Judith H. Maselli

Trends and Characteristics of US Emergency Department Visits, 1997-2007

CONTEXT The potential effects of increasing numbers of uninsured and underinsured persons on US emergency departments (EDs) is a concern for the health care safety net. OBJECTIVE To describe the changes in ED visits that occurred from 1997 through 2007 in the adult and pediatric US populations by sociodemographic group, designation of safety-net ED, and trends in ambulatory care-sensitive conditions. DESIGN, SETTING, AND PARTICIPANTS Publicly available ED visit data from the National Hospital Ambulatory Medical Care Survey (NHAMCS) from 1997 through 2007 were stratified by age, sex, race, ethnicity, insurance status, safety-net hospital classification, triage category, and disposition. Codes from the International Classification of Diseases, Ninth Revision (ICD-9), were used to extract visits related to ambulatory care-sensitive conditions. Visit rates were calculated using annual US Census estimates. MAIN OUTCOME MEASURES Total annual visits to US EDs and ED visit rates for population subgroups. RESULTS Between 1997 and 2007, ED visit rates increased from 352.8 to 390.5 per 1000 persons (rate difference, 37.7; 95% confidence interval [CI], -51.1 to 126.5; P = .001 for trend); the increase in total annual ED visits was almost double of what would be expected from population growth. Adults with Medicaid accounted for most of the increase in ED visits; the visit rate increased from 693.9 to 947.2 visits per 1000 enrollees between 1999 and 2007 (rate difference, 253.3; 95% CI, 41.1 to 465.5; P = .001 for trend). Although ED visit rates for adults with ambulatory care-sensitive conditions remained stable, ED visit rates among adults with Medicaid increased from 66.4 in 1999 to 83.9 in 2007 (rate difference, 17.5; 95% CI, -5.8 to 40.8; P = .007 for trend). The number of facilities qualifying as safety-net EDs increased from 1770 in 2000 to 2489 in 2007. CONCLUSION These findings indicate that ED visit rates have increased from 1997 to 2007 and that EDs are increasingly serving as the safety net for medically underserved patients, particularly adults with Medicaid.

Excessive Antibiotic Use for Acute Respiratory Infections in the United States

Estimating the amount and cost of excess antibiotic use in ambulatory practice and identifying the conditions that account for most excess use are necessary to guide intervention and policy decisions. Data from the 1998 National Ambulatory Medical Care Survey, a sample survey of United States ambulatory physician practices, was used to estimate primary care office visits and antibiotic prescription rates for acute respiratory infections. Weight-averaged antibiotic costs were calculated with use of 1996 prescription marketing data and adjusted for inflation. In 1998, an estimated 76 million primary care office visits for acute respiratory infections resulted in 41 million antibiotic prescriptions. Antibiotic prescriptions in excess of the number expected to treat bacterial infections amounted to 55% (22.6 million) of all antibiotics prescribed for acute respiratory infections, at a cost of approximately

National trends in ambulatory visits and antibiotic prescribing for skin and soft-tissue infections.

726 million. Upper respiratory tract infections (not otherwise specified), pharyngitis, and bronchitis were the conditions associated with the greatest amount of excess use. This study documents that the amount and cost of excessive antibiotic use for acute respiratory infections by primary care physicians are substantial and establishes potential target rates for antibiotic treatment of selected conditions.

Effect of Spanish interpretation method on patient satisfaction in an urban walk-in clinic.

