How to Uncover Sources of Unwarranted Practice Variation: A Case Study in Emergency Medicine

Forty years of statistical database analyses have demonstrated the existence of unwarranted practice variation in care delivery, that is, variations independent of medical need, evidence, or patient preference. Alas, little is known about the underlying mechanisms and thus finding interventions to reduce unwarranted variations remains difficult, hampering quality, equity, and efficiency of care. Whereas statistical analyses describe deviations from ideal patterns, ethnographically inspired analyses aim at understanding when, how, and why variations occur in practice. Based on case studies derived from shadowing emergency physicians, I demonstrate that analyzing practice variation in practice helps to (a) advance the understanding of mechanisms and (b) evaluate/expand the existing repertoire of interventions. Results revealed unmet expectations and new sources of known variations as well as interventions complementing systemic changes with those that empower individuals to better cope with the existing system. These findings highlight the benefits of mixed-methods for understanding and tackling practice variation.

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Defining emergency telehealth

Journal of Telemedicine and Telecare ◽

10.1177/1357633x19891653 ◽

2019 ◽

pp. 1357633X1989165

Author(s):

Neal Sikka ◽

Hartmut Gross ◽

Aditi U Joshi ◽

Edward Shaheen ◽

Michael J Baker ◽

...

Keyword(s):

Emergency Medicine ◽

Emergency Services ◽

Care Delivery ◽

Quality Care ◽

Cost Effective ◽

Public Health Care ◽

Emergency Physicians ◽

Working Definition ◽

Effective Manner ◽

Definition Of

The American College of Emergency Physicians Emergency Telehealth Section was charged with development of a working definition of emergency telehealth that aligns with the College’s definition of emergency medicine. A modified Delphi method was used by the section membership who represented telehealth providers in both private and public health-care delivery systems, academia and industry, rural and urban settings. Presented in this manuscript is the final definition of emergency telehealth developed with an additional six clarifying statements to address the context of the definition. Emergency telehealth is a core domain of emergency medicine and is inclusive of remotely providing all types of care for acute conditions of any kind requiring expeditious care irrespective of any prior relationship. The development of this definition is important to the global community of emergency physicians and all patients seeking acute care to ensure that appropriately trained clinicians are providing the highest quality of emergency services via the telehealth modality. We recommend implementing emergency telehealth in a manner that ensures appropriate qualifications of providers, appropriate/parity reimbursement for telehealth services and, most importantly, the delivery of quality care to patients in a safe, efficient, timely and cost-effective manner.

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Association between Green Space Structure and the Prevalence of Asthma: A Case Study of Toronto

International Journal of Environmental Research and Public Health ◽

10.3390/ijerph18115852 ◽

2021 ◽

Vol 18 (11) ◽

pp. 5852

Author(s):

Yuping Dong ◽

Helin Liu ◽

Tianming Zheng

Keyword(s):

Air Pollution ◽

Vegetation Index ◽

Green Space ◽

Normalized Difference Vegetation Index ◽

Chronic Inflammatory Disease ◽

Space Structure ◽

Tree Diversity ◽

Underlying Mechanisms ◽

Index Tree

Asthma is a chronic inflammatory disease that can be caused by various factors, such as asthma-related genes, lifestyle, and air pollution, and it can result in adverse impacts on asthmatics’ mental health and quality of life. Hence, asthma issues have been widely studied, mainly from demographic, socioeconomic, and genetic perspectives. Although it is becoming increasingly clear that asthma is likely influenced by green spaces, the underlying mechanisms are still unclear and inconsistent. Moreover, green space influences the prevalence of asthma concurrently in multiple ways, but most existing studies have explored only one pathway or a partial pathway, rather than the multi-pathways. Compared to greenness (measured by Normalized Difference Vegetation Index, tree density, etc.), green space structure—which has the potential to impact the concentration of air pollution and microbial diversity—is still less investigated in studies on the influence of green space on asthma. Given this research gap, this research took Toronto, Canada, as a case study to explore the two pathways between green space structure and the prevalence of asthma based on controlling the related covariates. Using regression analysis, it was found that green space structure can protect those aged 0–19 years from a high risk of developing asthma, and this direct protective effect can be enhanced by high tree diversity. For adults, green space structure does not influence the prevalence of asthma unless moderated by tree diversity (a measurement of the richness and diversity of trees). However, this impact was not found in adult females. Moreover, the hypothesis that green space structure influences the prevalence of asthma by reducing air pollution was not confirmed in this study, which can be attributed to a variety of causes.

