Visit Volume Research Articles

Access to and Use of Point-of-Care Ultrasound in the Emergency Department.

IntroductionGrowing evidence supports emergency physician (EP)-performed point-of-care ultrasound (PoC US). However, there is a utilization gap between academic emergency departments (ED) and other emergency settings. We elucidated barriers to PoC US use in a multistate sample of predominantly non-academic EDs to inform future strategies to increase PoC US utilization, particularly in non-academic centers.MethodsIn 2010, we surveyed ED directors in five states (Arkansas, Hawaii, Minnesota, Vermont, and Wyoming; n=242 EDs) about general ED characteristics. In four states we determined barriers to PoC US use, proportion of EPs using PoC US, use privileges, and whether EPs can bill for PoC US.ResultsResponse rates were >80% in each state. Overall, 47% of EDs reported PoC US availability. Availability varied by state, from 34% of EDs in Arkansas to 85% in Vermont. Availability was associated with higher ED visit volume, and percent of EPs who were board certified/board eligible in emergency medicine. The greatest barriers to use were limited training (70%), expense (39%), and limited need (perceived or real) (32%). When PoC US was used by EPs, 50% used it daily, 44% had privileges not requiring radiology confirmation, and 34% could bill separately for PoC US. Only 12% of EPs used it ≥80% of the time when placing central venous lines.ConclusionOnly 47% of EDs in our five-state sample of predominantly non-academic EDs had PoC US immediately available. When available, the greatest barriers to use were limited training, expense, and limited need. Recent educational and technical advancements may help overcome these barriers.

Emergency department characteristics and capabilities in Bogotá, Colombia.

BackgroundEmergency departments (EDs) are a critical, yet heterogeneous, part of international emergency care. The National ED Inventories (NEDI) survey has been used in multiple countries as a standardized method to benchmark ED characteristics. We sought to describe the characteristics, resources, capabilities, and capacity of EDs in the densely populated capital city of Bogotá, Colombia.MethodsBogotá EDs accessible to the general public 24/7 were surveyed using the 23-item NEDI survey used in several other countries (www.emnet-nedi.org). ED staff were asked about ED characteristics with reference to calendar year 2011.ResultsSeventy EDs participated (82 % response). Most EDs (87 %) were located in hospitals, and 83 % were independent hospital departments. The median annual ED visit volume was approximately 50,000 visits. Approximately 90 % (95 % confidence interval (CI) 80–96 %) had a contiguous layout, with medical and surgical care provided in one area. Almost all EDs saw both adults and children (91 %), while 6 % saw only adults and 3 % saw only children. Availability of technological and consultant resources in EDs was variable. Nearly every ED had cardiac monitoring (99 %, 95 % CI 92–100 %), but less than half had a dedicated CT scanner (39 %, 95 % CI 28–52 %). While most EDs were able to treat trauma 24/7 (81 %, 95 % CI 69–89 %), few could manage oncological (22 %, 95 % CI 13–34 %) or dental (3 %, 95 % CI 0–11 %) emergencies 24/7. The typical ED length-of-stay was between 1 and 6 h in 59 % of EDs (95 % CI, 46–70 %), while most others reported that patients remained for >6 h (39 %). Almost half of respondents (46 %, 95 % CI 34–59 %) reported their ED was over capacity.ConclusionsBogotá EDs have high annual visit volumes and long length-of-stay, and half are over capacity. To meet the emergency care needs of people in Bogotá and other large cities, Colombia should consider improving urban ED capacity and training more emergency medicine specialists capable of efficiently staffing its large and crowded EDs.Electronic supplementary materialThe online version of this article (doi:10.1186/s12245-015-0079-y) contains supplementary material, which is available to authorized users.

National cost savings from observation unit management of syncope.

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. 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. 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. 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.

