Dr. Michelle Lin is an emergency physician-scientist working to make emergency care more patient-centered, accessible, and equitable. Her active NIH-funded research projects develop new quality measures based on what matters most to patients; improve post-ED discharge care for high risk patients; and enhance physician diversity and retention. Her prior funded work has evaluated the impact of value-based care on emergency care delivery and payment; drivers of hospitalization during ED visits; and changes in the intensity of emergency care.

Dr. Lin leads the development of quality measures used nationally by emergency physicians in federally mandated payment programs through her leadership roles in the American College of Emergency Physicians and Clinical Emergency Data Registry. She is the sole emergency physician appointed to the All-Cause Admissions and Readmissions Standing Committee, with responsibility for issuing endorsement recommendations for all admissions and readmissions quality measures to CMS and other national regulatory bodies. She was previously a fellow and external consultant to the Centers for Medicare and Medicaid Innovation on projects evaluating access to care within advanced alternative payment models.

Dr. Lin has received several national awards for her work, including the 2021 Society for Academic Emergency Medicine Young Investigator Award and 2016 AcademyHealth Presidential Scholarship for New Health Services Researchers. She completed residency at Bellevue Hospital Center in New York City and fellowship in Health Policy Research at Brigham and Women's Hospital and Harvard Medical School, where she also completed a Masters in Clinical Epidemiology at the Harvard T.H. Chan School of Public Health.

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Clinical Focus

  • Emergency Medicine

Academic Appointments

Administrative Appointments

  • Chair, Clinical Emergency Data Registry Committee (Vice Chair and Chair-Elect 2018-2020), American College of Emergency Physicians (2018 - 2022)
  • Co-Chair, Quality Measure Lifecycle Management Workgroup, Quality and Patient Safety Committee, American College of Emergency Physicians (2019 - Present)

Honors & Awards

  • Distinguished Scholar Award, Office of Gender Equity in Science and Medicine, Icahn School of Medicine at Mount Sinai (2022)
  • Early Career Investigator Award, Society for Academic Emergency Medicine (2021)
  • Rising Star Researcher, New York American College of Emergency Physicians (2021)
  • Junior Faculty Award for Overall Academic Excellence, Faculty Council, Icahn School of Medicine at Mount Sinai (2020)
  • 45 Under 45 Top National Influencers in Emergency Medicine, Emergency Medicine Residents' Association (2019)
  • Academy for Women in Academic Emergency Medicine Momentum Award, Academy for Women in Academic Emergency Medicine, Society for Academic Emergency Medicine (2019)
  • Presidential Scholarship for New Health Services Researchers, AcademyHealth (2016)
  • Best Poster, Patient-Centered Outcomes and Comparative Effectiveness Research Day, Brigham and Women's Hospital, Harvard Medical School (2015)
  • Visiting Scholar, Inaugural Class, American Board of Medical Specialties (2014)
  • Winning Innovation, Teaching Value and Choosing Wisely Competition, American Board of Internal Medicine Foundation. (2013)

Boards, Advisory Committees, Professional Organizations

  • Quality and Value Interest Group Advisory Committee, AcademyHealth (2023 - Present)
  • Board of Governors, Emergency Medicine Data Institute, American College of Emergency Physicians (2022 - Present)
  • Editorial Board, Academic Emergency Medicine Journal (2021 - Present)
  • Executive Council (Vice President for Communications 2019-2021, Secretary 2021-2022), Academy for Women in Academic Emergency Medicine (2019 - 2022)

Professional Education

  • Fellowship, Brigham and Women's Hospital and Harvard Medical School, Health Policy Research
  • Residency, New York University and Bellevue Hospital Center, Emergency Medicine
  • MPH, Northwestern University, Public Health
  • MD, Northwestern University, Medicine
  • Masters, Harvard School of Public Health, Clinical Epidemiology

Research Interests

  • Diversity and Identity
  • Professional Development
  • Research Methods

Current Research and Scholarly Interests

Dr. Lin's active NIH-funded research portfolio includes developing a novel patient-reported outcome measure for emergency asthma care; evaluating post-acute transitions and outcomes for high-risk populations; and enhancing health professions workforce diversity and retention. Her prior funded projects have evaluated the impact of value-based care on emergency care delivery and payment; drivers of ED admission rates; and changes in the intensity of emergency care.

2023-24 Courses

Stanford Advisees

All Publications

  • The Clinical Emergency Data Registry: Structure, Use, and Limitations for Research. Annals of emergency medicine Lin, M. P., Sharma, D., Venkatesh, A., Epstein, S. K., Janke, A., Genes, N., Mehrotra, A., Augustine, J., Malcolm, B., Goyal, P., Griffey, R. T. 2024


    The Clinical Emergency Data Registry (CEDR) is a qualified clinical data registry that collects data from participating emergency departments (EDs) in the United States for quality measurement, improvement, and reporting purposes. This article aims to provide an overview of the data collection and validation process, describe the existing data structure and elements, and explain the potential opportunities and limitations for ongoing and future research use. CEDR data are primarily collected for quality reporting purposes and are obtained from diverse sources, including electronic health records and billing data that are de-identified and stored in a secure, centralized database. The CEDR data structure is organized around clinical episodes, which contain multiple data elements that are standardized using common data elements and are mapped to established terminologies to enable interoperability and data sharing. The data elements include patient demographics, clinical characteristics, diagnostic and treatment procedures, and outcomes. Key limitations include the limited generalizability due to the selective nature of participating EDs and the limited validation and completeness of data elements not currently used for quality reporting purposes, including demographic data. Nonetheless, CEDR holds great potential for ongoing and future research in emergency medicine due to its large-volume, longitudinal, near real-time, clinical data. In 2021, the American College of Emergency Physicians authorized the transition from CEDR to the Emergency Medicine Data Institute, which will catalyze investments in improved data quality and completeness for research to advance emergency care.

    View details for DOI 10.1016/j.annemergmed.2023.12.014

    View details for PubMedID 38276937

  • Barriers and Best Practices for the Use of Patient-Reported Outcome Measures in Emergency Medicine. Annals of emergency medicine Lin, M. P., Kligler, S. K., Friedman, B. W., Kim, H., Rising, K., Samuels-Kalow, M., Eucker, S. A. 2023


    Patient-reported outcome measures are commonly used in clinical trials and have been incorporated into routine clinical care in select specialties but have not been widely implemented in emergency medicine research and clinical care. We describe measurement-related barriers to patient-reported outcome measure use in the emergency department; administrative and practical considerations; implications of developing novel emergency medicine-specific patient-reported outcome measures; and key considerations for the use of patient-reported outcome measures in emergency medicine research and clinical care. Despite the unique barriers of the ED environment, potential solutions include the use of ED-validated patient-reported outcome measures when available; adapting existing short-form, multidimensional patient-reported outcome measures previously validated in diverse populations, ideally using computer-adapted testing; and collecting responses during anticipated wait times. With this work, we aim to inform barriers and best practices to the use of patient-reported outcome measures in emergency medicine research and clinical care to support future, more widespread implementation of patient-reported outcome measures within emergency care. The successful adoption of patient-reported outcome measures for diverse ED patient populations within the unique constraints of the acute care environment may help researchers, clinicians, and policymakers improve the quality and patient-centeredness of acute care.

    View details for DOI 10.1016/j.annemergmed.2022.12.017

    View details for PubMedID 36682996

  • A Quality Framework to Address Racial and Ethnic Disparities in Emergency Department Care. Annals of emergency medicine Khidir, H., Salhi, R., Sabbatini, A. K., Franks, N. M., Green, A., Richardson, L. D., Terry, A., Vasquez, N., Goyal, P., Kocher, K., Venkatesh, A. K., Lin, M. P. 2022


    The emergency department serves as a vital source of health care for residents in the United States, including as a safety net. However, patients from minoritized racial and ethnic groups have historically experienced disproportionate barriers to accessing health care services and lower quality of services than White patients. Quality measures and their application to quality improvement initiatives represent a critical opportunity to incentivize health care systems to advance health equity and reduce health disparities. Currently, there are no nationally recognized quality measures that track the quality of emergency care delivery by race and ethnicity and no published frameworks to guide the development and prioritization of quality measures to reduce health disparities in emergency care. To address these gaps, the American College of Emergency Physicians (ACEP) convened a working group of experts in quality measurement, health disparities, and health equity to develop guidance on establishing quality measures to address racial and ethnic disparities in the provision of emergency care. Based on iterative discussion over 3 working group meetings, we present a summary of existing emergency medicine quality measures that should be adapted to track racial and ethnic disparities, as well as a framework for developing new measures that focus on disparities in access to emergency care, care delivery, and transitions of care.

    View details for DOI 10.1016/j.annemergmed.2022.08.010

    View details for PubMedID 36257864

  • Decline in US Emergency Department admission rates driven by critical pathway conditions, 2006-2014 AMERICAN JOURNAL OF EMERGENCY MEDICINE Lin, M. P., Baker, O., Richardson, L. D., Schuur, J. D. 2022; 59: 94-99


    Despite increasing ED visits, evidence suggests overall hospitalization rates have decreased; however, it is unknown what clinical conditions account for these changes. We aim to describe condition-specific trends and hospital-level variation in hospitalization rates after ED visits from 2006 to 2014.Retrospective observational study of adult ED visits to U.S. acute care hospitals using nationally weighted data from the 2006-2014 National Emergency Department Survey. Our primary outcome was ED admission rate, defined as the number of admissions originating in the ED divided by the number of ED visits. We report admission rates overall and for each condition, including changes over time. We used logistic regression to compare the odds of ED admission from 2006 to 2014, adjusting for patient and hospital characteristics. We also measured hospital-level variation by calculating hospital-level median ED admission rates and interquartile ranges.After adjusting for patient and hospital characteristics, the odds of ED admission for any condition were 0.49 (CI 0.45, 0.52) in 2014 compared to 2006. The conditions with the greatest relative change in ED admission rates were chest pain (21.7 to 7.5%) and syncope (28.9 to 13.8%). The decline in ED admission rates were accompanied by increased variation in hospital-level ED admission rates.Recent reductions in ED admissions are largely attributable to decreased admissions for conditions amenable to outpatient critical pathways. Focusing on hospitals with persistently above-average ED admission rates may be a promising approach to improve the value of acute care.

    View details for DOI 10.1016/j.ajem.2022.06.036

    View details for Web of Science ID 000835545500006

    View details for PubMedID 35816838

  • Ambulatory Follow-up and Outcomes Among Medicare Beneficiaries After Emergency Department Discharge JAMA NETWORK OPEN Lin, M. P., Burke, R. C., Orav, E., Friend, T. H., Burke, L. G. 2020; 3 (10): e2019878


    Ambulatory follow-up care is frequently recommended after an emergency department (ED) visit. However, the frequency with which follow-up actually occurs and the degree to which follow-up is associated with postdischarge outcomes is unknown.To examine the frequency and variation in ambulatory follow-up among Medicare beneficiaries discharged from US EDs and the association between ambulatory follow-up and postdischarge outcomes.This cohort study of 9 470 626 ED visits to 4728 US EDs among Medicare beneficiaries aged 65 and older from 2011 to 2016 who survived the ED visit and were discharged to home used Kaplan-Meier curves and proportional hazards regression. Data analysis was conducted from December 2019 to July 2020.Ambulatory follow-up after discharge from the ED.Postdischarge mortality, subsequent ED visit, or inpatient hospitalization within 30 days of an index ED visit.The study sample consisted of 9 470 626 index outpatient ED visits to 4684 EDs; most visits (5 776 501 [61.0%]) were among women, and the mean (SD) age of patients was 77.3 (8.4) years. In this sample, the cumulative incidence of ambulatory follow-up was 40.5% (3 822 133 patients) at 7 days and 70.8% (6 662 525 patients) at 30 days, after accounting for censoring and for mortality as a competing risk. Characteristics associated with lower rates of ambulatory follow-up included beneficiary Medicaid eligibility (hazard ratio [HR], 0.77; 95% CI, 0.77-0.78; P < .001), Black race (HR, 0.82; 95% CI, 0.81-0.83; P < .001), and treatment at a rural ED (HR, 0.75; 95% CI, 0.73-0.77; P < .001) in the multivariable regression model. Ambulatory follow-up was associated with lower risk of postdischarge mortality (HR, 0.49; 95% CI, 0.49-0.50; P < .001) but higher risk of subsequent inpatient hospitalization (HR, 1.22; 95% CI, 1.21-1.23; P < .001) and ED visits (HR, 1.01; 95% CI, 1.00-1.01; P < .001), adjusting for visit diagnosis, patient demographic characteristics, and chronic conditions.In this cohort study of Medicare beneficiaries discharged from the ED, nearly 30% lacked ambulatory follow-up at 30 days, with variation in follow-up rates by patient and hospital characteristics. Having an ambulatory follow-up visit was associated with higher risk of subsequent hospitalization but lower risk of mortality. Ambulatory care access may be an important driver of clinical outcomes after an ED visit.