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The International Federation for Emergency Medicine report on emergency department crowding and access block: a brief summary

International Journal of Emergency Medicine ◽

10.1186/s12245-020-00312-x ◽

2021 ◽

Vol 14 (1) ◽

Author(s):

A. P. Javidan ◽

◽

K. Hansen ◽

I. Higginson ◽

P. Jones ◽

...

Keyword(s):

Emergency Department ◽

Emergency Medicine ◽

Task Force ◽

Video Conferencing ◽

International Federation ◽

Emergency Physicians ◽

Emergency Department Crowding ◽

Comprehensive Guidance ◽

The World ◽

Ed Crowding

Abstract Objective To develop comprehensive guidance that captures international impacts, causes, and solutions related to emergency department crowding and access block Methods Emergency physicians representing 15 countries from all IFEM regions composed the Task Force. Monthly meetings were held via video-conferencing software to achieve consensus for report content. The report was submitted and approved by the IFEM Board on June 1, 2020. Results A total of 14 topic dossiers, each relating to an aspect of ED crowding, were researched and completed collaboratively by members of the Task Force. Conclusions The IFEM report is a comprehensive document intended to be used in whole or by section to inform and address aspects of ED crowding and access block. Overall, ED crowding is a multifactorial issue requiring systems-wide solutions applied at local, regional, and national levels. Access block is the predominant contributor of ED crowding in most parts of the world.

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P026: Need for training in medical education: staff emergency physician perspectives

CJEM ◽

10.1017/cem.2017.228 ◽

2017 ◽

Vol 19 (S1) ◽

pp. S86

Author(s):

J. Bryan ◽

F. Al Rawi ◽

T. Bhandari ◽

J. Chu ◽

S. Hansen ◽

...

Keyword(s):

Emergency Medicine ◽

Medical Education ◽

Adult Education ◽

Family Medicine ◽

Graduate Training ◽

Formal Training ◽

Emergency Physicians ◽

Allied Health Professionals ◽

Evaluation Time ◽

Post Graduate Training

Introduction: Emergency medicine physicians in our urban/suburban area have a range of training in medical education; some have no formal training in medical education, whereas others have completed Master’s level training in adult education. Not all staff have a university appointment; of those who are affiliated with our university, 87 have appointments through the Department of Medicine, 21 through the Department of Pediatrics, and 117 through the Department of Family Medicine. Emergency physicians in our area are a diverse group of physicians in terms of both formal training in adult education and in the variety of settings in which we work. The purpose of this study was to gauge interest in formal training in adult education among emergency medicine physicians. Methods: With research ethics board approval, we created and sent a 10-item electronic questionnaire to emergency medicine staff in our area. The questionnaire included items on demographics, experience in emergency medicine, additional post-graduate training, current teaching activities and interest in short (30-60 minute) adult education sessions. Results: Of a potential 360 active emergency physicians in our area, 120 responded to the questionnaire (33.3%), representing 12 area hospitals. Nearly half of respondents had been in practice over 10 years (48.44%). Respondents were mainly FRCP (50%) or CCFP-EM (47.50%) trained. 33.3% of respondents had masters degrees, of which 15% were MEd. Most physicians were involved in teaching medical students (98.33%), FRCP residents (80%) and family medicine residents (88.3%), though many were also teaching off-service residents, and allied health professionals. More than half of respondents (60%) were interested in attending short sessions to improve their skills as adult educators. The topics of most interest were feedback and evaluation, time-efficient teaching, the learner in difficulty, case-based teaching and bedside teaching. Conclusion: Emergency physicians in our area have a wide variety of experience and training in medical education. They are involved in teaching learners from a range of training levels and backgrounds. Physicians who responded to our survey expressed an interest in additional formal teaching on adult education topics geared toward emergency medicine.

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Is Sexual Conflict a Driver of Speciation? A Case Study With a Tribe of Brush-footed Butterflies

Systematic Biology ◽

10.1093/sysbio/syaa070 ◽

2020 ◽

Author(s):

Ana Paula S Carvalho ◽

Ryan A St Laurent ◽

Emmanuel F A Toussaint ◽

Caroline Storer ◽

Kelly M Dexter ◽

...