REGIONAL WEBGIS USER ACCESS PATTERNS BASED ON A WEIGHTED BIPARTITE NETWORK

Abstract. With the rapid development of geographic information services, Web Geographic Information Systems (WebGIS) have become an indispensable part of everyday life; correspondingly, map search engines have become extremely popular with users and WebGIS sites receive a massive volume of requests for access. These WebGIS users and the content accessed have regional characteristics; to understand regional patterns, we mined regional WebGIS user access patterns based on a weighted bipartite network. We first established a weighted bipartite network model for regional user access to a WebGIS. Then, based on the massive user WebGIS access logs, we clustered geographic information accessed and thereby identified hot access areas. Finally we quantitatively analyzed the access interests of regional users and the visitation volume characteristics of regional user access to these hot access areas in terms of user access permeability, user usage rate, and user access viscosity. Our research results show that regional user access to WebGIS is spatially aggregated, and the hot access areas that regional users accessed are associated with specific periods of time. Most regional user contact with hot accessed areas is variable and intermittent but for some users, their access to certain areas is continuous as it is associated with ongoing or recurrent objectives. The weighted bipartite network model for regional user WebGIS access provides a valid analysis method for studying user behaviour in WebGIS and the proposed access pattern exhibits access interest of regional user is spatiotemporal aggregated and presents a heavy-tailed distribution. Understanding user access patterns is good for WebGIS providers and supports better operational decision-making, and helpful for developers when optimizing WebGIS system architecture and deployment, so as to improve the user experience and to expand the popularity of WebGIS.

The Practice Impact of Electronic Health Record System Implementation Within a Large Multispecialty Ophthalmic Practice.

Given the lack of previous reports examining the impact of electronic health record (EHR) system migration in ophthalmology, a study evaluating the practice and economic effect of implementing an EHR into an ophthalmic practice is warranted. To examine the clinical and economic impact of EHR system implementation into a large multispecialty ophthalmic practice. A retrospective case-control study was conducted comparing the pre-EHR and post-EHR time periods at the Cole Eye Institute, Cleveland, Ohio. Eight months were spent prior to implementation personalizing and customizing the system to enable advanced charting functions (July 1, 2011, to March 1, 2012). The periods were compared regarding total revenue, total visit volume, revenue per visit, coding volumes, and the number of diagnostic tests and procedures performed. In addition, the total costs of the EHR implementation and the expected return in EHR incentive payments were evaluated. Data analysis was performed from April 1, 2011, through April 5, 2013. Net revenue, patient volume, revenue to volume ratio, diagnostic and procedure volume, capital and implementation costs, EHR incentive payments received, and coding volumes (including eye and evaluation and management [E/M] codes). A total of 28,161 patient encounters were identified (13,969 in the pre-EHR period and 14,191 in the post-EHR period). No significant change was identified with total net fiscal revenue between the periods (median, -$44,372 per month; 25th to 75th interquartile range [IQR], -$103,850 to $83,126; P = .42). No significant change in patient volume (median, +217.0; IQR, -511.5 to 812.0; P = .57) or revenue per visit volume (median, -$7; IQR, -$9 to -$1; P = .20) was identified. The volume of diagnostic tests and procedures billed was unchanged after conversion (median, +93; IQR, -20 to 235; P = .13). Overall use of eye codes declined (-15.7%) and use of E/M codes increased (14.7%) following EHR implementation (P < .001). The composition of eye codes showed a 2% change toward comprehensive codes over intermediate codes after implementation, but only the composition of new E/M codes increased (42.6%) (P < .001 for both values). Total capital costs amounted to $1,571,864, and personnel costs amounted to $1,514,334. A cumulative amount of $983,103 from meaningful use attestation is expected by 2016. The analyses conducted in this study did not identify significant differences in revenue or productivity following EHR conversion in this clinical setting. The EHR incentive payments did not offset costs of implementation.

How Can eHealth Technology Address Challenges Related to Multimorbidity? Perspectives from Patients with Multiple Chronic Conditions.