    View details for DOI 10.1001/jamanetworkopen.2020.19878

    View details for Web of Science ID 000582042800003

    View details for PubMedID 33034640

    View details for PubMedCentralID PMC7547366

  • Effect of Accountable Care Organizations on Emergency Medicine Payment and Care Redesign: A Qualitative Study ANNALS OF EMERGENCY MEDICINE Lin, M. P., Revette, A., Carr, B. G., Richardson, L. D., Wiler, J. L., Schuur, J. D. 2020; 75 (5): 597-608


    Accountable care organizations are provider networks aiming to improve quality while reducing costs for populations. It is unknown how value-based care within accountable care organizations affects emergency medicine care delivery and payment. Our objective was to describe how accountable care has impacted emergency care redesign and payment.We performed a qualitative study of accountable care organizations, consisting of semistructured interviews with emergency department (ED) and accountable care organization leaders responsible for strategy, care redesign, and payment. We analyzed transcripts for key themes, using thematic analysis techniques.We performed 22 interviews across 7 accountable care organizations. All sites were enrolled in the Medicare Shared Savings Program; however, sites varied in region and maturity with respect to population health initiatives. Nearly all sites were focused on reducing low-value ED visits, expanding alternate venues for acute unscheduled care, and redesigning care to reduce ED admission rates through expanded care coordination, including programs targeting high-risk populations such as older adults and frequent ED users, telehealth, and expanded use of direct transfer to skilled nursing facilities from the ED. However, there has been no significant reform of payment for emergency medical care within these accountable care organizations. Nearly all informants expressed concern in regard to reduced ED reimbursement, given accountable care organization efforts to reduce ED utilization and increase clinician participation in alternative payment contracts. No participants expressed a clear vision for reforming payment for ED services.Care redesign within accountable care organizations has focused on outpatient access and alternatives to hospitalization. However, there has been little influence on emergency medicine payment, which remains fee for service. Evidence-based policy solutions are urgently needed to inform the adoption of value-based payment for acute unscheduled care.

    View details for DOI 10.1016/j.annemergmed.2019.09.010

    View details for Web of Science ID 000536748700010

    View details for PubMedID 31973914

  • Impact of a Women-focused Professional Organization on Academic Retention and Advancement: Perceptions From a Qualitative Study ACADEMIC EMERGENCY MEDICINE Lin, M. P., Lall, M. D., Samuels-Kalow, M., Das, D., Linden, J. A., Perman, S., Chang, A., Agrawal, P. 2019; 26 (3): 303-316


    Organizations to promote career networking and mentorship among women are recommended as a best practice to support the recruitment and retention of women physicians; however, the impact of such organizations is unknown. Our primary objective is to describe the impact of a national woman-focused organization for academic emergency physicians on retention and advancement.We conducted semistructured interviews of past and present organization leaders, as well as members at varying stages in their careers. Physicians with experience in qualitative methods conducted interviews and coded all transcripts using inductive content analysis techniques. Themes were reviewed and discussed to ensure consensus.We performed 17 interviews lasting 20 to 30 minutes each, resulting in 476 total minutes of transcript. Participants represented varying stages of career experience, ranging from 2 to 35 years since residency completion (median = 9.5 years). Median years of participation in the woman-focused organization was 10 years. Over half (53%) of participants were past presidents of the organization. The dominant themes encompassed facilitating academic advancement through scholarly productivity, leadership experiences, awards, and promotions; mentorship and sponsorship; peer support and collaborations; reduced professional isolation; and initiatives to address systemic gender inequities and challenges, including strategies to navigate bias, promote pay equity, and advocate for family-friendly workplace policies.Active participation in a woman-focused professional organization enhances members' career retention and advancement by creating opportunities and relationships that facilitate leadership, enabling scholarly work to advance equity and inclusion, and cultivating a sense of belonging. While challenges and barriers persist, the myriad benefits of a women-focused professional organization reported by members and leaders represent important steps toward greater equity for women and other underrepresented groups in academic medicine.

    View details for DOI 10.1111/acem.13699

    View details for Web of Science ID 000461220000005

    View details for PubMedID 30667132

  • Trends in Emergency Department Visits and Admission Rates Among US Acute Care Hospitals JAMA INTERNAL MEDICINE Lin, M. P., Baker, O., Richardson, L. D., Schuur, J. D. 2018; 178 (12): 1708-1710
  • Association Between Social Vulnerability and US HIV Priority Jurisdictions. Journal of acquired immune deficiency syndromes (1999) Bennett, C. L., Saxena, M., Boothroyd, D., Mahmoud-Werthmann, S., Lin, M. P. 2024; 96 (2): e4-e6

    View details for DOI 10.1097/QAI.0000000000003415

    View details for PubMedID 38771755

  • Innovations to address gender disparities and support the development of emergency medicine researchers. AEM education and training Zeidan, A., Cooper, R. J., Samuels-Kalow, M. E., Lin, M. P., Love, J. S., Ogle, K., Agrawal, P. 2024; 8 (Suppl 1): S43-S49

    View details for DOI 10.1002/aet2.10979

    View details for PubMedID 38774822

  • Geriatric Emergency Medication Safety Recommendations (GEMS-Rx): Modified Delphi Development of a High-Risk Prescription List for Older Emergency Department Patients. Annals of emergency medicine Skains, R. M., Koehl, J. L., Aldeen, A., Carpenter, C. R., Gettel, C. J., Goldberg, E. M., Hwang, U., Kocher, K. E., Southerland, L. T., Goyal, P., Berdahl, C. T., Venkatesh, A. K., Lin, M. P. 2024


    Half of emergency department (ED) patients aged 65 years and older are discharged with new prescriptions. Potentially inappropriate prescriptions contribute to adverse drug events. Our objective was to develop an evidence- and consensus-based list of high-risk prescriptions to avoid among older ED patients.We performed a modified, 3-round Delphi process that included 10 ED physician experts in geriatrics or quality measurement and 1 pharmacist. Consensus members reviewed all 35 medication categories from the 2019 American Geriatrics Society Beers Criteria and ranked each on a 5-point Likert scale (5=highest) for overall priority for avoidance (Round 1), risk of short-term adverse events and avoidability (Round 2), and reasonable medical indications for high-risk medication use (Round 3).For each round, questionnaire response rates were 91%, 82%, and 64%, respectively. After Round 1, benzodiazepines (mean, 4.60 [SD, 0.70]), skeletal muscle relaxants (4.60 [0.70]), barbiturates (4.30 [1.06]), first-generation antipsychotics (4.20 [0.63]) and first-generation antihistamines (3.70 [1.49]) were prioritized for avoidance. In Rounds 2 and 3, hypnotic "Z" drugs (4.29 [1.11]), metoclopramide (3.89 [0.93]), and sulfonylureas (4.14 [1.07]) were prioritized for avoidability, despite lower concern for short-term adverse events. All 8 medication classes were included in the final list. Reasonable indications for prescribing high-risk medications included seizure disorders, benzodiazepine/ethanol withdrawal, end of life, severe generalized anxiety, allergic reactions, gastroparesis, and prescription refill.We present the first expert consensus-based list of high-risk prescriptions for older ED patients (GEMS-Rx) to improve safety among older ED patients.

    View details for DOI 10.1016/j.annemergmed.2024.01.033

    View details for PubMedID 38483427

  • Pandemic phase-related racial and ethnic disparities in COVID-19 positivity and outcomes among patients presenting to emergency departments during the first two pandemic waves in the USA. Emergency medicine journal : EMJ Khosla, S., Del Rios, M., Chisolm-Straker, M., Bilal, S., Jang, T. B., Wang, H., Hartley, M., Loo, G. T., d'Etienne, J. P., Newgard, C. D., Courtney, D. M., Choo, E. K., Lin, M. P., Kline, J. A. 2024


    In many countries including the USA, the UK and Canada, the impact of COVID-19 on people of colour has been disproportionately high but examination of disparities in patients presenting to ED has been limited. We assessed racial and ethnic differences in COVID-19 positivity and outcomes in patients presenting to EDs in the USA, and the effect of the phase of the pandemic on these outcomes.This is a retrospective cohort study of adult patients tested for COVID-19 during, or 14 days prior to, the index ED visit in 2020. Data were obtained from the National Registry of Suspected COVID-19 in Emergency Care network which has data from 155 EDs across 27 US states. Hierarchical models were used to account for clustering by hospital. The outcomes included COVID-19 diagnosis, hospitalisation at index visit, subsequent hospitalisation within 30 days and 30-day mortality. We further stratified the analysis by time period (early phase: March-June 2020; late phase: July-September 2020).Of the 26 111 adult patients, 38% were non-Hispanic White (NHW), 29% Black, 20% Hispanic/Latino, 3% Asian and 10% all others; half were female. The median age was 56 years (IQR 40-69), and 53% were diagnosed with COVID-19; of those, 59% were hospitalised at index visit. Of those discharged from ED, 47% had a subsequent hospitalisation in 30 days. Hispanic/Latino patients had twice (adjusted OR (aOR) 2.3; 95% CI 1.8 to 3.0) the odds of COVID-19 diagnosis than NHW patients, after adjusting for age, sex and comorbidities. Black, Asian and other minority groups also had higher odds of being diagnosed (compared with NHW patients). On stratification, this association was observed in both phases for Hispanic/Latino patients. Hispanic/Latino patients had lower odds of hospitalisation at index visit, but when stratified, this effect was only observed in early phase. Subsequent hospitalisation was more likely in Asian patients (aOR 3.1; 95% CI 1.1 to 8.7) in comparison with NHW patients. Subsequent ED visit was more likely in Blacks and Hispanic/Latino patients in late phase.We found significant differences in ED outcomes that are not explained by comorbidity burden. The gap decreased but persisted during the later phase in 2020.

    View details for DOI 10.1136/emermed-2023-213101

    View details for PubMedID 38429072

  • Challenges surrounding the emergency physician workforce and their impact on the Emergency Medicine Match. Clinical and experimental emergency medicine Bennett, C. L., Lin, M., Camargo, C. A. 2023

    View details for DOI 10.15441/ceem.23.118

    View details for PubMedID 38012818

  • Beyond the Four Walls: The American College of Emergency Physicians 2022 New Practice Models Task Force Report. Annals of emergency medicine Oskvarek, J. J., Blutinger, E. J., Pilgrim, R., Joshi, A. U., Lin, M. P., Mazer-Amirshahi, M., Miller, G., Smiley, A., Becker, C. W., Pines, J. M. 2023


    Emergency physicians are highly trained to deliver acute unscheduled care. The emergency physician core skillset gained during emergency medicine residency can be applied to many other roles that benefit patients and extend and diversify emergency physician careers. In 2022, the American College of Emergency Physicians (ACEP) convened the New Practice Models Task Force to describe new care models and emergency physician opportunities outside the 4 walls of the emergency department. The Task Force consisted of 21 emergency physicians with broad experience and 2 ACEP staff. Fifty-nine emergency physician roles were identified (21 established clinical roles, 16 emerging clinical roles, 9 established nonclinical roles, and 13 emerging nonclinical roles). A strength-weakness-opportunity-threat (SWOT) analysis was performed for each role. Using the analysis, the Task Force made recommendations for guiding ACEP internal actions, advocacy, education, and research opportunities. Emphasis was placed on urgent care, rural medicine, telehealth/virtual care, mobile integrated health care, home-based services, emergency psychiatry, pain medicine, addiction medicine, and palliative care as roles with high or rising demand that draw on the emergency physician skillset. Advocacy recommendations focused on removing state and federal regulatory and legislative barriers to the expansion of new and emerging roles. Educational recommendations focused on aggregating available resources, developing a centralized resource for career guidance, and new educational content for emerging roles. The Task Force also recommended promoting research on potential advantages (eg, improved outcomes, lower cost) of emergency physicians in certain roles and new care models (eg, emergency physician remote supervision in rural settings).

