scholarly journals Balancing Efficiency and Access: Discouraging Emergency Department Boarding in a Global Budget System

2021 ◽  
Vol 22 (5) ◽  
pp. 1196-1201
Author(s):  
Benoit Stryckman ◽  
Diane Kuhn ◽  
Daniel Gingold ◽  
Kyle Fischer ◽  
J. David Gatz ◽  
...  
Keyword(s):  
Emergency Department ◽  
Safety Net ◽  
The United States ◽  
Unintended Consequences ◽  
Care Providers ◽  
Global Budget ◽  
Ambulance Diversion ◽  
Quality Of Patient Care ◽  
Vulnerable Patient ◽  
Balancing Efficiency

Reducing cost without sacrificing quality of patient care is an important yet challenging goal for healthcare professionals and policymakers alike. This challenge is at the forefront in the United States, where per capita healthcare costs are much higher than in similar countries around the world. The state of Maryland is unique in the hospital financing landscape due to its “capitation” payment system (also known as “global budget”), in which revenue for hospital-based services is set at the beginning of the year. Although Maryland’s system has yielded many benefits, including reduced Medicare spending, it also has had unintentional adverse consequences. These consequences, such as increased emergency department boarding and ambulance diversion, constrain Maryland hospitals’ ability to fulfill their role as emergency care providers and act as a safety net for vulnerable patient populations. In this article, we suggest policy remedies to mitigate the unintended consequences of Maryland’s model that should also prove instructive for a variety of emerging alternative payment mechanisms.

scholarly journals Impact of Medicare’s Hospital-Acquired Condition Policy on Infections in Safety Net and Non–Safety Net Hospitals

2015 ◽  
Vol 36 (6) ◽  
pp. 649-655 ◽  
Author(s):  
Louise Elaine Vaz ◽  
Kenneth P. Kleinman ◽  
Alison Tse Kawai ◽  
Robert Jin ◽  
William J. Kassler ◽  
...  
Keyword(s):  
Bloodstream Infection ◽  
Financial Incentives ◽  
Safety Net ◽  
The United States ◽  
Central Line ◽  
Unintended Consequences ◽  
Infection Rates ◽  
Healthcare Associated Infection ◽  
Hospital Acquired Conditions ◽  
Hospital Acquired

BACKGROUNDPolicymakers may wish to align healthcare payment and quality of care while minimizing unintended consequences, particularly for safety net hospitals.OBJECTIVETo determine whether the 2008 Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy had a differential impact on targeted healthcare-associated infection rates in safety net compared with non–safety net hospitals.DESIGNInterrupted time-series design.SETTING AND PARTICIPANTSNonfederal acute care hospitals that reported central line–associated bloodstream infection and ventilator-associated pneumonia rates to the Centers for Disease Control and Prevention’s National Health Safety Network from July 1, 2007, through December 31, 2013.RESULTSWe did not observe changes in the slope of targeted infection rates in the postpolicy period compared with the prepolicy period for either safety net (postpolicy vs prepolicy ratio, 0.96 [95% CI, 0.84–1.09]) or non–safety net (0.99 [0.90–1.10]) hospitals. Controlling for prepolicy secular trends, we did not detect differences in an immediate change at the time of the policy between safety net and non–safety net hospitals (P for 2-way interaction, .87).CONCLUSIONSThe Centers for Medicare and Medicaid Services Hospital-Acquired Conditions policy did not have an impact, either positive or negative, on already declining rates of central line–associated bloodstream infection in safety net or non–safety net hospitals. Continued evaluations of the broad impact of payment policies on safety net hospitals will remain important as the use of financial incentives and penalties continues to expand in the United States.Infect Control Hosp Epidemiol 2015;00(0): 1–7

scholarly journals Delayed Diagnosis of Acute Rheumatic Fever in a Patient with Multiple Emergency Department Visits