Patient eHealth technology offers potential support for disease self-management, but the value of existing applications for patients with multiple chronic conditions (MCCs) is unclear. To understand self-management and health care navigation challenges that patients face due to MCCs and to identify opportunities to support these patients through new and enhanced eHealth technology. After administering a screening survey, we conducted 10 focus groups of 3-8 patients grouped by age, sex, and common chronic conditions. Patients discussed challenges associated with having MCCs and their use of (and desires from) technology to support self-management. Three investigators used standard content analysis methods to code the focus group transcripts. Emergent themes were reviewed with all collaborators, and final themes and representative quotes were validated with a sample of participants. Fifty-three individuals with ≥3 chronic conditions and experience using technology for health-related purposes. Focus group participants had an average of five chronic conditions. Participants reported using technology most frequently to search for health information (96%), communicate with health care providers (92%), track medical information (83%), track medications (77%), and support decision-making about treatment (55%). Three themes emerged to guide eHealth technology development: (1) Patients with MCCs manage a high volume of information, visits, and self-care tasks; (2) they need to coordinate, synthesize, and reconcile health information from multiple providers and about different conditions; (3) their unique position at the hub of multiple health issues requires self-advocacy and expertise. Focus groups identified desirable eHealth resources and tools that reflect these themes. Although patients with multiple health issues use eHealth technology to support self-care for specific conditions, they also desire tools that transcend disease boundaries. By addressing the holistic needs of patients with MCCs, eHealth technology can advance health care from a disease-centered to a patient-centered model.

The long-term financial and clinical impact of an electronic health record on an academic ophthalmology practice.

Purpose. To examine financial and clinical work productivity outcomes associated with the use of the electronic health record (EHR). Methods. 191,360 billable clinical encounters were analyzed for 12 clinical providers over a 9-year study period during which an EHR was implemented. Main outcome measures were clinical revenues collected per provider and secondary outcomes were charge capture, patient visit coding levels, transcription costs, patient visit volume per provider, digital drawing, and digital imaging volume. Results. The difference in inflation adjusted net clinical revenue per provider per year did not change significantly in the period after EHR implementation (mean = $404,198; SD = $17,912) than before (mean = $411,420; SD = $39,366) (P = 0.746). Charge capture, the proportion of higher- and lower-level visit codes for new and established patients, and patient visits per provider remained stable. A total savings of $188,951 in transcription costs occurred over a 4-year time period post-EHR implementation. The rate of drawing the ophthalmic exam in the EHR was low (mean = 2.28%; SD = 0.05%) for all providers. Conclusions. This study did not show a clear financial gain after EHR implementation in an academic ophthalmology practice. Ophthalmologists do not rely on drawings to document the ophthalmic exam; instead, the ophthalmic exam becomes text-driven in a paperless world.

The impact of the Lisbon Football Derby on the profile of emergency department admissions.

Variations in emergency department admissions have been reported to happen as a result of major sports events. The work presented assessed changes in volume and urgency level of visits to a major Emergency Department in Lisbon during and after the city's football derby. Volume of attendances and patient urgency level, according to the Manchester Triage System, were retrospectively analyzed for the 2008-2011 period. Data regarding 24-hour periods starting 45 minutes before kick-off was collected, along with data from similar periods on the corresponding weekdays in the previous years, to be used as controls. Data samples were organized according to time frame (during and after the match), urgency level, and paired accordingly. A total of 14 relevant periods (7 match and 7 non-match) were analyzed, corresponding to a total of 5861 admissions. During the match time frame, a 20.6% reduction (p = 0.06) in the total number of attendances was found when compared to non-match days. MTS urgency level sub-analysis only showed a statistically significant reduction (26.5%; p = 0.05) in less urgent admissions (triage levels green-blue). Compared to controls, post-match time frames showed a global increase in admissions (5.6%; p = 0.45), significant only when considering less urgent ones (18.9%; p = 0.05). A decrease in the total number of emergency department attendances occurred during the matches, followed by a subsequent increase in the following hours. These variations only reached significance among visits triaged green-blue. During major sports events an overall decrease in emergency department admissions seems to take place, especially due to a drop in visits associated with less severe conditions.