    View details for DOI 10.1016/j.annemergmed.2023.08.488

    View details for PubMedID 37777937

  • Inhaled Corticosteroids Rarely Prescribed at Emergency Department Discharge Despite Low Rates of Follow-Up Care. The Journal of emergency medicine Kligler, S. K., Vargas-Torres, C., Abbott, E. E., Lin, M. P. 2023


    Guidelines recommend an inhaled corticosteroid (ICS) prescription on emergency department (ED) discharge after acute asthma exacerbations.We sought to identify rates and predictors of ICS prescription at ED discharge. Secondary outcomes included ICS prescription rates in a high-risk subgroup, outpatient follow-up rates within 30 days, and variation in ICS prescriptions among attending emergency physicians.This was a retrospective cohort study of adult asthma ED discharges for acute asthma exacerbation across 5 urban academic hospitals. We used multivariable logistic regression to evaluate predictors of ICS prescription after adjusting for patient characteristics and hospital-level clustering.Among 3948 adult ED visits, an ICS was prescribed in 6% (n = 238) of visits. Only 14% (n = 552) completed an outpatient visit within 30 days. Among patients with 2 or more ED visits in 12 months, the ICS prescription rate was 6.7%. ICS administration in the ED (odds ratio [OR] 9.91; 95% CI 7.99-12.28) and prescribing a β-agonist on discharge (OR 2.67; 95% CI 2.08-3.44) were associated with higher odds of ICS prescription. Decreased odds of ICS prescription were associated with Hispanic ethnicity (OR 0.71; 95% CI 0.51-0.99) relative to Black race, and private (OR 0.75; 95% CI 0.62-0.91) or no insurance (OR 0.54; 95% CI 0.35-0.84) relative to Medicaid. One-third (36%, n = 66) of ED attendings prescribed 0 ICS prescriptions during the study period.An ICS is infrequently prescribed on ED asthma discharge, and most patients do not have an outpatient follow-up within 30 days. Future studies should examine the extent to which ED ICS prescriptions improve outcomes for patients with barriers to accessing primary care.

    View details for DOI 10.1016/j.jemermed.2023.02.013

    View details for PubMedID 37041095

  • A Response to: The termination of an ectopic pregnancy is not an abortion. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Samuels-Kalow, M. E., Agrawal, P., Rodriguez, G., Zeidan, A., Love, J. S., Monette, D., Lin, M., Cooper, R. J., Madsen, T. E., Dobiesz, V. 2023

    View details for DOI 10.1111/acem.14714

    View details for PubMedID 36916860

  • Patient Sociodemographics and Comorbidities and Birth Hospital Characteristics Associated With Postpartum Emergency Department Care. JAMA network open Zarrin, H., Vargas-Torres, C., Janevic, T., Stern, T., Lin, M. P. 2023; 6 (3): e233927


    Postpartum emergency department (ED) visits may indicate poor access to care and risk for maternal morbidity.To identify patient and hospital characteristics associated with postpartum ED visit rates.This retrospective cohort study used data from the 2014 to 2016 New York State Inpatient Database and State Emergency Department Database. All obstetric discharges from acute care hospitals in New York State from January 1, 2014, through November 15, 2016, were included. Obstetric discharges in the inpatient database were linked to subsequent ED visits by the same patient in the ED database. Data were analyzed from February 2020 to August 2022.Patient characteristics assessed included age, race, insurance, home zip code income quartile, Charlson Comorbidity Index score, and obstetric risk factors. Hospital characteristics assessed included safety net status, teaching status, and status as a hospital disproportionally serving racial and ethnic minority populations.The primary outcome was any ED visit within 42 days of obstetric discharge. Multilevel logistic regression with 2-level nested mixed effects was used to account for patient and hospital characteristics and hospital-level clustering.Of 608 559 obstetric discharges, 35 299 (5.8%) were associated with an ED visit within 42 days. The median (IQR) birth hospital postpartum ED visit rate was 6.3% (4.6%-8.7%). The mean (SD) age was 28.4 (9.1) years, 53 006 (8.7%) were Asian patients, 90 675 (14.9%) were Black patients, 101 812 (16.7%) were Hispanic patients, and 275 860 (45.3%) were White patients; 292 991 (48%) were insured by Medicaid, and 290 526 (47.7%) had private insurance. Asian patients had the lowest postpartum ED visit rates (2118 ED visits after 53 006 births by Asian patients [3.99%]), and Black patients had the highest postpartum ED visit rates (8306 ED visits after 90 675 births by Black patients [9.15%]). Odds of postpartum ED visits were greater for Black patients (odds ratio [OR], 1.31; 95% CI, 1.26-1.35; P < .001) and Hispanic patients (OR, 1.19; 95% CI, 1.15-1.24; P < .001) relative to White patients; those with Medicare (OR, 1.55; 95% CI, 1.39-1.72; P < .001), Medicaid (OR, 1.37; 95% CI, 1.34-1.41; P < .001), or self-pay insurance (OR, 1.50; 95% CI, 1.41-1.59; P < .001) relative to commercial insurance; births that occurred at safety net hospitals (OR, 1.43; 95% CI, 1.37-1.51; P < .001) and hospitals disproportionately serving racial and ethnic minority populations (OR, 1.14; 95% CI, 1.08-1.20; P < .001); and births that occurred at hospitals with fewer than 500 births per year (OR, 1.25; 95% CI, 1.14-1.39; P < .001) relative to those with more than 2000 annual births. Adjusted odds of postpartum ED visits were lower after birth at teaching hospitals (OR,  0.82; 95% CI, 0.74-0.91; P < .001) and metropolitan hospitals (OR, 0.74; 95% CI, 0.65-0.85; P < .001).This cohort study found that Black and Hispanic patients experienced higher adjusted odds of postpartum ED visits across all hospital types, particularly at safety net hospitals and those disproportionately serving racial and ethnic minority populations . These findings support the urgent need to mitigate structural racism underlying maternal health disparities.

    View details for DOI 10.1001/jamanetworkopen.2023.3927

    View details for PubMedID 36943266

  • Proceedings from the 2021 SAEM Consensus Conference: Research Priorities for Interventions to Address Social Risks and Needs Identified in Emergency Department Patients. The western journal of emergency medicine Kraynov, L., Quarles, A., Kerrigan, A., Mayes, K. D., Mahmoud-Werthmann, S., Fockele, C. E., Duber, H. C., Doran, K. M., Lin, M. P., Cooper, R. J., Wang, N. E. 2023; 24 (2): 295-301


    Emergency departments (ED) function as a health and social safety net, regularly taking care of patients with high social risk and need. Few studies have examined ED-based interventions for social risk and need.Focusing on ED-based interventions, we identified initial research gaps and priorities in the ED using a literature review, topic expert feedback, and consensus-building. Research gaps and priorities were further refined based on moderated, scripted discussions and survey feedback during the 2021 SAEM Consensus Conference. Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions; 2) intervention implementation in the ED environment; and 3) intercommunication between patients, EDs, and medical and social systems.Using these methods, we derived six priorities based on three identified gaps in ED-based social risks and needs interventions: 1) assessment of ED-based interventions, 2) intervention implementation in the ED environment, and 3) intercommunication between patients, EDs, and medical and social systems. Assessing intervention effectiveness through patient-centered outcome and risk reduction measures should be high priorities in the future. Also noted was the need to study methods of integrating interventions into the ED environment and to increase collaboration between EDs and their larger health systems, community partners, social services, and local government.The identified research gaps and priorities offer guidance for future work to establish effective interventions and build relationships with community health and social systems to address social risks and needs, thereby improving the health of our patients.

    View details for DOI 10.5811/westjem.2022.11.57293

    View details for PubMedID 36976612

    View details for PubMedCentralID PMC10047718

  • 2021 SAEM Consensus Conference Proceedings: Research Priorities for Implementing Emergency Department Screening for Social Risks and Needs. The western journal of emergency medicine Yore, M., Fockele, C. E., Duber, H. C., Doran, K. M., Cooper, R. J., Lin, M. P., Campbell, S., Eswaran, V., Chang, B., Hong, H., Gbenedio, K., Stanford, K. A., Gavin, N. 2023; 24 (2): 302-311


    Despite literature on a variety of social risks and needs screening interventions in emergency department (ED) settings, there is no universally accepted or evidence-based process for conducting such interventions. Many factors hamper or promote implementation of social risks and needs screening in the ED, but the relative impact of these factors and how best to mitigate/leverage them is unknown.Drawing on an extensive literature review, expert assessment, and feedback from participants in the 2021 Society for Academic Emergency Medicine Consensus Conference through moderated discussions and follow-up surveys, we identified research gaps and rated research priorities for implementing screening for social risks and needs in the ED. We identified three main knowledge gaps: 1) screening implementation mechanics; 2) outreach and engagement with communities; and 3) addressing barriers and leveraging facilitators to screening. Within these gaps, we identified 12 high-priority research questions as well as research methods for future studies.Consensus Conference participants broadly agreed that social risks and needs screening is generally acceptable to patients and clinicians and feasible in an ED setting. Our literature review and conference discussion identified several research gaps in the specific mechanics of screening implementation, including screening and referral team composition, workflow, and use of technology. Discussions also highlighted a need for more collaboration with stakeholders in screening design and implementation. Additionally, discussions identified the need for studies using adaptive designs or hybrid effectiveness-implementation models to test multiple strategies for implementation and sustainability.Through a robust consensus process we developed an actionable research agenda for implementing social risks and needs screening in EDs. Future work in this area should use implementation science frameworks and research best practices to further develop and refine ED screening for social risks and needs and to address barriers as well as leverage facilitators to such screening.

    View details for DOI 10.5811/westjem.2022.10.57368

    View details for PubMedID 36976611

    View details for PubMedCentralID PMC10047739

  • A Response To Post-Roe Emergency Medicine: Important Considerations for Adolescents. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Samuels-Kalow, M. E., Agrawal, P., Rodriguez, G., Zeidan, A., Love, J. S., Monette, D., Lin, M., Cooper, R. J., Madsen, T. E., Dobiesz, V. 2023

    View details for DOI 10.1111/acem.14689

    View details for PubMedID 36762871

  • Trends In Treat-And-Release Emergency Care Visits With High-Intensity Billing In The US, 2006-19. Health affairs (Project Hope) Janke, A. T., Gettel, C., Koski-Vacirca, R., Lin, M. P., Kocher, K. E., Venkatesh, A. K. 2022; 41 (12): 1772-1780


    Clinicians' billing practices for professional services in the emergency department (ED) have come under scrutiny as the proportion of expensive high-intensity visits has grown in recent decades. Clinicians respond to payers' criticism by citing the worsening health status of undifferentiated patients alongside increasing expectations of ED care, with few data available to disentangle these phenomena from coding practices. We performed an observational study of US treat-and-release ED visits using data from the Nationwide Emergency Department Sample. In 2006, 4.8 percent of treat-and-release ED visits exhibited high-intensity billing, and this figure rose to 19.2 percent by 2019. The proportion of visits for older patients, those with more comorbidities, and those with nonspecific but potentially serious diagnoses grew. Of the observed growth in high-intensity billing, 47 percent was expected, based on changes in administrative measures for patient case-mix and care services. Any emergency care reimbursement reform must account for growing patient complexity and an evolving role for EDs in the health care system.