BACKGROUND Community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has emerged as a common cause of skin and soft-tissue infections (SSTIs) in the United States. It is unknown whether this development has affected the national rate of visits to primary care practices and emergency departments (EDs) and whether changes in antibiotic prescribing have occurred. METHODS We examined visits by patients with SSTIs to physician offices, hospital outpatient departments, and EDs using the National Ambulatory Medical Care Survey and National Hospital Ambulatory Medical Care Survey from 1997 to 2005. We estimated annual visit rates for all SSTIs and a subset classified as abscess/cellulitis. For abscess/cellulitis visits, we examined trends in characteristics of patients and clinical settings and in antibiotic prescribing. RESULTS Overall rate of visits for SSTIs increased from 32.1 to 48.1 visits per 1000 population (50%; P = .003 for trend), reaching 14.2 million by 2005. More than 95% of this change was attributable to visits for abscess/cellulitis, which increased from 17.3 to 32.5 visits per 1000 population (88% increase; P < .001 for trend). The largest relative increases occurred in EDs (especially in high safety-net-status EDs and in the South), among black patients, and among patients younger than 18 years. Use of antibiotics recommended for CA-MRSA increased from 7% to 28% of visits (P < .001) during the study period. Independent predictors of treatment with these antibiotics included being younger than 45 years, living in the South, and an ED setting. CONCLUSIONS The incidence of SSTIs has rapidly increased nationwide in the CA-MRSA era and appears to disproportionately affect certain populations. Although physicians are beginning to modify antibiotic prescribing practices, opportunities for improvement exist, targeting physicians caring for patients who are at high risk.

Redefining Readmission Risk Factors for General Medicine Patients

AbstractOBJECTIVE: To examine the effect of Spanish interpretation method on satisfaction with care. DESIGN: Self-administered post-visit questionnaire. SETTING: Urban, university-affiliated walk-in clinic. PARTICIPANTS: Adult, English- and Spanish-speaking patients presenting for acute care of non-emergent medical problems. MEASUREMENTS AND MAIN RESULTS: Satisfaction with overall clinic visit and with 7 provider characteristics was evaluated by multiple logistic regression, controlling for age, gender, ethnicity, education, insurance status, having a routine source of medical care, and baseline health. “Language-concordant” patients, defined as Spanish-speaking patients seen by Spanish-speaking providers and English-speaking patients, and patients using AT&T telephone interpreters reported identical overall visit satisfaction (77%; P=.57), while those using family or ad hoc interpreters were significantly less satisfied (54% and 49%; P<.01 and P=.007, respectively). AT&T interpreter use and language concordance also yielded similar satisfaction rates for provider characteristics (P>.2 for all values). Compared to language-concordant patients, patients who had family members interpret were less satisfied with provider listening (62% vs 85%; P=.003), discussion of sensitive issues (60% vs 76%; P=.02), and manner (62% vs 89%; P=.005). Patients who used ad hoc interpreters were less satisfied with provider skills (60% vs 83%; P=.02), manner (71% vs 89%; P=.02), listening (54% vs 85%; P=.002), explanations (57% vs 84%; P=.02), answers (57% vs 84%; P=.05), and support (63% vs 84%; P=.02). CONCLUSIONS: Spanish-speaking patients using AT&T telephone interpretation are as satisfied with care as those seeing language-concordant providers, while patients using family or ad hoc interpreters are less satisfied. Clinics serving a large population of Spanish-speaking patients can enhance patient satisfaction by avoiding the use of untrained interpreters, such as family or ad hoc interpreters.

The Influence of Procedure Volumes and Standardization of Care on Quality and Efficiency in Total Joint Replacement Surgery