2018 ◽  
Vol 2018 ◽  
pp. 1-4
Author(s):  
Inna Kaminecki ◽  
Renuka Verma ◽  
Jacqueline Brunetto ◽  
Loyda I. Rivera
Keyword(s):  
Emergency Department ◽  
Rheumatic Fever ◽  
Health Care Providers ◽  
Acute Rheumatic Fever ◽  
Group A Streptococcus ◽  
The United States ◽  
Emergency Department Visits ◽  
Penicillin G ◽  
Care Providers ◽  
Group A

While the incidence of acute rheumatic fever (ARF) in the United States has declined over the past years, the disease remains one of the causes of severe cardiovascular morbidity in children. The index of suspicion for ARF in health care providers may be low due to decreasing incidence of the disease and clinical presentation that can mimic other conditions. We present the case of a 5-year-old boy with a history of intermittent fevers, fatigue, migratory joint pain, and weight loss followinggroup A Streptococcuspharyngitis. The patient presented to the emergency department twice with the complaints described above. On his 3rd presentation, the workup for his symptoms revealed the diagnosis of acute rheumatic fever with severe mitral and aortic valve regurgitation. The patient was treated with penicillin G benzathine and was started on glucocorticoids for severe carditis. The patient was discharged with recommendations to continue secondary prophylaxis with penicillin G benzathine every 4 weeks for the next 10 years. This case illustrates importance of primary prevention of acute rheumatic fever with adequate antibiotic treatment ofgroup A Streptococcuspharyngitis. Parents should also receive information and education that a child with a previous attack of ARF has higher risk for a recurrent attack of rheumatic fever. This can lead to development of severe rheumatic heart disease. Prevention of recurrent ARF requires continuous antimicrobial prophylaxis. Follow-up with a cardiologist every 1-2 years is essential to assess the heart for valve damage.

The unintended consequences of The Centers for Medicare and Medicaid Services pay-for-performance structures on safety-net hospitals and the low-income, medically vulnerable population

2016 ◽  
Vol 30 (1) ◽  
pp. 10-15 ◽  
Author(s):  
Elmer B Fos
Keyword(s):  
Low Income ◽  
Pay For Performance ◽  
Safety Net ◽  
Unintended Consequences ◽  
Vulnerable Population ◽  
Financial Viability ◽  
Poor Patient ◽  
Vulnerable Patient ◽  
The Impact ◽  
Patient Mix

Safety-net hospitals are hospitals with patient mix that is substantially composed of the uninsured, underinsured, and low-income, medically vulnerable patient populations. They are the hospitals of last resort for poor patients. This article examined the impact of The Centers for Medicare and Medicaid Services pay-for-performance reimbursement policies on the financial viability of safety-net hospitals. Studies showed that these policies, which are based on the principle of reward and punishment, might have unintentionally placed safety-net hospitals on financial disadvantage compared to other hospital organizations. Several studies implied that these payment structures might have resulted in a situation where safety-net hospitals that are serving poor patient populations become more susceptible to penalties than hospitals that are serving affluent patients.

Treatment of Acute Gout Flares in the Emergency Department: Prescribing Patterns and Revisit Rates

2021 ◽  
pp. 106002802110322
Author(s):  
Luigi Brunetti ◽  
Janaki Vekaria ◽  
Peter E. Lipsky ◽  
Naomi Schlesinger
Keyword(s):  
Health Care ◽  
Emergency Department ◽  
The United States ◽  
Prescribing Patterns ◽  
Care Providers ◽  
Opioid Use ◽  
Hospital Visit ◽  
Opioid Prescription ◽  
Anti Inflammatory ◽  
Gout Flares