P-148 Innovations for IBD RN Role Development Using

Without a conscious effort to define nursing practice, the RN contribution to care may not reach its full potential. Due to staffing limitations, nurses have to set clear priorities and implement strategies to optimize their practice. In our GI department, several clinical practice innovations over the past 3 years have promoted increased efficiency and effectiveness of the IBD RN role. The first innovation was the reorganization of RN work assignments which promoted continuity of care. Instead of working to support clinic or answer phone calls, we now work with a select patient group. We work in clinic seeing patients with the providers simultaneously with taking phone calls and managing other between clinic tasks for our patient group. The second innovation was the development of the IBD Center which increased interdisciplinary collaboration. Our IBD team includes an IBD Psychologist, a Social Worker, Registered Dieticians, Advanced Practice Providers, and Medical Assistants in addition to the Gastroenterologist and IBD nurse. The third innovation was the clear definition of the IBD RN contribution to care. Our short term goal of practice is patient safety and compliance which includes clear communication and education. The long term goal for our pediatric patients with IBD is promoting life long positive attitudes. To implement our goals on a daily basis, our hospital's chosen care delivery model, “Relationship based Family Centered Care,” works well with the addition of targeted case management. Each innovation will be outlined so that RNs can examine their own setting and apply the principles we used to develop their own practice. To address the reorganization of work assignments, RN FTE allocations will be discussed with respect to provider FTE and patient visit volumes. For optimal continuity in our practice, we combined the traditional office work with clinic work. We prioritize meeting patients and families in person. The strategies used in our daily time management will be shared. Having a focus to the RN contribution is the RNs' value system for setting priorities on a minute to minute basis so the difference between a defined work process versus a job focus will be outlined to help RNs put theory into practice Getting to know individual patients and their families, working personally over time dramatically increased efficiency, effectiveness of communications, and understanding of family needs. Establishing a valued relationship is a powerful tool to influence. Working together as an IBD center allowed us to know the patient and family more completely. The RN is essential on the team to aid in identification of patients with poor compliance, dissatisfactions, and misunderstandings which can develop into poor health practices without support and education. Children with IBD have a life long condition which will benefit tremendously by establishing positive attitudes and behaviors towards health maintenance. By consciously defining how we implement our RN jobs we have become more effective in working with our patients. Maintaining continuity in our practice and using targeted case management strategies promotes working closely with families at critical time periods to establish positive patient outcomes.

89 United States Emergency Department Openings, Closures, and Annual Visit Volumes: 2001 to 2011

Emergency departments (EDs) provide round-the-clock emergency care and also serve as a health care “safety net.” Rising ED visit volumes have heightened concern about the impact of ED closures on access to health care. We examined ED openings and closures, in both rural and non-rural areas, in the US between 2001 and 2011.

132 Computed Tomography Utilization for Non-Traumatic Abdominal Pain in the Emergency Department Shows Minimal Variability

We examined the variability of computed tomography (CT) ordering practices for non-traumatic abdominal pain (NTAP) across physicians in the emergency department (ED) using both patient-visit and physician-level factors. A retrospective study was conducted among 6,502 ED visits for NTAP from January 1 to December 31, 2012 at a large, urban, academic, tertiary care hospital. Visits were selected by chief complaint (excluding trauma unit) and were excluded due to pregnancy, < 18-years-old, incomplete radiology data, physicians with < 45 visits or no physician provider. The relationship of patient-visit and physician-level factors with CT ordering was investigated using univariate and multivariate generalized linear models with repeated measures. A two-level hierarchical logistic regression model with physician-specific random intercepts was used to estimate the inter-physician variation with fixed effects of the patient-visit and physician-level factors. Intraclass correlation coefficient (ICC) based on the standard logistic function variance (π2/3) was calculated. The ED patient visits represented female (67.2%), 23-63 years old (73.6%), walk-ins (77.5%), during weekdays (75.7%), with moderate acuity (70.4%), and were discharged from the ED (72.1%). Overall CT utilization rate across physicians was 27.5%. Forty-five physicians provided care with the median annual visit volume (for the chief complaint of abdominal pain) of 129 (IQR: 97−209), and median CT ordering rate of 27.1% (IQR: 22.9−30.5%). The generalized linear regression analyses showed that after adjusting for the patient-visit factors only, admission team, prior CT test, ED arrivals in previous 4 hours, ultrasound, and white blood cell (WBC) count were statistically significant factors associated with CT ordering; after adjusting for the physician-level characteristics only, years after completing medical school, fellowship, and advanced triage physician were statistically significant factors. The hierarchical logistic regression analyses considering all patient-visit and physician-level factors together with physician-specific random effect showed that the patient-visit factors including age, arrival mode, acuity, admission team, prior CT, ED arrivals in previous 4 hours, ultrasound, and WBC count had statistically significant associations with physician CT ordering, whereas physician-level factors were not statistically significant. There was only 1 out of 45 physicians (2.2%) with an odds ratio not intersecting 1, which indicated the limited variation across physicians to order CT (Figure). After adjusting for patient-visit and physician-level factors, the calculated ICC was 1.68%. We found minimal physician variability in CT ordering practices for NTAP, similar to the findings by other researchers. Patient-visit factors such as age, arrival mode, acuity, admission team, prior CT, ED arrivals in previous 4 hours, ultrasound, and WBC count were found to largely influence CT ordering practices.