BACKGROUND Readmissions are costly both financially for our healthcare system and emotionally for our patients. Identifying factors that increase risk for readmissions may be helpful to focus resources to optimize the discharge process and reduce avoidable readmissions. OBJECTIVE To identify factors associated with readmission within 30 days for general medicine patients. METHODS We performed a retrospective observational study of an administrative database at an urban 550-bed tertiary care academic medical center. Cohort patients were discharged from the general medicine service over a 2-year period from June 1, 2006, to May 31, 2008. Clinical, operational, and sociodemographic factors were evaluated for association with readmission. RESULTS Our cohort included 10,359 consecutive admissions (6805 patients) discharged from the general medicine service. The 30-day readmission rate was 17.0%. In multivariate analysis, factors associated with readmission included black race (odds ratio [OR], 1.43; 95% confidence interval [CI], 1.24-1.65), inpatient use of narcotics (1.33; 1.16-1.53) and corticosteroids (1.24; 1.09-1.42), and the disease states of cancer (with metastasis 1.61; 1.33-1.95; without metastasis 1.95; 1.54-2.47), renal failure (1.19; 1.05-1.36), congestive heart failure (1.30; 1.09-1.56), and weight loss (1.26; 1.09-1.47). Medicaid payer status (1.15; 0.97-1.36) had a trend toward readmission. CONCLUSION Readmission of general medicine patients within 30 days is common and associated with several easily identifiable clinical and nonclinical factors. Identification of these risk factors can allow providers to target interventions to reduce potentially avoidable readmissions.

Missed opportunities for osteoporosis treatment in patients hospitalized for hip fracture

BACKGROUND The relationship between surgeon and hospital procedure volumes and clinical outcomes in total joint arthroplasty has long fueled a debate over regionalization of care. At the same time, numerous policy initiatives are focusing on improving quality by incentivizing surgeons to adhere to evidence-based processes of care. The purpose of this study was to evaluate the independent contributions of surgeon procedure volume, hospital procedure volume, and standardization of care on short-term postoperative outcomes and resource utilization in lower-extremity total joint arthroplasty. METHODS An analysis of 182,146 consecutive patients who underwent primary total joint arthroplasty was performed with use of data entered into the Perspective database by 3421 physicians from 312 hospitals over a two-year period. Adherence to evidence-based processes of care was defined by administration of appropriate perioperative antibiotic prophylaxis, beta-blockade, and venous thromboembolism prophylaxis. Patient outcomes included mortality, length of hospital stay, discharge disposition, surgical complications, readmissions, and reoperations within the first thirty days after discharge. Hierarchical models were used to estimate the effects of hospital and surgeon procedure volume and process standardization on individual and combined surgical outcomes and length of stay. RESULTS After adjustment in multivariate models, higher surgeon volume was associated with lower risk of complications, lower rates of readmission and reoperation, shorter length of hospital stay, and higher likelihood of being discharged home. Higher hospital volume was associated with lower risk of mortality, lower risk of readmission, and higher likelihood of being discharged home. The impact of process standardization was substantial; maximizing adherence to evidence-based processes of care resulted in improved clinical outcomes and shorter length of hospital stay, independent of hospital or surgeon procedure volume. CONCLUSIONS Although surgeon and hospital procedure volumes are unquestionably correlated with patient outcomes in total joint arthroplasty, process standardization is also strongly associated with improved quality and efficiency of care. The exact relationship between individual processes of care and patient outcomes has not been established; however, our findings suggest that process standardization could help providers optimize quality and efficiency in total joint arthroplasty, independent of hospital or surgeon volume.

Radiological Imaging of Patients with Suspected Urinary Tract Stones: National Trends, Diagnoses, and Predictors

OBJECTIVES: Although osteoporosis treatment can dramatically reduce fracture risk, rates of treatment after hip fracture remain low. In‐hospital initiation of recommended medications has improved outcomes in heart disease; hospitalization for hip fracture may represent a similar opportunity for improvement. The objective of this study was to examine rates of in‐hospital treatment with a combination of calcium and vitamin D (Cal+D) and antiresorptive or bone‐forming medications in patients hospitalized for hip fractures

A Cluster Randomized Trial of Decision Support Strategies for Reducing Antibiotic Use in Acute Bronchitis