Background The incidence and health care costs of gout flares have increased in the United States. The increased costs may be a result of a lack of adherence to treatment guidelines and medication knowledge. Identifying causes for this trend is vital to mitigate inappropriate resource use. Objectives The aim was to identify pharmacotherapy use related to gout treatment before, during hospital visit or stay, and on discharge in patients presenting to the emergency department (ED) with gout flares. Secondary end points included opioid use, revisit rates, and associated risk factors. Methods We performed a retrospective cohort study at a community teaching hospital ED. All consecutive patients visiting the ED from January 2016 to July 2019 with a primary diagnosis of gout flare were included. Data were extracted from the electronic medical records. Results The analysis included 214 patients. Anti-inflammatory medication was not prescribed in 33.6% during the hospital visit and 29.6% of patients on discharge. History of opioid use (odds ratio [OR] = 3.3; 95% CI = 1.3-8.6; P = 0.014) and gastroesophageal reflux disease (OR = 3.5; 95% CI = 1.09-10.9; P = 0.035) were associated with opioid prescription on discharge. ED revisits within 90 days for any gout-related or non–gout-related cause were recorded in 16.8% of patients. Conclusion and Relevance Roughly 30% of patients did not receive an anti-inflammatory on discharge, and opioids were frequently overused in gout management in the ED. There is an opportunity for further education of health care providers regarding gout treatment.

scholarly journals Surveillance for colorectal cancer survivors in an integrated safety-net health system in the United States

2018 ◽  
Vol 21 (1-2) ◽  
pp. 26-35 ◽  
Author(s):  
Bijal A Balasubramanian ◽  
Katelyn K Jetelina ◽  
Michael Bowen ◽  
Noel O Santini ◽  
Simon Craddock Lee
Keyword(s):  
Colorectal Cancer ◽  
United States ◽  
Primary Care ◽  
Health Insurance ◽  
Cancer Recurrence ◽  
Safety Net ◽  
The United States ◽  
Cancer Surveillance ◽  
Care Providers ◽  
Colorectal Cancer Surveillance

Introduction Guideline-recommended surveillance reduces the likelihood of colorectal cancer recurrence, yet surveillance rates are low in the United States. Little is known about colorectal cancer surveillance rates among patients without health insurance and their primary care clinicians/oncologists’ attitudes toward surveillance care. Methods A retrospective study of 205 patients diagnosed with Stage I–III colorectal cancer from 2008 to 2010 was conducted in an integrated system with a network of clinics and health care providers, delivering care to patients lacking health insurance coverage. Surveillance patterns were characterized from medical records, and logistic regression models examined correlates of guideline-concordant surveillance. Forty-four Parkland primary care physicians (PCPs) and 24 oncologists completed surveys to assess their attitudes and practices regarding colorectal cancer surveillance. Results Thirty-eight percent of colorectal cancer patients received guideline-concordant surveillance; those with early stage cancers were less likely to receive surveillance (odds ratio = 0.35; 95 confidence interval: 0.14, 0.87). PCPs and oncologists differed markedly on who is responsible for cancer surveillance care. Seventy-seven percent of oncologists responded that PCPs evaluated patients for cancer recurrence, while 76% of PCPs responded that these services were either ordered by oncologists or shared with PCPs. Sixty-seven percent of oncologists said that they rarely provide a treatment and surveillance care plan to survivors, and over half said that they infrequently communicate with patients’ other physicians about who will follow patients for their cancer and other medical issues. Discussion Care coordination between PCP and oncologist is needed to improve colorectal cancer surveillance. New models of shared care clearly delineating roles for oncologists and PCPs are needed to improve colorectal cancer survivorship care.

scholarly journals Perceived barriers to Chagas disease screening among a diverse group of prenatal care providers

PLoS ONE ◽  
2021 ◽  
Vol 16 (2) ◽  
pp. e0246783
Author(s):  
Helen Mahoney West ◽  
Carly E. Milliren ◽  
Olivera Vragovic ◽  
Julia R. Köhler ◽  
Christina Yarrington
Keyword(s):  
Family Medicine ◽  
Prenatal Care ◽  
Chagas Disease ◽  
Safety Net ◽  
The United States ◽  
Disease Screening ◽  
Perceived Barriers ◽  
Care Providers ◽  
Safety Net Hospital ◽  
Prenatal Care Providers

