Christopher W. Baugh

Emergency department utilization after the implementation of Massachusetts health reform

STUDY OBJECTIVE Health care reform in Massachusetts improved access to health insurance, but the extent to which reform affected utilization of the emergency department (ED) for conditions potentially amenable to primary care is unclear. Our objective is to determine the relationship between health reform and ED use for low-severity conditions. METHODS We studied ED visits, using a convenience sample of 11 Massachusetts hospitals for identical 9-month periods before and after health care reform legislation was implemented in 2006. Individuals most affected by the health reform law (the uninsured and low-income populations covered by the publicly subsidized insurance products) were compared with individuals unlikely to be affected by the legislation (those with Medicare or private insurance). Our main outcome measure was the rate of overall and low-severity ED visits for the study population and the comparison population during the period before and after health reform implementation. RESULTS Total visits increased from 424,878 in 2006 to 442,102 in 2008. Low-severity visits among publicly subsidized or uninsured patients decreased from 43.8% to 41.2% of total visits for that group (difference=2.6%; 95% confidence interval [CI] 2.25% to 2.85%), whereas low-severity visits for privately insured and Medicare patients decreased from 35.7% to 34.9% of total visits for that group (difference=0.8%; 95% CI 0.62% to 0.98%), for a difference in differences of 1.8% (95% CI 1.7% to 1.9%). CONCLUSION Although overall ED volume continues to increase, Massachusetts health reform was associated with a small but statistically significant decrease in the rate of low-severity visits for those populations most affected by health reform compared with a comparison population of individuals less likely to be affected by the reform. Our findings suggest that access to health insurance is only one of a multitude of factors affecting utilization of the ED.

Emergency department observation units: A clinical and financial benefit for hospitals.

Introduction: There are nearly 120 million visits to emergency departments each year, one for every three people in the United States. Fifty percent of all hospital admissions come from this group, a marked change from the mid-1990s when the emergency department was a source of only a third of admissions. As the population increases and ages, the growth rate for emergency department visits and the resulting admissions will exceed historical trends creating a surge in demand for inpatient beds. Background: Current health care reform efforts are highlighting deficiencies in access, cost, and quality of care in the United States. The need for more inpatient capacity brings attention to short-stay admissions and whether they are necessary. Emergency department observation units provide a suitable alternate venue for many such patients at lower cost without adversely affecting access or quality. Methods: This article serves as a literature synthesis in support of observation units, with special emphasis on the clinical and financial aspects of their use. The observation medicine literature was reviewed using PubMed, and selected sources were used to summarize the current state of practice. In addition, the authors introduce a novel conceptual framework around measures of observation unit efficiency. Findings and Practice Implications: Observation units provide high-quality and efficient care to patients with common complaints seen in the emergency department. More frequent use of observation can increase patient safety and satisfaction while decreasing unnecessary inpatient admissions and improving fiscal performance for both emergency departments and the hospitals in which they operate. For institutions with the volume to justify the fixed costs of operating an observation unit, the dominant strategy for all stakeholders is to create one.

Use of observation care in US emergency departments, 2001 to 2008.

Background Observation care is a core component of emergency care delivery, yet, the prevalence of emergency department (ED) observation units (OUs) and use of observation care after ED visits is unknown. Our objective was to describe the 1) prevalence of OUs in United States (US) hospitals, 2) clinical conditions most frequently evaluated with observation, and 3) patient and hospital characteristics associated with use of observation. Methods Retrospective analysis of the proportion of hospitals with dedicated OUs and patient disposition after ED visit (discharge, inpatient admission or observation evaluation) using the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 2001 to 2008. NHAMCS is an annual, national probability sample of ED visits to US hospitals conducted by the Center for Disease Control and Prevention. Logistic regression was used to assess hospital-level predictors of OU presence and polytomous logistic regression was used for patient-level predictors of visit disposition, each adjusted for multi-level sampling data. OU analysis was limited to 2007–2008. Results In 2007–2008, 34.1% of all EDs had a dedicated OU, of which 56.1% were under ED administrative control (EDOU). Between 2001 and 2008, ED visits resulting in a disposition to observation increased from 642,000 (0.60% of ED visits) to 2,318,000 (1.87%, p<.05). Chest pain was the most common reason for ED visit resulting in observation and the most common observation discharge diagnosis (19.1% and 17.1% of observation evaluations, respectively). In hospital-level adjusted analysis, hospital ownership status (non-profit or government), non-teaching status, and longer ED length of visit (>3.6 h) were predictive of OU presence. After patient-level adjustment, EDOU presence was associated with increased disposition to observation (OR 2.19). Conclusions One-third of US hospitals have dedicated OUs and observation care is increasingly used for a range of clinical conditions. Further research is warranted to understand the quality, cost and efficiency of observation care.

