scholarly journals Are trends in billing for high-intensity emergency care explained by changes in services provided in the emergency department? An observational study among US Medicare beneficiaries

BMJ Open ◽  
2018 ◽  
Vol 8 (1) ◽  
pp. e019357 ◽  
Author(s):  
Laura G Burke ◽  
Robert C Wild ◽  
E John Orav ◽  
Renee Y Hsia
Keyword(s):  
Emergency Department ◽  
Observational Study ◽  
Emergency Care ◽  
High Intensity ◽  
Patient Characteristics ◽  
Medicare Beneficiaries ◽  
Absolute Increase ◽  
Hospital Admission Rate ◽  
Outpatient Visits ◽  
Change In Mean

ObjectiveThere has been concern that an increase in billing for high-intensity emergency care is due to changes in coding practices facilitated by electronic health records. We sought to characterise the trends in billing for high-intensity emergency care among Medicare beneficiaries and to examine the degree to which trends in high-intensity billing are explained by changes in patient characteristics and services provided in the emergency department (ED).Design, setting and participantsObservational study using traditional Medicare claims to identify ED visits at non-federal acute care hospitals for elderly beneficiaries in 2006, 2009 and 2012.Outcomes measuresBilling intensity was defined by emergency physician evaluation and management (E&M) codes. We tested for overall trends in high-intensity billing (E&M codes 99285, 99291 and 99292) and in services provided over time using linear regression models, adjusting for patient characteristics. Additionally, we tested for time trends in rates of admission to the hospital and to the intensive care unit (ICU). Next, we classified outpatient visits into 39 diagnosis categories and analysed the change in proportion of high-intensity visits versus the change in number of services. Finally, we quantified the extent to which trends in high-intensity billing are explained by changes in patient demographics and services provided in the ED using multivariable modelling.ResultsHigh-intensity visits grew from 45.8% of 671 103 visits in 2006 to 57.8% of 629 010 visits in 2012 (2.0% absolute increase per year; 95% CI 1.97% to 2.03%) as did the mean number of services provided for admitted (1.28 to 1.41; +0.02 increase in procedures per year; 95% CI 0.018 to 0.021) and discharged ED patients (7.1 to 8.6; +0.25 increase in services per year; 95% CI 0.245 to 0.255). There was a reduction in hospital admission rate from 40.1% to 35.9% (−0.68% per year; 95% CI −0.71% to −0.65%; P<0.001), while the ICU rate of admission rose from 11.7% to 12.3% (+0.11% per year; 95% CI 0.09% to 0.12%; P<0.001). When we stratified by diagnosis category, there was a moderate correlation between change in visits billed as high intensity and the change in mean number of services provided per visit (r=0.38; 95% CI 0.07 to 0.63). Trends in patient characteristics and services provided accounted moderately for the trend in practice intensity for outpatient visits (pseudo R2of 0.47) but very little for inpatient visits (0.051) and visits overall (0.148).ConclusionsIncreases in services provided in the ED moderately account for the trends in billing for high-intensity emergency care for outpatient visits.

scholarly journals Patient mortality after surgery on the surgeon’s birthday: observational study

BMJ ◽  
2020 ◽  
pp. m4381
Author(s):  
Hirotaka Kato ◽  
Anupam B Jena ◽  
Yusuke Tsugawa
Keyword(s):  
Mortality Rate ◽  
Observational Study ◽  
Life Events ◽  
Fixed Effects ◽  
Severity Of Illness ◽  
Patient Characteristics ◽  
Critical Access Hospitals ◽  
Fee For Service ◽  
Medicare Beneficiaries ◽  
Study Analysis