Background Chagas disease is a vector borne infection of poverty endemic to Latin America which affects an estimated 40,000 women of child-bearing age in the United States (US). In the US Chagas disease is concentrated among individuals who have lived in endemic areas. Prenatal diagnosis and treatment are needed to prevent congenital transmission. The objective of this study was to assess perceived barriers to Chagas disease screening among prenatal care providers in Obstetrics/Gynecology and Family Medicine Departments of a tertiary care safety-net hospital caring for a significant at-risk population. Methodology/Principal findings An anonymous survey was distributed to 178 Obstetrics/Gynecology and Family Medicine practitioners. Of the 66 respondents, 39% thought Chagas screening was very important, and 48% somewhat important as a public health initiative. One third judged screening patients during clinic visits as very important. Most respondents (64%) reported being familiar with Chagas disease. However, only 32% knew how to order a test and only 22% reported knowing what to do if a test was positive. Conclusions/Significance These findings will be incorporated into measures to facilitate full implementation of Chagas screening, and can inform initiatives at other centers who wish to address this deeply neglected infection among their patient families. Greater integration of information on Chagas disease screening and treatment in medical and nursing education curricula can contribute to addressing this disease with the focus that its potentially fatal sequelae merit.

Unscheduled re-attendances to a paediatric Emergency Department: an audit

2010 ◽  
Vol 27 (Suppl 1) ◽  
pp. A9.3-A10
Author(s):  
Lisa Black
Keyword(s):  
Emergency Department ◽  
High Risk ◽  
High Risk Patient ◽  
Primary Care Providers ◽  
Safety Net ◽  
Upper Respiratory Tract ◽  
Periodic Review ◽  
Care Providers ◽  
Paediatric Emergency Department ◽  
Paediatric Emergency

IntroductionUnscheduled re-attendances (UR) continue to pose a problem to the Paediatric Emergency Department (PED) and there is paucity of research on this topic. 5% of PED attendances are UR.1 Although some are inevitable, it is important to identify strategies to minimise such attendances.ObjectivesTo estimate the size of the problem, identify high risk patient groups and determine other factors (system or doctor) related to UR within an inner city PED.MethodsAll patients under the age of 17, who reattended within 72 h, over a 28-day period, were identified and their Emergency Department notes reviewed.Results91 children were identified, which represented an UR rate of 3.88%, of which 69 (76%) were under 5 years old. Gastroenteritis (GE) and upper respiratory tract infection (URTI) were the predominant causes of UR. 67% of children were assessed by a junior doctor (JD {< ST2}) on initial presentation. On re-attendance, 74% were again assessed by a JD contrary to department policy and on both occasions less than half were discussed with a senior doctor. Only 70% were discharged with a documented safety net advising appropriate re-attendance. Four children had a revised diagnosis on re-attendance and 22% were ultimately admitted.ConclusionsUR is an important performance indicator and a periodic review should be a part of clinical governance activity. High risk groups for UR were <5 s, GE and URTI. We suggest that improved discharge information for parents with expected disease course, better supervision of JD / initial senior review and better collaboration with primary care providers may decrease such UR.

scholarly journals Reasons for Opioid Discontinuation and Unintended Consequences Following Opioid Discontinuation Within the TOPCARE Trial

Pain Medicine ◽  
2018 ◽  
Vol 20 (7) ◽  
pp. 1330-1337 ◽  
Author(s):  
Jawad M Husain ◽  
Marc LaRochelle ◽  
Julia Keosaian ◽  
Ziming Xuan ◽  
Karen E Lasser ◽  
...  
Keyword(s):  
Primary Care ◽  
Primary Care Providers ◽  
Safety Net ◽  
Opioid Therapy ◽  
Unintended Consequences ◽  
Care Providers ◽  
Opioid Use ◽  
Opioid Prescribing ◽  
Ed Visits