    View details for DOI 10.1377/hlthaff.2022.00484

    View details for PubMedID 36469824

  • Post-Roe Emergency Medicine: Policy, clinical, training, and individual implications for emergency clinicians. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Samuels-Kalow, M. E., Agrawal, P., Rodriguez, G., Zeidan, A., Love, J. S., Monette, D., Lin, M., Cooper, R. J., Madsen, T. E., Dobiesz, V. 2022


    In June 2022, the United States Supreme Court decision Dobbs v. Jackson Women's Health Organization overturned Roe v. Wade, removing almost 50years of precedent, and enabling the imposition of a wide range of state-level restrictions on abortion access. Historical data from the United States and internationally demonstrate that the removal of safe abortion options will increase complications and the health risks to pregnant patients. Because the emergency department is a critical access point for reproductive healthcare, emergency clinicians must be prepared for the policy, clinical, educational, and legal implications of this change. The goal of this paper, therefore, is to describe the impact of the reversal of Roe v. Wade on health equity and reproductive justice, the provision of emergency care education and training, and the specific legal and reproductive consequences for emergency clinicians. Finally, we conclude with specific recommended policy and advocacy responses for emergency medicine clinicians.

    View details for DOI 10.1111/acem.14609

    View details for PubMedID 36268814

  • 2021 SAEM Consensus Conference Proceedings: Research Priorities for Developing Emergency Department Screening Tools for Social Risks and Needs. The western journal of emergency medicine Furbacher, J., Fockele, C., Buono, B. D., Janneck, L., March, C., Molina, M., Duber, H. C., Doran, K. M., Lin, M. P., Cooper, R. J., Modi, P. 2022; 23 (6): 817-822


    INTRODUCTION: The Emergency Department (ED) acts as a safety net for our healthcare system. While studies have shown increased prevalence of social risks and needs among ED patients, there are many outstanding questions about the validity and use of social risks and needs screening tools in the ED setting.METHODS: In this paper, we present research gaps and priorities pertaining to social risks and needs screening tools used in the ED, identified through a consensus approach informed by literature review and external expert feedback as part of the 2021 SAEM Consensus Conference -- From Bedside to Policy: Advancing Social Emergency Medicine and Population Health.RESULTS: Four overarching research gaps were identified: (1) Defining the purpose and ethical implications of ED-based screening; (2) Identifying domains of social risks and needs; (3) Developing and validating screening tools; and (4) Defining the patient population and type of screening performed. Furthermore, the following research questions were determined to be of highest priority: (1) What screening tools should be used to identify social risks and needs? (2) Should individual EDs use a national standard screening tools or customized screening tools? (3) What are the most prevalent social risks and needs in the ED? and (4) Which social risks and needs are most amenable to intervention in the ED setting?CONCLUSION: Answering these research questions will facilitate the use of evidence-based social risks and needs screening tools that address knowledge gaps and improve the health of our communities by better understanding the underlying determinants contributing to their presentation and health outcomes.

    View details for DOI 10.5811/westjem.2022.8.57271

    View details for PubMedID 36409957

  • Cost variation and revisit rate for adult patients with asthma presenting to the emergency department. The American journal of emergency medicine Casey, M. F., Richardson, L. D., Weinstock, M., Lin, M. P. 2022; 61: 179-183


    BACKGROUND: Asthma is common, resulting in 53 million emergency department (ED) visits annually. Little is known about variation in cost and quality of ED asthma care.STUDY OBJECTIVE: We sought to describe variation in costs and 7-day ED revisit rates for asthma care across EDs. Our primary objective was to test for an association between ED costs and the likelihood of a 7-day revisit for another asthma exacerbation.METHODS: We used the 2014 Florida State Emergency Department Database to perform an observational study of ED visits by patients ≥18 years old with a primary diagnosis of asthma that were discharged home. We compared patient and hospital characteristics of index ED discharges with and without 7-day revisits, then tested the association between ED revisits and index ED costs. Multilevel regression was performed to account for hospital-level clustering.RESULTS: In 2014, there were 54,060 adult ED visits for asthma resulting in discharge, and 1667 (3%) were associated with an asthma-related ED revisit within 7 days. Median cost for an episode of ED asthma care was $597 with an interquartile range of $371-980. After adjusting for both patient and hospital characteristics, lack of insurance was associated with higher odds of revisit (OR 1.42, 95% CI 1.18-1.71), while private insurance, female gender, and older age were associated with lower odds of revisit. Hospital costs were not associated with ED revisits (OR = 1.00; 95% CI 1.00-1.00).CONCLUSION: Hospital costs associated with ED asthma visits vary but are not associated with odds of ED revisit.

    View details for DOI 10.1016/j.ajem.2022.09.021

    View details for PubMedID 36155254

  • Racial and Ethnic Disparities in Hospitalization and Clinical Outcomes Among Patients with COVID-19. The western journal of emergency medicine Serrano, F., Blutinger, E. J., Vargas-Torres, C., Bilal, S., Counts, C., Straight, M., Lin, M. P. 2022; 23 (5): 601-612


    INTRODUCTION: The recent spread of coronavirus disease 2019 (COVID-19) has disproportionately impacted racial and ethnic minority groups; however, the impact of healthcare utilization on outcome disparities remains unexplored. Our study examines racial and ethnic disparities in hospitalization, medication usage, intensive care unit (ICU) admission and in-hospital mortality for COVID-19 patients.METHODS: In this retrospective cohort study, we analyzed data for adult patients within an integrated healthcare system in New York City between February 28-August 28, 2020, who had a lab-confirmed COVID-19 diagnosis. Primary outcome was likelihood of inpatient admission. Secondary outcomes were differences in medication administration, ICU admission, and in-hospital mortality.RESULTS: Of 4717 adult patients evaluated in the emergency department (ED), 3219 (68.2%) were admitted to an inpatient setting. Black patients were the largest group (29.1%), followed by Hispanic/Latinx (29.0%), White (22.9%), Asian (3.86%), and patients who reported "other" race-ethnicity (19.0%). After adjusting for demographic, clinical factors, time, and hospital site, Hispanic/Latinx patients had a significantly lower adjusted rate of admission compared to White patients (odds ratio [OR] 0.51; 95% confidence interval [CI] 0.34-0.76). Black (OR 0.60; 95% CI 0.43-0.84) and Asian patients (OR 0.47; 95% CI 0.25 - 0.89) were less likely to be admitted to the ICU. We observed higher rates of ICU admission (OR 2.96; 95% CI 1.43-6.15, and OR 1.83; 95% CI 1.26-2.65) and in-hospital mortality (OR 4.38; 95% CI 2.66-7.24; and OR 2.96; 95% CI 2.12-4.14) at two community-based academic affiliate sites relative to the primary academic site.CONCLUSION: Non-White patients accounted for a disproportionate share of COVID-19 patients seeking care in the ED but were less likely to be admitted. Hospitals serving the highest proportion of minority patients experienced the worst outcomes, even within an integrated health system with shared resources. Limited capacity during the COVID-19 pandemic likely exacerbated pre-existing health disparities across racial and ethnic minority groups.

    View details for DOI 10.5811/westjem.2022.3.53065

    View details for PubMedID 36205667

  • Predictors of Outpatient Follow-Up Care after Adult Emergency Department Asthma Visits and Association with 30-Day Outcomes. The Journal of asthma : official journal of the Association for the Care of Asthma Abbott, E. E., Vargas-Torres, C., Kligler, S. K., Spadafore, S., Lin, M. P. 2022: 1-13


    Guidelines recommend outpatient follow-up after emergency department visits for asthma, but factors related to rates of follow-up among the adult population are understudied. We sought to describe patient and community-level predictors of outpatient follow-up after an index ED visit for asthma and evaluate the association between outpatient follow-up visits and subsequent ED revisits. We conducted a retrospective observational cohort study of adult patients with emergency departments visits for asthma. The primary predictor was time to outpatient follow-up visit within 30 days of the index ED visit. The primary outcome was all-cause ED revisit within 30 days of the index ED visit. Cox proportional hazards regression was utilized to test the association between time to outpatient follow-up and hazard of ED revisit within 30 days. Time to outpatient follow-up visit within 30 days was not significantly associated with hazard of 30-day ED revisit for asthma (HR 1.05; 95% CI 0.69-1.61). However, male patients (HR 1.45; 95% C 1.11-1.89) and smokers (HR 1.67; 95% CI 1.22-2.29) were significantly more likely to have an ED revisit. Younger, Black patients with Medicaid were less likely to receive follow-up care relative to older patients insured by Medicare. While follow-up visits were not associated with 30-day revisit rates, differences by age, race, and insurance status suggest disproportionate barriers to accessing care. Future research may target these subgroups to improve transitions of care after an ED visit for asthma.

    View details for DOI 10.1080/02770903.2022.2109166

    View details for PubMedID 35938828

  • "Why bother?": Barriers to reporting gender and sexual harassment in emergency medicine ACADEMIC EMERGENCY MEDICINE Zeidan, A., Patel, J., Dys, G., Dean, L., Curt, A., Lin, M. P., Samuels-Kalow, M. 2022


    Gender and sexual harassment in emergency medicine (EM) is persistent in the workplace but remains underreported. Barriers to reporting in EM are largely unknown. This study explored barriers to reporting gender and sexual harassment among EM faculty and residents and potential improvements to reporting systems.We conducted semistructured interviews with EM faculty and residents across the United States, utilizing purposive sampling to ensure diverse representation. All interviews were recorded, transcribed, and coded by two independent investigators. Interviews were conducted until thematic saturation and prominent themes were identified from coded data.A total of 32 interviews were completed with women and men faculty and residents. Prominent themes were identified representing compounding barriers to reporting. Participants described confusion over what constitutes a reportable definition of gender and sexual harassment, unfamiliarity with reporting processes, and multiple avenues (both informal and formal through departmental, hospital, and institutional systems) for reporting. Participants expressed limited confidence in formal reporting systems and related several perceived and actual negative outcomes of reporting. A number of improvements were recommended centering around creating reporting systems that supported, empowered, and protected survivors; improving transparency about reporting processes; and ensuring accountability at a departmental and institutional level.Significant barriers to reporting exist and deter individuals from reporting. Given the negative consequences of ongoing gender and sexual harassment, emergency departments and institutions must take responsibility to reduce barriers and support individuals throughout the reporting process.

    View details for DOI 10.1111/acem.14544

    View details for Web of Science ID 000820917000001

    View details for PubMedID 35791497

  • Emergency departments in the United States treating high proportions of patients with ambulatory care sensitive conditions: a retrospective cross-sectional analysis BMC HEALTH SERVICES RESEARCH Hsuan, C., Zebrowski, A., Lin, M. P., Buckler, D. G., Carr, B. G. 2022; 22 (1): 854


    One in nine emergency department (ED) visits by Medicare beneficiaries are for ambulatory care sensitive conditions (ACSCs). This study aimed to examine the association between ACSC ED visits to hospitals with the highest proportion of ACSC visits ("high ACSC hospitals) and safety-net status.This was a cross-sectional study of ED visits by Medicare fee-for-service beneficiaries ≥ 65 years using 2013-14 claims data, Area Health Resources File data, and County Health Rankings. Logistic regression estimated the association between an ACSC ED visit to high ACSC hospitals, accounting for individual, hospital, and community factors, including whether the visit was to a safety-net hospital. Safety net status was measured by Disproportionate Share Hospital (DSH) index patient percentage; public hospital status; and proportion of dual-eligible beneficiaries. Hospital-level correlation was calculated between ACSC visits, DSH index, and dual-eligible patients. We stratified by type of ACSC visit: acute or chronic.Among 5,192,729 ACSC ED visits, the odds of visiting a high ACSC hospital were higher for patients who were Black (1.37), dual-eligible (1.18), and with the highest comorbidity burden (1.26, p < 0.001 for all). ACSC visits had increased odds of being to high ACSC hospitals if the hospitals were high DSH (1.43), served the highest proportion of dual-eligible beneficiaries (2.23), and were for-profit (relative to non-profit) (1.38), and lower odds were associated with public hospitals (0.64) (p < 0.001 for all). This relationship was similar for visits to high chronic ACSC hospitals (high DSH: 1.59, high dual-eligibility: 2.60, for-profit: 1.41, public: 0.63, all p < 0.001) and to a lesser extent, high acute ACSC hospitals (high DSH: 1.02; high dual-eligibility: 1.48, for-profit: 1.17, public: 0.94, p < 0.001). The proportion of ACSC visits at all hospitals was weakly correlated with DSH proportion (0.2) and the proportion of dual-eligible patients (0.29), and this relationship was also seen for both chronic and acute ACSC visits, though stronger for the chronic ACSC visits.Visits to hospitals with a high proportion of acute ACSC ED visits may be less likely to be to hospitals classified as safety net hospitals than those with a high proportion of chronic ACSC visits.