Trends in use in a Canadian pediatric emergency department.

Emergency department (ED) crowding is a significant problem in Canada and has been associated with decreased quality of care in general and pediatric emergency departments (PEDs). Although boarding of admitted patients in the ED is the main contributor to adult ED overcrowding, factors involved in PED crowding may be different. The objective of this study was to report the trend in PED services use and to document the degree of overcrowding experienced in a Canadian PED. A retrospective cohort study was conducted using administrative data from a tertiary care PED from 2002 to 2011. The primary outcome was PED use (total volume of visits and case severity per triage levels using the Canadian Triage and Acuity Scale [CTAS] score and admissions). Secondary outcomes included measures of PED overcrowding, such as rates of patients leaving without being seen (LWBS) and length of stay (LOS). Total volumes increased by 30% over the 10-year study period, whereas hospitalizations remained stable at approximately 10%. Trends in CTAS levels did not indicate meaningful changes in the severity of cases treated at our PED. LWBS proportions among CTAS 3, CTAS 4, and CTAS 5 groups and LOS for all CTAS groups progressively and statistically increased from year to year. Over the course of the study period, there was a substantial increase in PED visits, which likely contributed to the worsening markers of PED flow outcomes. Further study into the effects of PED crowding on patient outcomes is warranted.

Health reform and shifts in funding for sexually transmitted infection services.

In the Affordable Care Act era, no-cost-to-patient publicly funded sexually transmitted infection (STI) clinics have been challenged as the standard STI care delivery model. This study examined the impact of removing public funding and instituting a flat fee within an STI clinic under state-mandated insurance coverage. Cross-sectional database analysis examined changes in visit volumes, demographics, and payer mix for 4 locations in Massachusetts' largest safety net hospital (STI clinic, primary care [PC], emergency department [ED], obstetrics/gynecology [OB/GYN] for 3 periods: early health reform implementation, reform fully implemented but public STI clinic funding retained, termination of public funding and institution of a US$75 fee in STI clinic for those not using insurance). Sexually transmitted infection visits decreased 20% in STI clinic (P < 0.001), increased 107% in PC (P < 0.001), slightly decreased in ED, and did not change in OB/GYN. The only large demographic shift observed was in the sex of PC patients--women comprised 51% of PC patients seen for STI care in the first time period, but rose sharply to 70% in the third time period (P < 0.0001). After termination of public funding, 50% of STI clinic patients paid flat fee, 35% used public insurance, and 15% used private insurance. Mandatory insurance, public funding loss, and institution of a flat STI clinic fee were associated with overall decreases in STI visit volume, with significant STI clinic visit decreases and PC STI visit increases. This may indicate partial shifting of STI services into PC. Half of STI clinic patients chose to pay the flat fee even after reform was fully implemented.