Abstract Objective To identify reasons for opioid discontinuation and post-discontinuation outcomes among patients in the Transforming Opioid Prescribing in Primary Care (TOPCARE) study. Design In TOPCARE, an intervention to improve adherence to opioid prescribing guidelines, randomized intervention primary care providers (PCPs) received nurse care manager support, an electronic registry, academic detailing, and electronic tools, and control PCPs received electronic tools only. Setting Four Boston safety net primary care practices. Subjects Patients in both TOPCARE study arms who discontinued opioid therapy during the trial. Methods Through chart review, we examined the reason for discontinuation and post-discontinuation outcomes: one or more PCP visits, one or more pain-related emergency department (ED) visits, evidence of opioid use disorder (OUD), and referral for OUD treatment. Results Opioid discontinuations occurred in 83/586 (14.2%) intervention and 42/399 (10.5%) control patients (P = 0.09). Among patients who discontinued opioids, 81 (65%) discontinued for misuse, with no difference by group (P = 0.38). Aberrancy in monitoring (e.g., discordant urine drug test results) was the most common type of misuse prompting discontinuation (occurring in (51/83 [61%] of intervention patients vs 19/42 [45%, P = 0.08] of control patients). Intervention patients who discontinued opioids had less PCP follow-up (65% vs 88%, P < 0.01) compared with control patients. We found no differences between groups for pain-related ED visits, evidence of OUD, or OUD treatment referral following discontinuation. Conclusions The decreased follow-up among TOPCARE intervention patients who discontinued opioids highlights the need to understand unintended consequences of involuntary opioid discontinuations resulting from interventions to reduce opioid risk.

scholarly journals 1292. Integrating HIV and Hepatitis C Screening in a High-Risk Emergency Department Population

2019 ◽  
Vol 6 (Supplement_2) ◽  
pp. S466-S466
Author(s):  
Tasleem Chechi ◽  
Nam Tran ◽  
Allyson C Sage ◽  
Sarah Waldman ◽  
Larissa S May
Keyword(s):  
Emergency Department ◽  
Hepatitis C ◽  
Universal Screening ◽  
Safety Net ◽  
The United States ◽  
High Rate ◽  
Molecular Testing ◽  
Newly Diagnosed ◽  
Opt Out ◽  
Hcv Screening

Abstract Background With the acceleration of the hepatitis C (HCV) epidemic in the United States and the ongoing public health impact of undetected human immunodeficiency virus (HIV) co-infection, there is a critical need for enhanced secondary prevention efforts where patients accessing care are not routinely screened. The purpose of this program was to implement routine opt-out HIV and HCV screenings in a high-volume urban emergency department (ED) through the use of an EMR enhancement to increase a provider’s likelihood of testing eligible patients, and to provide linkage to care for patients identified to have positive tests. Methods From November 27, 2018 to March 31, 2019, EMR-based HIV and HCV screening was implemented in a quaternary care ED in Northern California. EMR best practice alerts were developed based on a combination of local and CDC guidelines and populated on registered patients receiving blood laboratories or receiving STI testing. Laboratory HIV/HCV screening utilized a unique two-specimen collection scheme to enable molecular testing without requiring patient return visits. Patients were excluded if they chose to opt out from testing or the provider deemed opt out was not possible. Upon notification of a positive test result through the EMR, a patient navigator was responsible for providing disease education and linking patients to care. Results The prevalence of HCV antibody positivity was 9.6% (637/6,627) and 0.97% (55/5,628) for HIV. Of the 255 HCV-RNA positives, 110 were known and 145 newly diagnosed. Of the 90 HIV patients, 31 were known and 8 newly diagnosed. Although current CDC hepatitis C screening guidelines recommend screening all adults born during 1945–1965, we conducted universal screening of adults 18 years or older. Of those screened antibody-positive for HCV 64% fell within the 1945–1965 birth cohort. Conclusion Introducing routine opt-out testing using an automated EMR-based screening program is an effective method to identify and screen eligible patients for HIV and HCV in episodic care safety net settings where universal screenings are not routinely implemented. The unexpectedly high rate of HIV seroprevalence suggests the ED environment continues to be an important setting to access populations not receiving routine care despite longstanding CDC recommendations for universal screening. Disclosures All authors: No reported disclosures.

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