    View details for DOI 10.1186/s12913-022-08240-7

    View details for Web of Science ID 000820231600002

    View details for PubMedID 35780130

    View details for PubMedCentralID PMC9250723

  • Development of a Novel Emergency Department Quality Measure to Reduce Very Low-Risk Syncope Hospitalizations ANNALS OF EMERGENCY MEDICINE Probst, M. A., Janke, A. T., Haimovich, A. D., Venkatesh, A. K., Lin, M. P., Kocher, K. E., Nemnom, M., Thiruganasambandamoorthy, V. 2022; 79 (6): 509-517


    Emergency department (ED) evaluations for syncope are common, representing 1.3 million annual US visits and $2 billion in related hospitalizations. Despite evidence supporting risk stratification and outpatient management, variation in syncope hospitalization rates persist. We sought to develop a new quality measure for very low-risk adult ED patients with syncope that could be applied to administrative data.We developed this quality measure in 2 phases. First, we used an existing prospective, observational ED patient data set to identify a very low-risk cohort with unexplained syncope using 2 variables: age less than 50 years and no history of heart disease. We then applied this to the 2019 Nationwide Emergency Department Sample (NEDS) to assess its potential effect, assessing for hospital-level factors associated with hospitalization variation.Of the 8,647 adult patients in the prospective cohort, 3,292 (38%) patients fulfilled these 2 criteria: age less than 50 years and no history of heart disease. Of these, 15 (0.46%) suffered serious adverse events within 30 days. In the NEDS, there were an estimated 566,031 patients meeting these 2 criteria, of whom 15,507 (2.7%; 95% confidence interval [CI] 2.48% to 3.00%) were hospitalized. We found substantial variation in the hospitalization rates for this very low-risk cohort, with a median rate of 1.7% (range 0% to 100%; interquartile range 0% to 3.9%). Factors associated with increased hospitalization rates included a yearly ED volume of more than 80,000 (odds ratio [OR] 3.14; 95% CI 2.02 to 4.89) and metropolitan teaching status (OR 1.5; 95% CI 1.24 to 1.81).In summary, our novel syncope quality measure can assess variation in low-value hospitalizations for unexplained syncope. The application of this measure could improve the value of syncope care.

    View details for DOI 10.1016/j.annemergmed.2022.03.008

    View details for Web of Science ID 000805602200010

    View details for PubMedID 35487840

    View details for PubMedCentralID PMC9117517

  • Diversity of leadership in academic emergency medicine: Are we making progress? The American journal of emergency medicine Linden, J. A., Baird, J., Madsen, T. E., Rounds, K., Lall, M. D., Raukar, N. P., Fang, A., Lin, M., Sethuraman, K., Dobiesz, V. A. 2022; 57: 6-13


    BACKGROUND: Faculty who identify as women or racial/ethnic groups underrepresented in medicine (URiM) are less likely to occupy senior leadership positions or be promoted. Recent attention has focused on interventions to decrease this gap; thus, we aim to evaluate changes in leadership and academic promotion for these populations over time.METHODS: Successive cross-sectional observational study of six years (2015 to 2020) of data from the Academy of Administrators/Association of Academic Chairs of Emergency Medicine- Benchmark Survey. Primary analyses focused on gender/URiM differences in leadership roles and academic rank. Secondary analysis focused on disparities during the first 10 years of practice. Statistical modeling was conducted to address the primary aim of assessing differences in gender/URiM representation in EM leadership roles/rank over time.RESULTS: 12,967 responses were included (4589 women, 8378 men). Women had less median years as faculty (7 vs 11). Women and URiM were less likely to hold a leadership role and had lower academic rank with no change over the study period. More women were consistently in the early career cohort (within 10 years or less as faculty) : 2015 =-75.0% [95% CI:± 3.8%] v 61.4% [95% CI:± 3.0%]; 2020 =-75.1% [95% CI: ± 2.9%] v 63.3%, [95% CI:: ± 2.5%]. Men were significantly more likely to have any leadership role compared to women in 2015 and 2020 (2015 = 54.3% [95% CI: ± 3.1%] v 44.8%, [95% CI: ± 4.3%]; 2020 = 43.1% [95% CI:± 2.5%] v 34.8 [95% CI:± 3.1%]). Higher academic rank (associate/professor) was significantly more frequent among early career men than women in 2015 (21.1% [95% CI:± 2.58%] v 12.9%; [95% CI:± 3.0%]) and 2020 (23.1% [95% CI:± 2.2%] v 17.4%; [95% CI:± 2.5%]).CONCLUSIONS: Disparities in women and URiM faculty leadership and academic rank persist, with no change over a six-year time span. Men early career faculty are more likely to hold leadership positions and be promoted to higher academic rank, suggesting early career inequities must be a target for future interventions.

    View details for DOI 10.1016/j.ajem.2022.04.009

    View details for PubMedID 35462120

  • Executive summary of the 2021 SAEM Consensus Conference: From Bedside to Policy: Advancing Social Emergency Medicine and Population Health Through Research, Collaboration, and Education ACADEMIC EMERGENCY MEDICINE Schoenfeld, E. M., Lin, M. P., Samuels-Kalow, M. E. 2022; 29 (3): 354-363


    Social emergency medicine (social EM) examines the intersection of emergency care and the social factors that influence health outcomes. In 2021, the SAEM consensus conference focused on social EM and population health, with the goal of prioritizing research topics, creating collaborations, and advancing the field of social EM.Organization of the conference began in 2019 within SAEM. Cochairs were identified and a planning committee created the framework for the conference. Leaders for subgroups were identified, and subgroups performed literature reviews and identified additional stakeholders within EM and community organizations. As a result of the COVID-19 pandemic, the conference format was modified.A total of 246 participants registered for the conference and participated in some capacity at three distinct online sessions. Research prioritization subgroups were as follows-group 1: ED screening and referral for social and access needs; group 2: structural competency; and group 3: race, racism, and antiracism. Thirty-two "projects in progress" were presented within five domains-identity and health: people and places; health care systems; training and education; material needs; and individual and structural violence.Despite ongoing challenges posed by the COVID-19 pandemic, the 2021 SAEM consensus conference brought together hundreds of stakeholders to define research priorities and create collaborations to push the field forward.

    View details for DOI 10.1111/acem.14451

    View details for Web of Science ID 000769056800001

    View details for PubMedID 35064982

    View details for PubMedCentralID PMC9196762

  • Perspectives on Telehealth for older adults during the COVID-19 pandemic using the quadruple aim: interviews with 48 physicians BMC GERIATRICS Goldberg, E. M., Lin, M. P., Burke, L. G., Jimenez, F. N., Davoodi, N. M., Merchant, R. C. 2022; 22 (1): 188


    Telehealth delivery expanded quickly during the COVID-19 pandemic after the reduction of payment and regulatory barriers, but older adults are the least likely to benefit from this expansion. Little is known about physician experiences initiating telehealth and factors that fostered or discouraged adoption during the COVID-19 pandemic with older adult patients. Therefore, our objective was to understand experiences of frontline physicians caring for older adults via telehealth during the COVID-19 pandemic.We conducted semi-structured interviews from September 2020 to November 2020 with 48 physicians. We recruited a diverse sample of geriatricians (n = 18), primary care (n = 15), and emergency (n = 15) physicians from all United Stated (US) regions, rural-urban settings, and academic-community practices who cared for older adult patients during the pandemic using purposive sampling methods. We completed framework analysis of the transcribed interviews to identify emerging themes and used the Quadruple Aim to organize themes.Frontline physicians described telehealth as a more flexible, value-based, and patient-centered mode of health care delivery. Benefits of using telehealth to treat older adults included reducing deferred care and increasing timely care, improving efficiency for physicians, enhancing communication with caregivers and patients, reducing patient travel burdens, and facilitating health outreach and education. Challenges included unequal access for rural, older, or cognitively impaired patients. Physicians noted that payment parity with in-person visits, between video and telephone visits, and relaxation of restrictive regulations would enhance their ability to continue to offer telehealth.Frontline physicians who treated older adults during the COVID-19 pandemic were largely in favor of continuing telehealth use beyond the pandemic; however, they noted that sustainability would depend on enacting policies that address access inequities and reimbursement concerns. Our data provide policy insights that if placed into action could facilitate the long-term success of telehealth and encourage a more flexible healthcare delivery system in the US.

    View details for DOI 10.1186/s12877-022-02860-8

    View details for Web of Science ID 000766154600001

    View details for PubMedID 35260091

    View details for PubMedCentralID PMC8903127

  • Nearly all thirty most frequently used emergency department drugs experienced shortages from 2006-2019 AMERICAN JOURNAL OF EMERGENCY MEDICINE Lin, M. P., Vargas-Torres, C., Shin-Kim, J., Tin, J., Fox, E. 2022; 53: 135-139


    Drug shortages contribute to avoidable medication error and patient harm; these shortages are exacerbated in the Emergency Department due to the time-sensitive nature of acute care.We performed a cross-sectional study to describe the frequency and duration of drug shortages associated with the most frequent medications administered in the ED. We identified the most frequently used ED medications and calculated number of visits associated with these medications using the 2006-2019 National Hospital Ambulatory Medical Care Survey. We obtained the frequency and duration of shortages associated with these medications from the University of Utah Drug Information System. We calculated duration and total ED visits associated with shortages of the most frequently used ED medications.From 2006 through 2019, the most frequently used drugs were ondansetron (255.1 million ED visits), 0.9% normal saline (251.3 million ED visits), and ibuprofen (188.5 million ED visits). All but two of the top thirty most frequently used medications experienced a shortage. The median shortage duration was 425 days, while the longest were for injectable morphine (3,202 days). The number of ED visits associated with drugs experiencing shortages increased from 2,564,425 (2.2% of U.S. ED visits) in 2006 to 67,221,968 (60.4%) in 2019. The most common reasons for shortage include manufacturing delays and increased demand.Drug shortages were more frequent and persistent from 2006 through 2019. Further studies on the clinical impact of these shortages are needed, in addition to policy interventions to mitigate shortages.