Abstract Objective To determine whether patient mortality after surgery differs between surgeries performed on surgeons’ birthdays compared with other days of the year. Design Retrospective observational study. Setting US acute care and critical access hospitals. Participants 100% fee-for-service Medicare beneficiaries aged 65 to 99 years who underwent one of 17 common emergency surgical procedures in 2011-14. Main outcome measures Patient postoperative 30 day mortality, defined as death within 30 days after surgery, with adjustment for patient characteristics and surgeon fixed effects. Results 980 876 procedures performed by 47 489 surgeons were analyzed. 2064 (0.2%) of the procedures were performed on surgeons’ birthdays. Patient characteristics, including severity of illness, were similar between patients who underwent surgery on a surgeon’s birthday and those who underwent surgery on other days. The overall unadjusted 30 day mortality on the operating surgeon’s birthday was 7.0% (145/2064) and that on other days was 5.6% (54 824/978 812). After adjusting for patient characteristics and surgeon fixed effects (effectively comparing outcomes of patients treated by the same surgeon on different days), patients who underwent surgery on a surgeon’s birthday exhibited higher mortality compared with patients who underwent surgery on other days (adjusted mortality rate, 6.9% v 5.6%; adjusted difference 1.3%, 95% confidence interval 0.1% to 2.5%; P=0.03). Event study analysis of patient mortality by day of surgery relative to a surgeon’s birthday found similar results. Conclusions Among Medicare beneficiaries who underwent common emergency surgeries, those who received surgery on the surgeon’s birthday experienced higher mortality compared with patients who underwent surgery on other days. These findings suggest that surgeons might be distracted by life events that are not directly related to work.

scholarly journals Effectiveness of Hospital Emergency Department Regionalization and Categorization Policy on Appropriate Patient Emergency Care Use - A nationwide long-term observational study in Taiwan

2020 ◽  
Author(s):  
Chih-Yuan Lin ◽  
Yue-Chune Lee
Keyword(s):  
Emergency Department ◽  
Observational Study ◽  
Emergency Care ◽  
Research Database ◽  
Policy Intervention ◽  
Hospital Emergency Department ◽  
Care Policy ◽  
Hospital Emergency ◽  
Visit Rate ◽  
Ed Visits

Abstract Background: The goal of this study was to examine the effect of hospital emergency department (ED) regionalization policy and the categorization of hospital emergency care policy (categorization policy) on patient appropriate ED use.Methods: We conducted an observational study of the effect of emergency care policy intervention on patients' visits. Seven years of data from the Taiwan National Health Insurance Research Database (NHIRD) were examined. Taiwan implemented a nationwide three-tiered hospital ED regionalization and categorization policies in 2007 and 2009, respectively. There were 1,835,860 ED visits found among one million random samples from the NHIRD between 2005 and 2011. ED visits were categorized by the modified New York University ED algorithm. A time series analysis was performed to examine the change in the rate of appropriate ED use after the policy took effect.Results: Total ED visits increased by 10.7% from 2005 to 2011. Average appropriate ED visit rate was 66.9% during the policy intervention. The trend in the appropriate ED visit rate showed no significant policy effect.Conclusions: Provider side of regionalization and categorization policies did increase emergency care accessibility. However, regionalization and categorization policies no significant effect on patient appropriate ED use.

scholarly journals Emergency care access to primary care records: an observational study

2020 ◽  
Vol 27 (3) ◽  
pp. e100153
Author(s):  
Thomas Bowden ◽  
David Lyell ◽  
Enrico Coiera
Keyword(s):  
Primary Care ◽  
Observational Study ◽  
Hospital Admission ◽  
Emergency Care ◽  
Patient Characteristics ◽  
Care Access ◽  
Process Outcomes ◽  
Primary Care Record ◽  
Access To Primary Care ◽  
The Impact