Keyword(s):

Sexual Conflict ◽

Abiotic Factors ◽

Evolutionary Mechanisms ◽

Diversification Rates ◽

Exon Capture ◽

Key Driver ◽

Underlying Mechanisms ◽

Analytical Approaches ◽

Acting In Concert

Abstract Understanding the evolutionary mechanisms governing the uneven distribution of species richness across the tree of life is a great challenge in biology. Scientists have long argued that sexual conflict is a key driver of speciation. This hypothesis, however, has been highly debated in light of empirical evidence. Recent advances in the study of macroevolution make it possible to test this hypothesis with more data and increased accuracy. In the present study, we use phylogenomics combined with four different diversification rate analytical approaches to test whether sexual conflict is a driver of speciation in brush-footed butterflies of the tribe Acraeini. The presence of a sphragis, an external mating plug found in most species among Acraeini, was used as a proxy for sexual conflict. Diversification analyses statistically rejected the hypothesis that sexual conflict is associated with shifts in diversification rates in Acraeini. This result contrasts with earlier studies and suggests that the underlying mechanisms driving diversification are more complex than previously considered. In the case of butterflies, natural history traits acting in concert with abiotic factors possibly play a stronger role in triggering speciation than does sexual conflict. [Acraeini butterflies; arms race; exon capture phylogenomics; Lepidoptera macroevolution; sexual selection; sphragis.]

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Quality improvement primer part 2: executing a quality improvement project in the emergency department

CJEM ◽

10.1017/cem.2017.393 ◽

2017 ◽

Vol 20 (4) ◽

pp. 532-538 ◽

Cited By ~ 9

Author(s):

Lucas B. Chartier ◽

Antonia S. Stang ◽

Samuel Vaillancourt ◽

Amy H. Y. Cheng

Keyword(s):

Health Care ◽

Emergency Department ◽

Emergency Medicine ◽

Quality Improvement ◽

Improvement Project ◽

Emergency Department Setting ◽

Pdsa Cycle ◽

Time To Antibiotics ◽

Final Article

ABSTRACTThe topics of quality improvement (QI) and patient safety have become important themes in health care in recent years, particularly in the emergency department setting, which is a frequent point of contact with the health care system for patients. In the first of three articles in this series meant as a QI primer for emergency medicine clinicians, we introduced the strategic planning required to develop an effective QI project using a fictional case study as an example. In this second article we continue with our example of improving time to antibiotics for patients with sepsis, and introduce the Model for Improvement. We will review what makes a good aim statement, the various categories of measures that can be tracked during a QI project, and the relative merits and challenges of potential change concepts and ideas. We will also present the Model for Improvement’s rapid-cycle change methodology, the Plan-Do-Study-Act (PDSA) cycle. The final article in this series will focus on the evaluation and sustainability of QI projects.

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Magnetic resonance imaging as a case study of cost factors in high-technology health care delivery

10.1117/12.195439 ◽

1994 ◽

Author(s):

Leon Kaufman

Keyword(s):

Magnetic Resonance Imaging ◽

Health Care ◽

Magnetic Resonance ◽

Health Care Delivery ◽

Care Delivery ◽

High Technology ◽

Resonance Imaging ◽

Cost Factors

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Health system characteristics of quality care delivery: A comparative case study examination of palliative care for cancer patients in four regions in Ontario, Canada

Palliative Medicine ◽

10.1177/0269216311416697 ◽

2011 ◽

Vol 26 (4) ◽

pp. 322-335 ◽

Cited By ~ 17

Author(s):

Jonathan Sussman ◽

Lisa Barbera ◽

Daryl Bainbridge ◽

Doris Howell ◽

Jinghao Yang ◽

...

Keyword(s):

Palliative Care ◽

Health System ◽

Acute Care ◽

Pattern Analysis ◽

Care Delivery ◽

Quality Care ◽

Structural Features ◽

Comparative Case Study ◽

Care Utilization

Background: A number of palliative care delivery models have been proposed to address the structural and process gaps in this care. However, the specific elements required to form competent systems are often vaguely described. Aim: The purpose of this study was to explore whether a set of modifiable health system factors could be identified that are associated with population palliative care outcomes, including less acute care use and more home deaths. Design: A comparative case study evaluation was conducted of ‘palliative care’ in four health regions in Ontario, Canada. Regions were selected as exemplars of high and low acute care utilization patterns, representing both urban and rural settings. A theory-based approach to data collection was taken using the System Competency Model, comprised of structural features known to be essential indicators of palliative care system performance. Key informants in each region completed study instruments. Data were summarized using qualitative techniques and an exploratory factor pattern analysis was completed. Results: 43 participants (10+ from each region) were recruited, representing clinical and administrative perspectives. Pattern analysis revealed six factors that discriminated between regions: overall palliative care planning and needs assessment; a common chart; standardized patient assessments; 24/7 palliative care team access; advanced practice nursing presence; and designated roles for the provision of palliative care services. Conclusions: The four palliative care regional ‘systems’ examined using our model were found to be in different stages of development. This research further informs health system planners on important features to incorporate into evolving palliative care systems.

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