    View details for DOI 10.1016/j.ajem.2021.12.064

    View details for Web of Science ID 000828795600024

    View details for PubMedID 35033771

    View details for PubMedCentralID PMC8862149

  • Institutional Solutions Addressing Disparities in Compensation and Advancement of Emergency Medicine Physicians: A Critical Appraisal of Gaps and Associated Recommendations. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Madsen, T. E., Heron, S., Lall, M. D., Blomkalns, A., Arbelaez, C., Lopez, B., Lin, M., Rounds, K., Sethuraman, K. N., Safdar, B. 1800


    BACKGROUND: Disparities in salary and advancement of emergency medicine (EM) faculty by race and gender have been consistently demonstrated for over three decades. Prior studies have largely focused on individual-level solutions. To identify systems-based interventions, the Society of Academic Emergency Medicine (SAEM) formed the Research Equity Task Force in 2018 with members from multiple academies (the Academy of Academic Chairs in Emergency Medicine (AACEM), the Academy of Academic Administrators in Emergency Medicine (AAAEM), the Academy for Women in Academic Emergency Medicine (AWAEM), and the Academy for Diversity and Inclusion in Emergency Medicine (ADIEM), and sought recommendations from EM departmental leaders.METHODS: The taskforce conducted interviews containing both open-ended narrative and closed-ended questions in multiple phases. Phase 1 included a convenience sample of chairs of EM departments across the U.S., and phase 2 included vice-chairs and other faculty who lead promotion and advancement. The taskforce identified common themes from the interviews and then developed three-tiered sets of recommendations (minimal, target, and aspirational) based on participant responses. In phase 3, iterative feedback was collected and implemented on these recommendations from study participants and chairs participating in a national AACEM webinar.RESULTS: In findings from 53 interviews of chairs, vice-chairs, and faculty leaders from across the U.S., we noted heterogeneity in the faculty development and promotion processes across institutions. Four main themes were identified from the interviews: the need for a directed, structured promotion process, provision of structured mentorship, clarity on requirements for promotion within tracks, and transparency in salary structure. Recommendations were developed to address gaps in structured mentorship and equitable promotion and compensation.CONCLUSIONS: These recommendations for AEM departments have the potential to increase structured mentorship programs, improve equity in promotion and advancement, and reduce disparities in the AEM workforce. These recommendations have been endorsed by SAEM, AACEM, AWAEM, and ADIEM.

    View details for DOI 10.1111/acem.14452

    View details for PubMedID 35064998

  • Development of a qualified clinical data registry for emergency medicine JOURNAL OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS OPEN Epstein, S. K., Griffey, R. T., Lin, M. P., Augustine, J. J., Goyal, P., Venkatesh, A. K. 2021; 2 (6): e12547


    The passage of the Medicare Access and CHIP Reauthorization Act (MACRA) in 2015 marked a fundamental transition in physician payment by the Centers for Medicare and Medicaid Services (CMS) from traditional fee-for service to value-based models. MACRA led to the creation of the CMS Quality Payment Program (QPP), which bases the value of physician care in large part on physician quality reporting. The QPP enabled a shift away from legacy CMS-stewarded quality measures that had limited applicability to individual specialties toward specialty-specific quality measures developed and stewarded by physician specialty societies using Qualified Clinical Data Registries (QCDRs). This article describes the development of the first nationally available emergency medicine QCDR as a means for emergency physicians to participate in the QPP, measure, and benchmark emergency physician quality.

    View details for DOI 10.1002/emp2.12547

    View details for Web of Science ID 000738818500030

    View details for PubMedID 34984413

    View details for PubMedCentralID PMC8692185

  • A Scoping Review of Current Social Emergency Medicine Research. The western journal of emergency medicine Shah, R., Della Porta, A., Leung, S., Samuels-Kalow, M., Schoenfeld, E. M., Richardson, L. D., Lin, M. P. 2021; 22 (6): 1360-1368


    INTRODUCTION: Social emergency medicine (EM) is an emerging field that examines the intersection of emergency care and social factors that influence health outcomes. We conducted a scoping review to explore the breadth and content of existing research pertaining to social EM to identify potential areas where future social EM research efforts should be directed.METHODS: We conducted a comprehensive PubMed search using Medical Subject Heading terms and phrases pertaining to social EM topic areas (e.g., "homelessness," "housing instability") based on previously published expert consensus. For searches that yielded fewer than 100 total publications, we used the PubMed "similar publications" tool to expand the search and ensure no relevant publications were missed. Studies were independently abstracted by two investigators and classified as relevant if they were conducted in US or Canadian emergency departments (ED). We classified relevant publications by study design type (observational or interventional research, systematic review, or commentary), publication site, and year. Discrepancies in relevant publications or classification were reviewed by a third investigator.RESULTS: Our search strategy yielded 1,571 publications, of which 590 (38%) were relevant to social EM; among relevant publications, 58 (10%) were interventional studies, 410 (69%) were observational studies, 26 (4%) were systematic reviews, and 96 (16%) were commentaries. The majority (68%) of studies were published between 2010-2020. Firearm research and lesbian, gay, bisexual, transgender, and queer (LGBTQ) health research in particular grew rapidly over the last five years. The human trafficking topic area had the highest percentage (21%) of interventional studies. A significant portion of publications -- as high as 42% in the firearm violence topic area - included observational data or interventions related to children or the pediatric ED. Areas with more search results often included many publications describing disparities known to predispose ED patients to adverse outcomes (e.g., socioeconomic or racial disparities), or the influence of social determinants on ED utilization.CONCLUSION: Social emergency medicine research has been growing over the past 10 years, although areas such as firearm violence and LGBTQ health have had more research activity than other topics. The field would benefit from a consensus-driven research agenda.

    View details for DOI 10.5811/westjem.2021.4.51518

    View details for PubMedID 34787563

  • Emergency Department Utilization for Emergency Conditions During COVID-19 ANNALS OF EMERGENCY MEDICINE Venkatesh, A. K., Janke, A. T., Li Shu-Xia, Rothenberg, C., Goyal, P., Terry, A., Lin, M. 2021; 78 (1): 84-91


    We use a national emergency medicine clinical quality registry to describe recent trends in emergency department (ED) visitation overall and for select emergency conditions.Data were drawn from the Clinical Emergency Department Registry, including 164 ED sites across 35 states participating in the registry with complete data from January 2019 through November 15, 2020. Overall ED visit counts, as well as specific emergency medical conditions identified by International Classification of Diseases, Tenth Revision, Clinical Modification code (myocardial infarction, cerebrovascular accident, cardiac arrest/ventricular fibrillation, and venous thromboembolisms), were tabulated. We plotted biweekly visit counts overall and across specific geographic regions.The largest declines in visit counts occurred early in the pandemic, with a nadir in April 46% lower than the 2019 monthly average. By November, overall ED visit counts had increased, but were 23% lower than prepandemic levels. The proportion of all ED visits that were for the select emergency conditions increased early in the pandemic; however, total visit counts for acute myocardial infarction and cerebrovascular disease have remained lower in 2020 compared with 2019. Despite considerable geographic and temporal variation in the trajectory of the coronavirus disease 2019 outbreak, the overall pattern of ED visits observed was similar across regions and time.The persistent decline in ED visits for these time-sensitive emergency conditions raises the concern that coronavirus disease 2019 may continue to impede patients from seeking essential care. Efforts thus far to encourage individuals with concerning signs and symptoms to seek emergency care may not have been sufficient.

    View details for DOI 10.1016/j.annemergmed.2021.01.011

    View details for Web of Science ID 000663934300021

    View details for PubMedID 33840512

    View details for PubMedCentralID PMC7805390

  • Here to chair: Gender differences in the path to leadership. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine Sethuraman, K. N., Lin, M., Rounds, K., Fang, A., Lall, M. D., Parsons, M., Linden, J. A., Gursahani, K., Raukar, N., Perman, S. M., Dobiesz, V. A. 2021


    The progress of women professionals across all sectors including academia in the past several decades has resulted in few reaching the highest echelons of leadership.1 Since the early 1990s, women have made up greater than 40% of United States (U.S.) medical school classes, yet are less likely to become full professors or hold senior leadership positions as compared to men.2.

    View details for DOI 10.1111/acem.14221

    View details for PubMedID 33511736

  • Effectiveness and Reach of the Primary Palliative Care for Emergency Medicine (PRIM-ER) Pilot Study: a Qualitative Analysis JOURNAL OF GENERAL INTERNAL MEDICINE Chung, F. R., Turecamo, S., Cuthel, A. M., Grudzen, C. R., PRIM-ER Investigators 2021; 36 (2): 296-304


    Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centered outcomes.To understand the facilitators that contributed to the success of the Primary Palliative Care for Emergency Medicine (PRIM-ER) quality improvement pilot intervention.Effectiveness was evaluated through semi-structured interviews. Reach outcomes were measured by percent of all full-time emergency providers (physicians, physician assistants, nurses) who completed the intervention education components and baseline survey assessing attitudes and knowledge on end-of-life care.Emergency medicine providers affiliated with two medical centers (N = 197). Interviews conducted with six key informants at both institutions.Interviews were recorded, transcribed, and analyzed using deductive and inductive approaches. Descriptive statistics include reach outcomes and baseline survey results.Both sites successfully implemented all components of the intervention and achieved a high level (> 75%) of intervention reach. Two themes emerged as facilitators to successful effectiveness facilitators of PRIM-ER: (1) institutional leadership support and (2) leveraging established quality improvement (QI) processes. Institutional support included leveraging leadership with authority to (a) mandate trainings; (b) substitute PRIM-ER education for normally scheduled education; and (c) provide protected time to implement intervention components. Effectiveness was also enhanced by capitalizing on existing QI processes which included (a) leveraging interdisciplinary partnerships and communication plans and (b) monitoring performance improvement data.Capitalizing on strong institutional leadership support and established QI processes enhanced the reach and effectiveness of the PRIM-ER pilot. These findings will guide the PRIM-ER researchers in scaling up the intervention in the remaining 33 sites, as well as enhance the planning of other complex quality improvement interventions in clinical Identifier: NCT03424109; Grant Number: AT009844-01.

    View details for DOI 10.1007/s11606-020-06302-2

    View details for Web of Science ID 000585616000002

    View details for PubMedID 33111240

    View details for PubMedCentralID PMC7878660

  • The terminology of social emergency medicine: Measuring social determinants of health, social risk, and social need JOURNAL OF THE AMERICAN COLLEGE OF EMERGENCY PHYSICIANS OPEN Samuels-Kalow, M. E., Ciccolo, G. E., Lin, M. P., Schoenfeld, E. M., Camargo, C. A. 2020; 1 (5): 852-856


    Emergency medicine has increasingly focused on addressing social determinants of health (SDoH) in emergency medicine. However, efforts to standardize and evaluate measurement tools and compare results across studies have been limited by the plethora of terms (eg, SDoH, health-related social needs, social risk) and a lack of consensus regarding definitions. Specifically, the social risks of an individual may not align with the social needs of an individual, and this has ramifications for policy, research, risk stratification, and payment and for the measurement of health care quality. With the rise of social emergency medicine (SEM) as a field, there is a need for a simplified and consistent set of definitions. These definitions are important for clinicians screening in the emergency department, for health systems to understand service needs, for epidemiological tracking, and for research data sharing and harmonization. In this article, we propose a conceptual model for considering SDoH measurement and provide clear, actionable, definitions of key terms to increase consistency among clinicians, researchers, and policy makers.

    View details for DOI 10.1002/emp2.12191

    View details for Web of Science ID 000648695300025

    View details for PubMedID 33145531

    View details for PubMedCentralID PMC7593464

  • Assessment of Emergency Medicine Residents' Clinical Reasoning: Validation of a Script Concordance Test WESTERN JOURNAL OF EMERGENCY MEDICINE Steinberg, E., Cowan, E., Lin, M. P., Sielicki, A., Warrington, S. 2020; 21 (4): 978-984
  • Association between care delivery interventions to enhance access and patients' perceived access in the Comprehensive Primary Care Initiative HEALTHCARE-THE JOURNAL OF DELIVERY SCIENCE AND INNOVATION Lin, M. P., MacDonald, L., Jin, J., Reddy, A. 2020; 8 (2): 100412


    The Comprehensive Primary Care (CPC) initiative was an alternative payment model implemented from 2012 to 2016 to strengthen primary care by enhancing core functions, including access to care. The association between interventions to enhance access and patients' perception of access is unknown. We performed a cross-sectional analysis of CPC practice surveys and CAHPS patient survey responses pertaining to access and timeliness in 2016. There were regional differences in both patients' perceptions of access and interventions to enhance access, but no association between interventions and patients' perceptions. Practices with fewer clinicians and whose patients had fewer chronic conditions had better perceived access.

