared comparisons, regression modeling, and predictive margins.

      Results: Of 135 EDs, 64 (47%) responded with 33 in urban and 31 in rural counties. Clinical pathways were equally present in urban and rural EDs (67% vs 74%, p=0.5). Compared with urban EDs, rural EDs reported greater access to extended care facilities (21% vs 52%, p=0.02) but less access to observation units (52% vs 35%, p=0.04). Common barriers to connecting ED patients to outpatient services exist in both settings, including lack of social support (88% and 76%, p=0.20), and patient/family preference (68% and 68%, p=1.0). However, rural EDs were more likely to report time required for care coordination (88% vs 66%, p=0.05) and less likely to report limitations to home care (21% vs 48%, p=0.05) as barriers. In regression modeling, ED volume was predictive of the presence of clinical pathways rather than rurality.

      Conclusion: While rural-urban differences in resources and barriers exist, ED size rather than rurality may be a more important indicator of ability to reduce avoidable hospitalizations.

      • 1 supplemental file
      Cover page: Are Rural and Urban Emergency Departments Equally Prepared to Reduce Avoidable Hospitalizations?Creative Commons 'BY' version 4.0 license
      • Article
      • Peer Reviewed
      Western Journal of Emergency Medicine: Integrating Emergency Care with Population Health, Volume 24, Issue 5 (2023)

      Background: Treatment for partners of patients diagnosed with sexually transmitted infections (STI), referred to as expedited partner therapy (EPT), is infrequently used in the emergency department (ED). This was a pilot program to initiate and evaluate EPT through medication-in-hand (“take-home”) kits or paper prescriptions. In this study we aimed to assess the frequency of EPT prescribing, the efficacy of a randomized best practice advisory (BPA) on the uptake, perceptions of emergency clinicians regarding the EPT pilot, and factors associated with EPT prescribing.

      Methods: We conducted this pilot study at an academic ED in the midwestern US between August–October 2021. The primary outcome of EPT prescription uptake and the BPA impact was measured via chart abstraction and analyzed through summary statistics and the Fisher exact test. We analyzed the secondary outcome of barriers and facilitators to program implementation through ED staff interviews (physicians, physician assistants, and nurses). We used a rapid qualitative assessment method for the analysis of the interviews.

      Results: During the study period, 52 ED patients were treated for chlamydia/gonorrhea, and EPT was offered to 25% (95% CI 15%–39%) of them. Expedited partner therapy was prescribed significantly more often (42% vs 8%; P < 0.01) when the interruptive pop-up alert BPA was shown compared to not shown. Barriers identified in the interviews included workflow constraints and knowledge of EPT availability. The BPA was viewed positively by the majority of participants.

      Conclusion: In this pilot EPT program, expedited partner therapy was provided to 25% of ED patients who appeared eligible to receive it. The interruptive pop-up alert BPA significantly increased EPT prescribing. Barriers identified to EPT prescribing should be the subject of future interventions to improve provision of EPT from the emergency department.

      • 3 supplemental PDFs
      • 1 supplemental image
      Cover page: Mixed-methods Evaluation of an Expedited Partner Therapy Take-home Medication Program: Pilot Emergency Department Intervention to Improve Sexual Health EquityCreative Commons 'BY' version 4.0 license
      • Article
      • Peer Reviewed
      UC Berkeley Previously Published Works (2017)

      Objectives

      Administrative claims data sets are often used for emergency care research and policy investigations of healthcare resource utilization, acute care practices, and evaluation of quality improvement interventions. Despite the high profile of emergency department (ED) visits in analyses using administrative claims, little work has evaluated the degree to which existing definitions based on claims data accurately captures conventionally defined hospital-based ED services. We sought to construct an operational definition for ED visitation using a comprehensive Medicare data set and to compare this definition to existing operational definitions used by researchers and policymakers.

      Methods

      We examined four operational definitions of an ED visit commonly used by researchers and policymakers using a 20% sample of the 2012 Medicare Chronic Condition Warehouse (CCW) data set. The CCW data set included all Part A (hospital) and Part B (hospital outpatient, physician) claims for a nationally representative sample of continuously enrolled Medicare fee-for-services beneficiaries. Three definitions were based on published research or existing quality metrics including: 1) provider claims-based definition, 2) facility claims-based definition, and 3) CMS Research Data Assistance Center (ResDAC) definition. In addition, we developed a fourth operational definition (Yale definition) that sought to incorporate additional coding rules for identifying ED visits. We report levels of agreement and disagreement among the four definitions.

      Results

      Of 10,717,786 beneficiaries included in the sample data set, 22% had evidence of ED use during the study year under any of the ED visit definitions. The definition using provider claims identified a total of 4,199,148 ED visits, the facility definition 4,795,057 visits, the ResDAC definition 5,278,980 ED visits, and the Yale definition 5,192,235 ED visits. The Yale definition identified a statistically different (p < 0.05) collection of ED visits than all other definitions including 17% more ED visits than the provider definition and 2% fewer visits than the ResDAC definition. Differences in ED visitation counts between each definition occurred for several reasons including the inclusion of critical care or observation services in the ED, discrepancies between facility and provider billing regulations, and operational decisions of each definition.

      Conclusion

      Current operational definitions of ED visitation using administrative claims produce different estimates of ED visitation based on the underlying assumptions applied to billing data and data set availability. Future analyses using administrative claims data should seek to validate specific definitions and inform the development of a consistent, consensus ED visitation definitions to standardize research reporting and the interpretation of policy interventions.
        Cover page: Identification of Emergency Department Visits in Medicare Administrative Claims: Approaches and Implications
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