Dr. Lin is an emergency physician and health services researcher whose goal is to transform acute care delivery to best meet the needs of those who experience the greatest barriers to accessing health care. Her active NIH-funded research portfolio aims to develop a novel patient-reported outcome measure for emergency asthma care; evaluate post-acute care transitions and outcomes for high-risk populations; and enhance 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 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 National Quality Forum's All-Cause Admissions and Readmissions Standing Committee, with responsibility for issuing endorsement recommendations pertaining to both all-cause and condition-specific admissions and readmissions quality measures to 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.
- Emergency Medicine
Clinical Instructor, Emergency Medicine
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
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)
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
Diversity and Identity
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.
Decline in US Emergency Department admission rates driven by critical pathway conditions, 2006-2014
AMERICAN JOURNAL OF EMERGENCY MEDICINE
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
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
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
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 2018; 178 (12): 1708-1710
Cost variation and revisit rate for adult patients with asthma presenting to the emergency department.
The American journal of emergency medicine
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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
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 settings.ClinicalTrials.gov 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
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 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
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
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
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 2020; 35 (3): 965-966
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
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
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 2018; 33 (10): 1601-1603
Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department
PATIENT EDUCATION AND COUNSELING
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
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
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
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
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
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
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 2016; 34 (6): 1176-1178