Characteristics of United States emergency departments that routinely perform alcohol risk screening and counseling for patients presenting with drinking-related complaints.

IntroductionEmergency department (ED) screening and counseling for alcohol misuse have been shown to reduce at-risk drinking. However, barriers to more widespread adoption of this service remain unclear.MethodsWe performed a secondary analysis of a nationwide survey of 277 EDs to determine the proportion of EDs that routinely perform alcohol screening and counseling among patients presenting with alcohol-related complaints and to identify potential institutional barriers and facilitators to routine screening and counseling. The survey was randomly mailed to 350 EDs sampled from the 2007 National Emergency Department Inventory (NEDI), with 80% of ED medical directors responding after receiving the mailing or follow-up fax/email. The survey asked about a variety of preventive services and ED directors’ opinions regarding perceived barriers to offering preventive services in their EDs.ResultsOverall, only 27% of all EDs and 22% of Level I/II trauma center EDs reported routinely screening and counseling patients presenting with drinking-related complaints. Rates of routine screening and counseling were similar across geographic areas, crowding status, and urban-rural status. EDs that performed routine screening and counseling often offered other preventive services, such as tobacco cessation (P<0.01) and primary care linkage (P=0.01). EDs with directors who expressed concern about increased financial costs to the ED, inadequate follow-up, and diversion of nurse/physician time all had lower rates of screening and counseling and also more frequently reported lacking the perceived capacity to perform routine counseling and screening. Among EDs that did not routinely perform alcohol screening and counseling, more crowded than non-crowded (P<0.01) and more metro than rural (P<0.01) EDs reported lacking the capacity to perform routine screening and counseling. The capacity to perform routine screening also decreased as ED visit volume increased (P=0.04).ConclusionTo increase routine alcohol screening and counseling for patients presenting with alcohol-related complaints, ED directors’ perceived barriers related to an ED’s capacity to perform screening, such as limited financial and staff resources, should be addressed, as should directors’ concerns regarding the implementation of preventive health services in EDs. Uniform reimbursement methods should be used to increase ED compensation for performing this important and effective service.

A cross-sectional study of emergency department boarding practices in the United States.

The median emergency department (ED) boarding time for admitted patients has been a nationally reportable core measure that now also affects ED accreditation and reimbursement. However, no direct national probability samples of ED boarding data have been available to guide this policy until now. The authors studied new National Hospital Ambulatory Medical Care Survey (NHAMCS) survey items to establish baseline values, to generate hypotheses for future research, and to help improve survey quality in the future. This was a cross-sectional, multistage, stratified annual analysis of EDs and ED visits from the National Hospital Ambulatory Medical Care Survey public use files from 2007 to 2010, a total of 139,502 visit records. These data represent the only national measure of ED boarding. The main outcome of interest was boarding duration for individual patient visits. Data analyses accounted for complex sampling design. The national median boarding time was 79 minutes, with an interquartile range of 36 to 145 minutes. The prevalence of boarding for more than 2 hours among admitted patients was 32% (95% confidence interval [CI] = 30% to 35%). Average ED volume, occupancy, acuity, and hospital admission rates increased abruptly from the second to the third quartile of median boarding duration. The half of hospitals with the longest median boarding times accounted for 73% of ED visits and 79% of ED hospitalizations nationally. Thirty-nine percent of EDs (95% CI = 32% to 46%) reported never holding patients for more than 2 hours, but visit-level analysis at these EDs found that 21% of admissions did in fact stay in the ED over 2 hours. Only 19% of EDs (95% CI = 16% to 22%) used a strategy of moving admitted patients to alternative sites in the hospital during crowded times. In this national survey, ED boarding of admitted patients disproportionately affects hospitals with higher ED volumes, which also see sicker patients who wait longer to be seen, but not hospitals with higher proportions of Medicaid or uninsured visits. This finding implies that, unlike other quality measures, there is a negative volume-outcome relationship for timely hospitalization from the ED.