    View details for DOI 10.1016/j.hjdsi.2020.100412

    View details for Web of Science ID 000541481500012

    View details for PubMedID 32102756

    View details for PubMedCentralID PMC8820204

  • Perception of Physician Empathy Varies With Educational Level and Gender of Patients Undergoing Low-Yield Computerized Tomographic Imaging JOURNAL OF PATIENT EXPERIENCE Kline, J. A., Lin, M. P., Hall, C. L., Puskarich, M. A., Dehon, E., Kuehl, D. R., Wang, R. C., Hess, E. P., Runyon, M. S., Wang, H., Courtney, D. 2020; 7 (3): 386-394


    Lack of empathic communication between providers and patients may contribute to low value diagnostic testing in emergency care. Accordingly, we measured the perception of physician empathy and trust in patients undergoing low-value computed tomography (CT) in the emergency department (ED).Multicenter study of ED patients undergoing CT scanning, acknowledged by ordering physicians as unlikely to show an emergent condition. Near the end of their visit, patients completed the Jefferson Scale of Patient Perception of Physician Empathy (JSPPPE), Trust in Physicians Survey (TIPS), and the Group Based Medical Mistrust Scale (GBMMS). We stratified results by patient demographics including gender, race, and education.We enrolled 305 participants across 9 sites with diverse geographic, racial, and ethnic representation. The median scores (interquartile ranges) for the JSPPPE, TIPS, and GBMMS for all patients were 29 (24-33.5), 55 (47-62), and 18 (12-29). Compared with white patients, nonwhite patients had similar JSPPPE and TIPS scores but had higher (worse) GBMMS scores. Females had significantly lower JSPPPE and TIPS scores than males, and scores were lower (worse) in females with college degrees. Patients in the lowest tier of educational status had the highest (better) JSPPPE and TIPS scores. Scores were invariant with physician characteristics.Among patients undergoing low-value CT scanning in the ED, the degree of patient perception of physician empathy and trust varied based on the patients' level of education and gender. Given this variation, an intervention to increase patient perception of physician empathy should contain individualized strategies to address these subgroups, rather than a one-size-fits-all approach.

    View details for DOI 10.1177/2374373519838529

    View details for Web of Science ID 000552748600022

    View details for PubMedID 32821799

    View details for PubMedCentralID PMC7410137

  • Shared Decision Making for Syncope in the Emergency Department: A Randomized Controlled Feasibility Trial ACADEMIC EMERGENCY MEDICINE Probst, M. A., Lin, M. P., Sze, J. J., Hess, E. P., Breslin, M., Frosch, D. L., Sun, B. C., Langan, M., Thiruganasambandamoorthy, V., Richardson, L. D. 2020; 27 (9): 853-865


    Significant practice variation is seen in the management of syncope in the emergency department (ED). We sought to evaluate the feasibility of performing a randomized controlled trial of a shared decision making (SDM) tool for low-to-intermediate-risk syncope patients presenting to the ED.We performed a randomized controlled trial of adults (≥30 years) with unexplained syncope who presented to an academic ED in the United States. Patients with a serious diagnosis identified in the ED were excluded. Patients were randomized, 1:1, to receive either usual care or a personalized syncope decision aid (SynDA) meant to facilitate SDM. Our primary outcome was feasibility, i.e., ability to enroll 50 patients in 24 months. Secondary outcomes included patient knowledge, involvement (measured with OPTION-5), rating of care, and clinical outcomes at 30 days post-ED visit.After screening 351 patients, we enrolled 50 participants with unexplained syncope from January 2017 to January 2019. The most common reason for exclusion was lack of clinical equipoise to justify SDM (n = 124). Patients in the SynDA arm tended to have greater patient involvement, as shown by higher OPTION-5 scores: 52/100 versus 27/100 (between-group difference = -25.4, 95% confidence interval = -13.5 to -37.3). Both groups had similar levels of clinical knowledge, ratings of care, and serious clinical outcomes at 30 days.Among ED patients with unexplained syncope, a randomized controlled trial of a shared decision-making tool is feasible. Although this study was not powered to detect differences in clinical outcomes, it demonstrates feasibility, while providing key lessons and effect sizes that could inform the design of future SDM trials.

    View details for DOI 10.1111/acem.13955

    View details for Web of Science ID 000523604800001

    View details for PubMedID 32147870

    View details for PubMedCentralID PMC7483321

  • US ED Opioid-Related Visits Increase, While Use of Medication for Opioid Use Disorder Undetectable, 2011-2016 JOURNAL OF GENERAL INTERNAL MEDICINE Shastry, S., Manini, A. F., Richardson, L. D., Lin, M. P. 2020; 35 (3): 965-966

    View details for DOI 10.1007/s11606-019-05249-3

    View details for Web of Science ID 000520587800062

    View details for PubMedID 31414352

    View details for PubMedCentralID PMC7080918

  • Primary Palliative Care for Emergency Medicine (PRIM-ER): Protocol for a Pragmatic, Cluster-Randomised, Stepped Wedge Design to Test the Effectiveness of Primary Palliative Care Education, Training and Technical Support for Emergency Medicine BMJ OPEN Grudzen, C. R., Brody, A. A., Chung, F. R., Cuthel, A. M., Mann, D., McQuilkin, J. A., Rubin, A. L., Swartz, J., Tan, A., Goldfeld, K. S., Abella, B., Abraham, G., Cridge, T., Asselta, R., Ballaraon, B., Bastani, A., Bastien, D., Black, A., Bledsoe, S., Bolden, D., Bolden, D., Bollman, T., Bonato, A., Elie, M., Caterino, J., Chiu, L., Chodosh, J., Christenson, M., Cooper, J., Deutsch, A., Elsayem, A., Ergorova, N., Evelyn, K., Bellolio, F., Feronti, C., Fleischer-Black, J., Frontera, N., Fuller, T., Gafford, E., Gamboa, M., Gang, M., Garduno, S., Gartner, M., Goett, R., Grange, E., Guerry, R., Harris, J., Cohen, D., Hirtz, C., Hochman, J., Horwitz, L., Isaacs, E., Johnson, M., Johnson, D., Jubanyik, K., Kim, A., Knight, G., Kulacz, R., Lamba, S., Lin, M., Linsata, H., Liroff, M., Long, E., Loprinzi-Brauer, C., Navarro, A., Madsen, T., Mclay, K., Miller, J., Morello, C., O'Neill, J., Otero, R., Ouchi, K., Richardson, L., Richardson, C., Rowe, T., Schoenfeld, E., Shaw, M., Shelley, D., Shreves, A., Siller, J., Singer, E., Southerland, L., Stuecher, L., Swor, R., Szabo, K., Torre, A., Toulson, K., Troxel, A., Urosek, R., Uspal, J., Varghese, T., Venkat, A., Wood, T., Zimny, E., PRIM-ER Investigators 2019; 9 (7): e030099


    Emergency departments (ED) care for society's most vulnerable older adults who present with exacerbations of chronic disease at the end of life, yet the clinical paradigm focuses on treatment of acute pathologies. Palliative care interventions in the ED capture high-risk patients at a time of crisis and can dramatically improve patient-centred outcomes. This study aims to implement and evaluate Primary Palliative Care for Emergency Medicine (PRIM-ER) on ED disposition, healthcare utilisation and survival in older adults with serious illness.This is the protocol for a pragmatic, cluster-randomised stepped wedge trial to test the effectiveness of PRIM-ER in 35 EDs across the USA. The intervention includes four core components: (1) evidence-based, multidisciplinary primary palliative care education; (2) simulation-based workshops; (3) clinical decision support; and (4) audit and feedback. The study is divided into two phases: a pilot phase, to ensure feasibility in two sites, and an implementation and evaluation phase, where we implement the intervention and test the effectiveness in 33 EDs over 2 years. Using Centers for Medicare and Medicaid Services (CMS) data, we will assess the primary outcomes in approximately 300 000 patients: ED disposition to an acute care setting, healthcare utilisation in the 6 months following the ED visit and survival following the index ED visit. Analysis will also determine the site, provider and patient-level characteristics that are associated with variation in impact of PRIM-ER.Institutional Review Board approval was obtained at New York University School of Medicine to evaluate the CMS data. Oversight will also be provided by the National Institutes of Health, an Independent Monitoring Committee and a Clinical Informatics Advisory Board. Trial results will be submitted for publication in a peer-reviewed journal.NCT03424109; Pre-results.

    View details for DOI 10.1136/bmjopen-2019-030099

    View details for Web of Science ID 000485269700075

    View details for PubMedID 31352424

    View details for PubMedCentralID PMC6661655

  • Trends and predictors of hospitalization after emergency department asthma visits among US Adults, 2006-2014 JOURNAL OF ASTHMA Lin, M. P., Vargas-Torres, C., Schuur, J. D., Shi, D., Wisnivesky, J., Richardson, L. D. 2020; 57 (8): 811-819


    Background: Asthma hospitalizations are an ambulatory care-sensitive condition; a majority originate in emergency departments (EDs).Objective: Describe trends and predictors of adult asthma hospitalizations originating in EDs.Methods: Observational study of ED visits resulting in hospitalization using a nationally representative sample. We tested trend in hospitalization rates from 2006 to 2014 using logistic regression, then assessed the association between hospitalization rates and patient and hospital characteristics using hierarchical multivariable regression accounting for hospital-level clustering.Results: Total ED asthma visits increased 15% from 2006 to 2014, from 1.06 to 1.22 million, while the likelihood of hospitalization decreased (20.9-18.2%, p < 0.01). Adjusting for increased asthma prevalence, ED visit rates and hospitalization rates decreased by 10 and 21%, respectively. Hospitalization was independently associated with older age, female gender (OR = 1.23, 95% CI 1.20-1.26), higher Charlson score (OR = 1.99, 95% CI 1.97-2.01), Medicaid (OR = 1.05, 95% CI 1.01-1.08) and Medicare (OR = 1.26, 95% CI 1.22-1.31) insurance, and trauma centers (OR = 1.34, 95% CI 1.12-1.60). Hospitalization was less likely for uninsured visits (OR = 0.7, 95% CI 0.67-0.73), lower income areas (OR = 0.89, 95% CI 0.85-0.93), non-metropolitan teaching hospitals (OR = 0.83, 95% CI 0.71-0.96), Midwestern (OR = 0.84, 95% CI 0.69-1.01) or Western regions (OR 0.69, 95% CI 0.56-0.83). Unmeasured hospital-specific effects account for 15.8% of variability in hospital admission rates after adjusting for patient and hospital factors.Conclusions: Total asthma ED visits increased, but prevalence-adjusted ED visits, and ED hospitalization rates have declined. Uninsured patients have disproportionately more ED visits but 30% lower odds of hospitalization. Substantial variation implies unmeasured clinical, social and environmental factors accounting for hospital-specific differences in hospitalization.

    View details for DOI 10.1080/02770903.2019.1621889

    View details for Web of Science ID 000472413800001

    View details for PubMedID 31112431

    View details for PubMedCentralID PMC8820214

  • Engagement of Accountable Care Organizations in Acute Care Redesign: Results of a National Survey JOURNAL OF GENERAL INTERNAL MEDICINE Lin, M. P., Muhlestein, D., Carr, B. G., Richardson, L. D., Wiler, J. L., Schuur, J. D. 2018; 33 (10): 1601-1603

    View details for DOI 10.1007/s11606-018-4525-4

    View details for Web of Science ID 000446086400007

    View details for PubMedID 29948805

    View details for PubMedCentralID PMC6153234

  • Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department PATIENT EDUCATION AND COUNSELING Lin, M. P., Probst, M. A., Puskarich, M. A., Dehon, E., Kuehl, D. R., Wang, R. C., Hess, E. P., Butler, K., Runyon, M. S., Wang, H., Courtney, D., Muckley, B., Hobgood, C. D., Hall, C. L., Kline, J. A. 2018; 101 (4): 717-722


    We assessed emergency department (ED) patient perceptions of how physicians can improve their language to determine patient preferences for 11 phrases to enhance physician empathy toward the goal of reducing low-value advanced imaging.Multi-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning.We enroled 305 participants across nine sites. The statement "I have carefully considered what you told me about what brought you here today" was most frequently rated as important (88%). The statement "I have thought about the cost of your medical care to you today" was least frequently rated as important (59%). Participants preferred statements indicating physicians had considered their "vital signs and physical examination" (86%), "past medical history" (84%), and "what prior research tells me about your condition" (79%). Participants also valued statements conveying risks of testing, including potential kidney injury (78%) and radiation (77%).The majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing.Our findings suggest specific phrases have the potential to enhance ED patient perceptions of physician empathy. Further research is needed to determine whether statements to convey empathy affect diagnostic testing rates.