ObjectiveTo measure lookup rates of externally held primary care records accessed in emergency care and identify patient characteristics, conditions and potential consequences associated with access.MeasuresRates of primary care record access and re-presentation to the emergency department (ED) within 30 days and hospital admission.DesignA retrospective observational study of 77 181 ED presentations over 4 years and 9 months, analysing 8184 index presentations in which patients’ primary care records were accessed from the ED. Data were compared with 17 449 randomly selected index control presentations. Analysis included propensity score matching for age and triage categories.Results6.3% of overall ED presentations triggered a lookup (rising to 8.3% in year 5); 83.1% of patients were only looked up once and 16.9% of patients looked up on multiple occasions. Lookup patients were on average 25 years older (z=−9.180, p<0.001, r=0.43). Patients with more urgent triage classifications had their records accessed more frequently (z=−36.47, p<0.001, r=0.23). Record access was associated with a significant but negligible increase in hospital admission (χ2 (1, n=13 120)=98.385, p<0.001, phi=0.087) and readmission within 30 days (χ2 (1, n=13 120)=86.288, p<0.001, phi=0.081).DiscussionEmergency care clinicians access primary care records more frequently for older patients or those in higher triage categories. Increased levels of inpatient admission and re-presentation within 30 days are likely linked to age and triage categories.ConclusionFurther studies should focus on the impact of record access on clinical and process outcomes and which record elements have the most utility to shape clinical decisions.

scholarly journals Using trigger tools to identify triage errors by ambulance dispatch nurses in Sweden: an observational study

BMJ Open ◽  
2020 ◽  
Vol 10 (3) ◽  
pp. e035004 ◽  
Author(s):  
Douglas Spangler ◽  
Lennart Edmark ◽  
Ulrika Winblad ◽  
Jessica Colldén-Benneck ◽  
Helena Borg ◽  
...  
Keyword(s):  
Primary Care ◽  
Emergency Department ◽  
Decision Support ◽  
Observational Study ◽  
Decision Support System ◽  
Support System ◽  
Emergency Care ◽  
Incident Reporting Systems ◽  
Dispatch Centre ◽  
Reporting Systems

ObjectivesThis study aimed to assess whether trigger tools were useful identifying triage errors among patients referred to non-emergency care by emergency medical dispatch nurses, and to describe the characteristics of these patients.DesignAn observational study of patients referred by dispatch nurses to non-emergency care.SettingDispatch centres in two Swedish regions.ParticipantsA total of 1089 adult patients directed to non-emergency care by dispatch nurses between October 2016 and February 2017. 53% were female and the median age was 61 years.Primary and secondary outcome measuresThe primary outcome was a visit to an emergency department within 7 days of contact with the dispatch centre. Secondary outcomes were (1) visits related to the primary contact with the dispatch centre, (2) provision of care above the primary level (ie, interventions not available at a typical local primary care centre) and (3) admission to hospital in-patient care.ResultsOf 1089 included patients, 260 (24%) visited an emergency department within 7 days. Of these, 209 (80%) were related to the dispatch centre contact, 143 (55%) received interventions above the primary care level and 99 (38%) were admitted to in-patient care. Elderly (65+) patients (OR 1.45, 95% CI 1.05 to 1.98) and patients referred onwards to other healthcare providers (OR 1.58, 95% CI 1.15 to 2.19) had higher likelihoods of visiting an emergency department. Six avoidable patient harms were identified, none of which were captured by existing incident reporting systems, and all of which would have received an ambulance if the decision support system had been strictly adhered to.ConclusionThe use of these patient outcomes in the framework of a Global Trigger Tool-based review can identify patient harms missed by incident reporting systems in the context of emergency medical dispatching. Increased compliance with the decision support system has the potential to improve patient safety.

The impact of an emergency care access point on pediatric attendances at the emergency department: An observational study

2020 ◽  
Vol 38 (2) ◽  
pp. 191-197
Author(s):  
Mireille E.M. Platter ◽  
Roel A.J. Kurvers ◽  
Loes Janssen ◽  
Marjoke M.J. Verweij ◽  
Dennis G. Barten
Keyword(s):  
Emergency Department ◽  
Observational Study ◽  
Emergency Care ◽  
Access Point ◽  
Care Access ◽  
The Impact

scholarly journals Effectiveness of hospital emergency department regionalization and categorization policy on appropriate patient emergency care use: a nationwide observational study in Taiwan