Factors Associated With the Disposition of Severely Injured Patients Initially Seen at Non–Trauma Center Emergency Departments

Trauma is the leading cause of potential years of life lost before age 65 years in the United States. Timely care in a designated trauma center has been shown to reduce mortality by 25%. However, many severely injured patients are not transferred to trauma centers after initially being seen at non–trauma center emergency departments (EDs). To determine patient-level and hospital-level factors associated with the decision to admit rather than transfer severely injured patients who are initially seen at non–trauma center EDs and to ascertain whether insured patients are more likely to be admitted than transferred compared with uninsured patients. Retrospective analysis of the 2009 Nationwide Emergency Department Sample. We included all ED encounters for major trauma (Injury Severity Score, >15) seen at non–trauma centers in patients aged 18 to 64 years. We excluded ED discharges and ED deaths. We quantified the absolute risk difference between admission vs transfer by insurance status, while adjusting for age, sex, mechanism of injury, Injury Severity Score, weekend admission and month of visit, and urban vs rural status and median household income of the home zip code, as well as annual ED visit volume and teaching status and US region. Inpatient admission vs transfer to another acute care facility. In 2009, a total of 4513 observations from 636 non–trauma center EDs were available for analysis, representing a nationally weighted population of 19,312 non–trauma center ED encounters for major trauma. Overall, 54.5% in 2009 were admitted to the non–trauma center. Compared with patients without insurance, the adjusted absolute risk of admission vs transfer was 14.3% (95% CI, 9.2%-19.4%) higher for patients with Medicaid and 11.2% (95% CI, 6.9%-15.4%) higher for patients with private insurance. Other factors associated with admission vs transfer included severe abdominal injuries (risk difference, 15.9%; 95% CI, 9.4%-22.3%), urban teaching hospital vs non–teaching hospital (risk difference, 26.2%; 95% CI, 15.2%-37.2%), and annual ED visit volume (risk difference, 3.4%; 95% CI, 1.6%-5.3% higher for every additional 10,000 annual ED visits). Patients with severe injuries initially evaluated at non–trauma center EDs were less likely to be transferred if insured and were at risk of receiving suboptimal trauma care. Efforts in monitoring and optimizing trauma interhospital transfers and outcomes at the population level are warranted.

Capitation Combined With Pay-For-Performance Improves Antibiotic Prescribing Practices In Rural China

Pay-for-performance in health care holds promise as a policy lever to improve the quality and efficiency of care. Although the approach has become increasingly popular in developing countries in recent years, most policy designs do not permit the rigorous evaluation of its impact. Thus, evidence of its effect is limited. In collaboration with the government of Ningxia Province, a predominantly rural area in northwest China, we conducted a matched-pair cluster-randomized experiment between 2009 and 2012 to evaluate the effects of capitation with pay-for-performance on primary care providers' antibiotic prescribing practices, health spending, outpatient visit volume, and patient satisfaction. We found that the intervention led to a reduction of approximately 15 percent in antibiotic prescriptions and a small reduction in total spending per visit to village posts-essentially, community health clinics. We found no effect on other outcomes. Our results suggest that capitation with pay-for-performance can improve drug prescribing practices by reducing overprescribing and inappropriate prescribing. Our study also shows that rigorous evaluations of health system interventions are feasible when conducted in close collaboration with the government.

Influence of Frailty‐Related Diagnoses, High‐Risk Prescribing in Elderly Adults, and Primary Care Use on Readmissions in Fewer than 30 Days for Veterans Aged 65 and Older