OBJECTIVES Overutilization of computed tomography (CT) is a growing public health concern due to increasing health care costs and exposure to radiation; these must be weighed against the potential benefits of CT for improving diagnoses and treatment plans. The objective of this study was to determine the national trends of CT and ultrasound (US) utilization for assessment of suspected urolithiasis in emergency departments (EDs) and if these trends are accompanied by changes in diagnosis rates for urolithiasis or other significant disorders and hospitalization rates. METHODS This was a retrospective cross-sectional analysis of ED visits from the National Hospital Ambulatory Medical Care Survey (NHAMCS) between 1996 and 2007. The authors determined the proportion of patient visits for flank or kidney pain receiving CT or US testing and calculated the diagnosis and hospitalization rates for urolithiasis and other significant disorders. Patient-specific and hospital-level variables associated with the use of CT were examined. RESULTS Utilization of CT to assess patients with suspected urolithiasis increased from 4.0% to 42.5% over the study period (p < 0.001). In contrast, the use of US remained low, at about 5%, until it decreased beginning in 2005 to 2007 to 2.4% (p = 0.01). The proportion of patients diagnosed with urolithiasis (approximately 18%, p = 0.55), with other significant diagnoses (p > 0.05), and admitted to the hospital (approximately 11%, p = 0.49) did not change significantly. The following characteristics were associated with a higher likelihood of receiving a CT scan: male sex (odd ratio [OR] = 1.83, 95% confidence interval [CI] = 1.22 to 2.77), patients presenting with severe pain (OR = 2.96, 95% CI = 1.14 to 7.65), and those triaged in 15 minutes or less (OR = 2.41, 95% CI = 1.08 to 5.37). CT utilization was lower for patients presenting to rural hospitals (vs. urban areas; OR = 0.34, 95% CI = 0.19 to 0.61) and those managed by a nonphysician health care provider (OR = 0.19, 95% CI = 0.07 to 0.53). CONCLUSIONS From 1996 to 2007, there was a 10-fold increase in the utilization of CT scan for patients with suspected kidney stone without an associated change in the proportion of diagnosis of kidney stone, diagnosis of significant alternate diagnoses, or admission to the hospital.

Does Aspirin Have a Role in Venous Thromboembolism Prophylaxis in Total Knee Arthroplasty Patients

BACKGROUND National quality indicators show little change in the overuse of antibiotics for uncomplicated acute bronchitis. We compared the effect of 2 decision support strategies on antibiotic treatment of uncomplicated acute bronchitis. METHODS We conducted a 3-arm cluster randomized trial among 33 primary care practices belonging to an integrated health care system in central Pennsylvania. The printed decision support intervention sites (11 practices) received decision support for acute cough illness through a print-based strategy, the computer-assisted decision support intervention sites (11 practices) received decision support through an electronic medical record-based strategy, and the control sites (11 practices) served as a control arm. Both intervention sites also received clinician education and feedback on prescribing practices, as well as patient education brochures at check-in. Antibiotic prescription rates for uncomplicated acute bronchitis in the winter period (October 1, 2009, through March 31, 2010) following introduction of the intervention were compared with the previous 3 winter periods in an intent-to-treat analysis. RESULTS Compared with the baseline period, the percentage of adolescents and adults prescribed antibiotics during the intervention period decreased at the printed decision support intervention sites (from 80.0% to 68.3%) and at the computer-assisted decision support intervention sites (from 74.0% to 60.7%) but increased slightly at the control sites (from 72.5% to 74.3%). After controlling for patient and clinician characteristics, as well as clustering of observations by clinician and practice site, the differences for the intervention sites were statistically significant from the control sites (P = .003 for control sites vs printed decision support intervention sites and P = .01 for control sites vs computer-assisted decision support intervention sites) but not between themselves (P = .67 for printed decision support intervention sites vs computer-assisted decision support intervention sites). Changes in total visits, 30-day return visit rates, and proportion diagnosed as having uncomplicated acute bronchitis were similar among the study sites. CONCLUSIONS Implementation of a decision support strategy for acute bronchitis can help reduce the overuse of antibiotics in primary care settings. The effect of printed vs computer-assisted decision support strategies for providing decision support was equivalent. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT00981994.