    View details for DOI 10.1016/j.pec.2017.11.012

    View details for Web of Science ID 000428618600018

    View details for PubMedID 29173841

  • Facilitators and Barriers to Reducing Emergency Department Admissions for Chest Pain: A Qualitative Study. Critical pathways in cardiology Lin, M. P., Natsui, S., Sinnette, C., Ball, A., Weissman, J. S., Schuur, J. D. 2018; 17 (4): 201-207


    BACKGROUND: Chest pain of possible cardiac etiology is a leading reason for emergency department (ED) visits and hospitalizations nationwide. Evidence suggests outpatient management is safe and effective for low-risk patients; however, ED admission rates for chest pain vary widely. To identify barriers and facilitators to outpatient management after ED visits, we performed a multicenter qualitative study of key stakeholders.METHODS AND RESULTS: We identified Massachusetts hospitals with below-average admission rates for adult ED chest pain visits from 2010 to 2011. We performed a qualitative case study of 27 stakeholders across 4 hospitals to identify barriers and facilitators to outpatient management. Clinicians cited ability to coordinate follow-up care, including stress testing and cardiology consultation, as key facilitators of ED discharge. When these services are unavailable, or inconsistently available, they present a barrier to outpatient management. Clinicians identified pressure to maintain throughput and the lack of observation units as barriers to ED discharge. At 3 of 4 hospitals without observation units, clinicians did not use clinical protocols to guide the admission decision. At the site with a dedicated ED observation unit, low ED admission rates were attributed to clinician adherence to clinical protocols.CONCLUSIONS: In conclusion, most participants have not adopted protocols focused on reducing variation in ED chest pain admissions. Robust systems to ensure follow-up care after ED visits may reduce admission rates by mitigating the perceived risk of discharging ED patients with chest pain. Greater use of observation protocols may promote adoption of clinical guidelines and reduce admission rates.

    View details for DOI 10.1097/HPC.0000000000000145

    View details for PubMedID 30418250

  • ED-Based Care Coordination Reduces Costs for Frequent ED Users AMERICAN JOURNAL OF MANAGED CARE Lin, M. P., Blanchfield, B. B., Kakoza, R. M., Vaidya, V., Price, C., Goldner, J. S., Higgins, M., Lessenich, E., Laskowski, K., Schuur, J. D. 2017; 23 (12): 762-766


    We evaluated a pilot quality improvement intervention implemented in an urban academic medical center emergency department (ED) to improve care coordination and reduce ED visits and hospitalizations among frequent ED users.Randomized controlled trial.We identified the most frequent ED users in both the 30 days prior to the intervention and the 12 months prior to the intervention. We randomized the top 72 patients to receive either our pilot intervention or usual care. The intervention consisted of a community health worker who assisted patients with navigating care and identifying unmet social needs and an ED-based clinical team that developed interdisciplinary acute care plans for eligible patients. After 7 months, we analyzed ED visits, hospitalizations, and costs for the intervention and control groups.We randomized 72 patients to the intervention (n = 36) and control (n = 36) groups. Patients randomized to the intervention group had 35% fewer ED visits (P = .10) and 31% fewer admissions from the ED (P = .20) compared with the control group. Average ED direct costs per patient were 15% lower and average inpatient direct costs per patient were 8% lower for intervention patients compared with control patients.ED-based care coordination is a promising approach to reduce ED use and hospitalizations among frequent ED users. Our program also demonstrated a decrease in costs per patient. Future efforts to promote population health and control costs may benefit from incorporating similar programs into acute care delivery systems.

    View details for Web of Science ID 000418381400011

    View details for PubMedID 29261242

  • Emergency Physician Knowledge, Attitudes, and Behavior Regarding ACEP's Choosing Wisely Recommendations: A Survey Study ACADEMIC EMERGENCY MEDICINE Lin, M. P., Thomas Nguyen, Probst, M. A., Richardson, L. D., Schuur, J. D. 2017; 24 (6): 668-675


    In 2013, the American College of Emergency Physicians joined the Choosing Wisely campaign; however, its impact on emergency physician behavior is unknown. We assessed knowledge, attitudes, and self-reported behaviors regarding the Choosing Wisely recommendations.We performed a cross-sectional survey of emergency physicians at a national meeting. We approached 819 physicians; 765 (93.4%) completed the survey.As a result of the Choosing Wisely campaign, most respondents (64.5%) felt more comfortable discussing low-value services with patients, 54.5% reported reducing utilization, and 52.5% were aware of local efforts to promote the campaign. A majority (62.97%) of respondents were able to identify at least four of five recommendations. The most prevalent low-value practices were computed tomography (CT) brain for minor head injury (29.9%) and antibiotics for acute sinusitis (26.9%). Few respondents reported performing lumbar radiograph for nontraumatic low back pain (7.8%) and Foley catheter for patients who can void (5.6%). Respondents reported patient/family expectations as the most important reason for ordering antibiotics for sinusitis (68%) and imaging for low back pain (56.8%). However, concern for serious diagnosis was the most important reason for performing CT chest for patients with normal D-dimer (49.7%) and CT abdomen for recurrent uncomplicated renal colic (42.5%). A minority (3.8% to 26.7%) of respondents identified malpractice risk as the primary reason for performing low-value services.Despite familiarity with Choosing Wisely, many emergency physicians report performing low-value services. Primary reasons for low-value services differ: antibiotic prescribing was driven by patient/family expectations, while concern for serious diagnosis influenced advanced diagnostic imaging. Greater efforts are needed to promote effective dissemination and implementation; such efforts may be targeted based on differing reasons for low-value services.

    View details for DOI 10.1111/acem.13167

    View details for Web of Science ID 000405244600002

    View details for PubMedID 28164409

  • Estimating the Cost of Care for Emergency Department Syncope Patients: Comparison of Three Models WESTERN JOURNAL OF EMERGENCY MEDICINE Probst, M. A., McConnell, J. K., Weiss, R. E., Laurie, A. L., Yagapen, A. N., Lin, M. P., Caterino, J. M., Shah, M. N., Sun, B. C. 2017; 18 (2): 253-257


    We sought to compare three hospital cost-estimation models for patients undergoing evaluation for unexplained syncope using hospital cost data. Developing such a model would allow researchers to assess the value of novel clinical algorithms for syncope management.We collected complete health services data, including disposition, testing, and length of stay (LOS), on 67 adult patients (age 60 years and older) who presented to the emergency department (ED) with syncope at a single hospital. Patients were excluded if a serious medical condition was identified. We created three hospital cost-estimation models to estimate facility costs: V1, unadjusted Medicare payments for observation and/or hospital admission; V2: modified Medicare payment, prorated by LOS in calendar days; and V3: modified Medicare payment, prorated by LOS in hours. Total hospital costs included unadjusted Medicare payments for diagnostic testing and estimated facility costs. We plotted these estimates against actual cost data from the hospital finance department, and performed correlation and regression analyses.Of the three models, V3 consistently outperformed the others with regard to correlation and goodness of fit. The Pearson correlation coefficient for V3 was 0.88 (95% confidence interval [CI] 0.81, 0.92) with an R-square value of 0.77 and a linear regression coefficient of 0.87 (95% CI 0.76, 0.99).Using basic health services data, it is possible to accurately estimate hospital costs for older adults undergoing a hospital-based evaluation for unexplained syncope. This methodology could help assess the potential economic impact of implementing novel clinical algorithms for ED syncope.

    View details for DOI 10.5811/westjem.2016.10.31171

    View details for Web of Science ID 000412221100012

    View details for PubMedID 28210361

    View details for PubMedCentralID PMC5305134

  • Health Policy and Shared Decision Making in Emergency Care: A Research Agenda Maughan, B. C., Meisel, Z. F., Venkatesh, A. K., Lin, M. P., Perry, W. M., Schuur, J. D., Pines, J. M., Kizzie-Gillett, C. L., Vaughan, W., Grudzen, C. R. WILEY. 2016: 1380-1385


    Although the Patient Protection and Affordable Care Act and other laws have promoted the use of shared decision making (SDM) in recent years, few specific policies have addressed the opportunities and challenges of utilizing SDM in the emergency department (ED). Policies relating to physician payment, quality measurement, and medical-legal risks each present unique challenges to adoption of SDM in the ED. This article summarizes findings from a health policy breakout session of the 2016 Academic Emergency Medicine Consensus Conference "Shared Decision Making in the Emergency Department: Development of a Policy-relevant, Patient-centered Research Agenda." The objectives were to 1) describe federal and state policies that influence utilization or assessment of SDM; 2) identify policies and policy-focused knowledge gaps that serve as barriers to adoption of ED SDM; and 3) to define a consensus-based, policy-focused research agenda to support adoption of SDM in emergency care.

    View details for DOI 10.1111/acem.13098

    View details for Web of Science ID 000390562300011

    View details for PubMedID 27628463

    View details for PubMedCentralID PMC5634330

  • Hospital-level variation and predictors of admission after ED visits for atrial fibrillation: 2006 to 2011 AMERICAN JOURNAL OF EMERGENCY MEDICINE Lin, M. P., Ma, J., Weissman, J. S., Bernard, K. R., Schuur, J. D. 2016; 34 (11): 2094-2100


    Outpatient management of atrial fibrillation can be a safe alternative to inpatient admission after emergency department (ED) visits. We aim to describe trends and predictors of hospital admission for atrial fibrillation and determine the variation in admission among US hospitals.We analyzed ED visits and hospital admissions for adult patients with a principal diagnosis of atrial fibrillation or atrial flutter in the Nationwide Emergency Department Sample 2006 to 2011. We identified patient and hospital characteristics associated with admission using hierarchical multivariate logistic regression. We analyzed admission rates overall and for patients at low risk of thromboembolic complications (CHA2DS2-VASc score 0). We compared hospital-level variance with residual variance to estimate the intraclass correlation in models with and without hospital characteristics.From 2006 to 2011, annual ED visits for atrial fibrillation and atrial flutter increased by 30.9% and admission rates decreased from 69.7% to 67.4% (P= .02). Admission was associated with setting (metropolitan teaching vs nonmetropolitan, odds ratio = 1.93 [1.62-2.29]) and region (Northeast vs West, odds ratio = 2.09 [1.67-2.60]). Among patients with 0 CHA2DS2-VASc score, the national average admission rate was 46.4%. The intraclass correlation was 20.7% adjusting for patient characteristics and hospital clustering, and 19.2% after additionally adjusting for hospital variables.From 2006 to 2011, ED visits for atrial fibrillation in the United States increased by almost a third, with a minimal change in ED admission rates. One-fifth of variation in admission rates is due to hospital site and not explained by hospital characteristics. Hospital-specific practice patterns may identify opportunities to increase outpatient management.

    View details for DOI 10.1016/j.ajem.2016.07.023

    View details for Web of Science ID 000389517200008

    View details for PubMedID 27498917

  • Survey of emergency physicians regarding emergency contraception AMERICAN JOURNAL OF EMERGENCY MEDICINE Probst, M. A., Lin, M. P., Lawrence, L. G., Robey-Gavin, E., Pendery, L. S., Strayer, R. J. 2016; 34 (6): 1176-1178

    View details for DOI 10.1016/j.ajem.2016.03.056

    View details for Web of Science ID 000377338700062

    View details for PubMedID 27073136

    View details for PubMedCentralID PMC5338573