2021 ◽  
Vol 21 (1) ◽  
Author(s):  
Chih-Yuan Lin ◽  
Yue-Chune Lee
Keyword(s):  
Emergency Department ◽  
Health Services ◽  
Observational Study ◽  
Policy Implementation ◽  
Emergency Care ◽  
Research Database ◽  
New York University ◽  
Hospital Emergency ◽  
Visit Rate ◽  
Ed Visits

Abstract Background Emergency department (ED) overcrowding is a health services issue worldwide. Modern health policy emphasizes appropriate health services utilization. However, the relationship between accessibility, capability, and appropriateness of ED use is unknown. Thus, this study aimed to examine the effect of hospital ED regionalization policy and categorization of hospital emergency capability policy (categorization policy) on patient-appropriate ED use. Methods Taiwan implemented a nationwide three-tiered hospital ED regionalization and categorization of hospital emergency capability policies in 2007 and 2009, respectively. We conducted a retrospective observational study on the effect of emergency care policy intervention on patient visit. Between 2005 and 2011, the Taiwan National Health Insurance Research Database recorded 1,835,860 ED visits from 1 million random samples. ED visits were categorized using the Yang-Ming modified New York University-ED algorithm. A time series analysis was performed to examine the change in appropriate ED use rate after policy implementation. Results From 2005 to 2011, total ED visits increased by 10.7%. After policy implementation, the average appropriate ED visit rate was 66.9%. The intervention had no significant effect on the trend of appropriate ED visit rate. Conclusions Although regionalization and categorization policies did increase emergency care accessibility, it had no significant effect on patient-appropriate ED use. Further research is required to improve data-driven policymaking.

scholarly journals Early in-hospital course of critically ill nontrauma patients in a resuscitation room of a German emergency department (OBSERvE2 study)

2021 ◽  
Author(s):  
C. Grahl ◽  
T. Hartwig ◽  
L. Weidhase ◽  
S. Laudi ◽  
S. Petros ◽  
...  
Keyword(s):  
Emergency Department ◽  
Observational Study ◽  
Critically Ill ◽  
Patient Characteristics ◽  
Therapeutic Interventions ◽  
Hospital Treatment ◽  
Critically Ill Patient ◽  
Time Intervals ◽  
Resuscitation Room ◽  
Life Threatening

Abstract Background Management of critically ill nontrauma (CINT) patients in the resuscitation room of the emergency department (ED) is very challenging. Detailed data describing the patient characteristics and management of this population are lacking. This observational study describes the epidemiology, management and outcome in CINT ED patients in the resuscitation room. Methods This prospective, single center observational study included all adult patients who were consecutively admitted to the ED resuscitation room during 2 periods of 1 year (September 2014–August 2015 vs. September 2017– August 2018). Patient characteristics, out-of-hospital/in-hospital treatment, admission-related conditions, time intervals for diagnostics and interventions and outcome were recorded using a self-developed questionnaire. Results A total of 34,303 patients in the first and 35,039 patients in the second study period were admitted to the ED, of whom 532 and 457 patients, respectively, were admitted to the nontrauma resuscitation room due to acute life-threatening conditions. The patient characteristics did not differ significantly between the study periods (male: 58% vs. 59%, age: 68 ± 17 years vs. 65 ± 17 years). Time intervals for diagnostic and therapeutic interventions were similar. The CINT patients during the second study period were treated faster compared to the first study period (end of ED management: 53 ± 33 min vs. 41 ± 24 min, p < 0.0001). The 30-day all-cause mortality was comparable (34.0% vs. 36.3%). Conclusion Observation of critically ill patient management in the ED resuscitation room showed reliable results between both study periods. Structured ED management guidelines for CINT patients may provide comparable results at one institution.

scholarly journals How the COVID-19 pandemic has adversely affected the economics of U.S. emergency care

2020 ◽  
Author(s):  
Jesse M. Pines ◽  
Mark S. Zocchi ◽  
Bernard S. Black ◽  
Rebecca Kornas ◽  
Pablo Celedon ◽  
...  
Keyword(s):  
Emergency Department ◽  
Emergency Medicine ◽  
Observational Study ◽  
Emergency Care ◽  
Moving Averages ◽  
Ed Visits ◽  
National Emergency