To determine the effect of two variables not previously studied in the readmissions literature (frailty-related diagnoses and high-risk medications in the elderly (HRME)) and one understudied variable (volume of primary care visits in the prior year). Retrospective cohort study using data from a study designed to examine outcomes associated with inappropriate prescribing in elderly adults. All Veterans Affairs (VA) facilities with acute inpatient beds in fiscal year 2006 (FY06). All veterans aged 65 and older by October 1, 2005, who received VA care at least once per year between October 1, 2004, and September 30, 2006, and were hospitalized at least once during FY06 on a medical or surgical unit. A generalized linear interactive risk prediction model included demographic and clinical characteristics (mental health and chronic medical conditions, frailty-related diagnoses, number of medications) in FY05; incident HRME in FY06 before index hospitalization or readmission; chronic HRME in FY05; and FY05 emergency department (ED), hospital, geriatric, palliative, or primary care use. Facility-level variables were complexity, rural versus urban, and FY06 admission rate. The mean adjusted readmission rate was 18.3%. The new frailty-related diagnoses variable is a risk factor for readmission in addition to Charlson comorbidity score. Incident HRME use was associated with lower rates of readmission, as were higher numbers of primary care visits in the prior year. Frailty-related diagnoses may help to target individuals at higher risk of readmission to receive more-intensive care transition services. HRME use does not help in this targeting. A higher number of face-to-face primary care visits in the prior year, unlike ED and hospital use, correlates with fewer readmissions and may be another avenue for targeting prevention strategies.

Prevalence and treatment of pain in EDs in the United States, 2000 to 2010

ObjectivesTo describe changes in the prevalence and severity of pain and prescribing of non-opioid analgesics in US emergency departments (EDs) from 2000 to 2010. MethodsAnalysis of serial cross-sectional data regarding ED visits from the National Hospital Ambulatory Medical Care Survey. Visits were limited to patients ≥18 years old without malignancy. Outcome measures included annual volume of visits among adults with a primary symptom or diagnosis of pain, annual rates of patient-reported pain severity, and predictors of non-opioid receipt for non-malignant pain. ResultsRates of pain remained stable, representing approximately 45% of visits from 2000 through 2010. Patients reported pain as their primary symptom twice as often as providers reported a primary pain diagnosis (40% vs 20%). The percentage of patients reporting severe pain increased from 25% (95% confidence intervals [CI] 22%-27%) in 2003 to 40% (CI 37%-42%) in 2008. From 2000 to 2010, the proportion of pain visits treated with pharmacotherapies increased from 56% (CI 53%-58%) to 71% (CI 69%-72%), although visits treated exclusively with non-opioids decreased 21% from 28% (CI 27%-30%) to 22% (CI 20%-23%). The adjusted odds of non-opioid rather than opioid receipt were greater among visits for patients 18 to 24 years old (odds ratio [OR] 1.35, CI 1.24-1.46), receiving fewer medicines (OR 2.91, CI 2.70-3.15) and those with a diagnosis of mental illness (OR 2.24, CI 1.99-2.52). ConclusionsLarge increases in opioid utilization in EDs have coincided with reductions in the use of non-opioid analgesics and an unchanging prevalence of pain among patients.

Combining surveillance systems: effective merging of U.S. Veteran and military health data.

BackgroundThe U.S. Department of Veterans Affairs (VA) and Department of Defense (DoD) had more than 18 million healthcare beneficiaries in 2011. Both Departments conduct individual surveillance for disease events and health threats.MethodsWe performed joint and separate analyses of VA and DoD outpatient visit data from October 2006 through September 2010 to demonstrate geographic and demographic coverage, timeliness of influenza epidemic awareness, and impact on spatial cluster detection achieved from a joint VA and DoD biosurveillance platform.ResultsAlthough VA coverage is greater, DoD visit volume is comparable or greater. Detection of outbreaks was better in DoD data for 58% and 75% of geographic areas surveyed for seasonal and pandemic influenza, respectively, and better in VA data for 34% and 15%. The VA system tended to alert earlier with a typical H3N2 seasonal influenza affecting older patients, and the DoD performed better during the H1N1 pandemic which affected younger patients more than normal influenza seasons. Retrospective analysis of known outbreaks demonstrated clustering evidence found in separate DoD and VA runs, which persisted with combined data sets.ConclusionThe analyses demonstrate two complementary surveillance systems with evident benefits for the national health picture. Relative timeliness of reporting could be improved in 92% of geographic areas with access to both systems, and more information provided in areas where only one type of facility exists. Combining DoD and VA data enhances geographic cluster detection capability without loss of sensitivity to events isolated in either population and has a manageable effect on customary alert rates.