Randomized Clinical Trial of an Emergency Department Observation Syncope Protocol Versus Routine Inpatient Admission

STUDY OBJECTIVE Older adults are frequently hospitalized from the emergency department (ED) after an episode of unexplained syncope. Current admission patterns are costly, with little evidence of benefit. We hypothesize that an ED observation syncope protocol will reduce resource use without adversely affecting patient-oriented outcomes. METHODS This randomized trial at 5 EDs compared an ED observation syncope protocol to inpatient admission for intermediate-risk adults (≥50 years) presenting with syncope or near syncope. Primary outcomes included inpatient admission rate and length of stay. Secondary outcomes included 30-day and 6-month serious outcomes after hospital discharge, index and 30-day hospital costs, 30-day quality-of-life scores, and 30-day patient satisfaction. RESULTS Study staff randomized 124 patients. Observation resulted in a lower inpatient admission rate (15% versus 92%; 95% confidence interval [CI] difference -88% to -66%) and shorter hospital length of stay (29 versus 47 hours; 95% CI difference -28 to -8). Serious outcome rates after hospital discharge were similar for observation versus admission at 30 days (3% versus 0%; 95% CI difference -1% to 8%) and 6 months (8% versus 10%; 95% CI difference -13% to 9%). Index hospital costs in the observation group were

Observation Care — High-Value Care or a Cost-Shifting Loophole?

629 (95% CI difference -

Critical pathways for post-emergency outpatient diagnosis and treatment: tools to improve the value of emergency care.

1,376 to -

Estimating Observation Unit Profitability with Options Modeling

56) lower than in the admission group. There were no differences in 30-day quality-of-life scores or in patient satisfaction. CONCLUSION An ED observation syncope protocol reduced the primary outcomes of admission rate and hospital length of stay. Analyses of secondary outcomes suggest reduction in index hospital costs, with no difference in safety events, quality of life, or patient satisfaction. Our findings suggest that an ED observation syncope protocol can be replicated and safely reduce resource use.

Healthcare costs associated with rivaroxaban or warfarin use for the treatment of venous thromboembolism

Protocolized observation care in dedicated hospital units can result in higher-value care for some conditions, but by treating observation billing for inpatient care the same as for observation-unit care, current policy promotes cost shifting without rewarding higher value.

National Cost Savings From Observation Unit Management of Syncope

The decision to admit a patient to the hospital after an emergency department (ED) visit is expensive, frequently not evidence-based, and variable. Outpatient critical pathways are a promising approach to reduce hospital admission after emergency care. Critical pathways exist to risk stratify patients for potentially serious diagnoses (e.g., acute myocardial infarction [AMI]) or evaluate response to therapy (e.g., community-acquired pneumonia) within a short time period (i.e., less than 36 hours), to determine if further hospital-based acute care is needed. Yet, such pathways are variably used while many patients are admitted for conditions for which they could be treated as outpatients. In this article, the authors propose a model of post-ED critical pathways, describe their role in emergency care, list common diagnoses that are amenable to critical pathways in the outpatient setting, and propose a research agenda to address barriers and solutions to increase the use of outpatient critical pathways. If emergency providers are to routinely conduct rapid evaluations in outpatient or observation settings, they must have several conditions at their disposal: 1) evidence-based tools to accurately risk stratify patients for protocolized care, 2) systems of care that reliably facilitate workup in the outpatient setting, and 3) a medical environment conducive to noninpatient pathways, with aligned risks and incentives among patients, providers, and payers. Increased use of critical pathways after emergency care is a potential way to improve the value of emergency care.

Minimizing Attrition for Multisite Emergency Care Research

BACKGROUND Over the past two decades, the use of observation units to treat such common conditions as chest pain, asthma, and others has greatly increased. These units allow patients to be directed out of emergency department (ED) acute care beds while potentially avoiding inpatient admission. Many studies have demonstrated the clinical effectiveness of care delivered in such a setting compared to the ED or inpatient ward. However, there are limited data published about observation unit finance. METHODS Using the economic principles of stock options, opportunity costs, and net present value (NPV), a model that captures the value generated by admitting a patient to an observation unit was derived. In addition, an appendix is included showing how this model can be used to calculate the dollar value of an observation unit admission. RESULTS A model is presented that captures more complexity of observation finance than the simple difference between payments and costs. The calculated estimate in the Appendix suggests that the average value of a single observation unit admission was about