ABSTRACTObjectiveWe describe how the coronavirus (COVID-19) pandemic impacted emergency department (ED) economics, acuity, and staffing.MethodsWe conducted an observational study of visits during January to September 2020 compared to 2019 in 136 EDs staffed by a national emergency medicine group. We created ratios of three-week moving averages for 2020 visits, acuity, costs divided by 2019 moving averages, by age and ED size. We tabulated reductions in clinician hours and FTEs compared to early 2020 staffing.Results2020-2019 ED visit ratios declined in March nadiring mid-April for both adults (to 0.60) and children (to 0.30) and rose thereafter but remained below 2019 levels through September 2020. The ratio of adult RVUs/visit rose to 1.1 for adults and 1.2 for children in the early pandemic, falling to 1.04 and 1.1 through September. The ratio of direct salary expenses in freestanding (FSED) and small EDs declined less dramatically than in medium and large EDs. Clinical revenues in medium and large EDs declined more sharply and recovered slowly but plateaued well below 2019 levels. By September 2020, expenses were still higher than revenues for small EDs, similar for FSEDs, and somewhat higher for medium and large EDs. During the pandemic, physician hours fell 15% and APP hours 27% during COVID-19 translating to 174 lost physician and 193 lost APP FTEs.ConclusionThe COVID-19 pandemic reduced ED visits and increased acuity in the first 7 months of the pandemic, leading to a contraction of the ED workforce, and threatening ED economics, more so in small and FSEDs.

scholarly journals TREATMENTS, RESOURCE UTILIZATION, AND OUTCOMES OF COVID-19 PATIENTS PRESENTING TO EMERGENCY DEPARTMENTS ACROSS PANDEMIC WAVES: AN OBSERVATIONAL STUDY BY THE CANADIAN COVID-19 EMERGENCY DEPARTMENT RAPID RESPONSE NETWORK (CCEDRRN)

2021 ◽  
Author(s):  
Corinne M Hohl ◽  
Rhonda J Rosychuk ◽  
Jeffrey P Hau ◽  
Jake Hayward ◽  
Megan Landes ◽  
...  
Keyword(s):  
Emergency Department ◽  
Critical Care ◽  
Observational Study ◽  
Disease Severity ◽  
Acute Care ◽  
Resource Utilization ◽  
Emergency Departments ◽  
Patient Characteristics ◽  
Response Network ◽  
Second Wave

Background: Treatment strategies for coronavirus disease 2019 (COVID-19) evolved between pandemic waves. Our objective was to compare treatments, acute care resource utilization, and outcomes of COVID-19 patients presenting to Emergency Departments across two pandemic waves. Methods: This observational study enrolled consecutive eligible COVID-19 patients presenting to 46 Emergency Departments participating in the Canadian COVID-19 Emergency Department Rapid Response Network (CCEDRRN) between March 1 and December 31, 2020. We collected data by retrospective chart review. Our primary outcome was in-hospital mortality. We used logistic regression modeling to assess the impact of pandemic wave on outcomes. Results: We enrolled 9,967 patients in 8 provinces, 3,336 from the first and 6,631 from the second wave. Patients in the second wave were younger, fewer met criteria for severe COVID-19, and more were discharged from the Emergency Department. Adjusted for patient characteristics and disease severity, steroid use increased (odds ratio [OR] 8.0; 95% confidence interval [CI] 6.4 — 10.0), while the use of invasive mechanical ventilation decreased (OR 0.5; 95%CI 0.4 — 0.6) in the second wave. After adjusting for differences in patient characteristics and disease severity, the odds of hospitalization (OR 0.7; 95%CI 0.6 — 0.8) and critical care admission (OR 0.6; 95%CI 0.4 — 0.7) decreased, while mortality remained unchanged (OR 1.0; 95%CI 0.7-1.4). Interpretation: In patients presenting to Canadian acute care facilities, rapid uptake of steroid therapy was evident. Mortality was stable despite lower critical care utilization in the second wave.

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