Mary E. Reed

Immediate and Delayed Traumatic Intracranial Hemorrhage in Patients With Head Trauma and Preinjury Warfarin or Clopidogrel Use

STUDY OBJECTIVE Patients receiving warfarin or clopidogrel are considered at increased risk for traumatic intracranial hemorrhage after blunt head trauma. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage in these patients, however, are unknown. The objective of this study is to address these gaps in knowledge. METHODS A prospective, observational study at 2 trauma centers and 4 community hospitals enrolled emergency department (ED) patients with blunt head trauma and preinjury warfarin or clopidogrel use from April 2009 through January 2011. Patients were followed for 2 weeks. The prevalence of immediate traumatic intracranial hemorrhage and the cumulative incidence of delayed traumatic intracranial hemorrhage were calculated from patients who received initial cranial computed tomography (CT) in the ED. Delayed traumatic intracranial hemorrhage was defined as traumatic intracranial hemorrhage within 2 weeks after an initially normal CT scan result and in the absence of repeated head trauma. RESULTS A total of 1,064 patients were enrolled (768 warfarin patients [72.2%] and 296 clopidogrel patients [27.8%]). There were 364 patients (34.2%) from Level I or II trauma centers and 700 patients (65.8%) from community hospitals. One thousand patients received a cranial CT scan in the ED. Both warfarin and clopidogrel groups had similar demographic and clinical characteristics, although concomitant aspirin use was more prevalent among patients receiving clopidogrel. The prevalence of immediate traumatic intracranial hemorrhage was higher in patients receiving clopidogrel (33/276, 12.0%; 95% confidence interval [CI] 8.4% to 16.4%) than patients receiving warfarin (37/724, 5.1%; 95% CI 3.6% to 7.0%), relative risk 2.31 (95% CI 1.48 to 3.63). Delayed traumatic intracranial hemorrhage was identified in 4 of 687 (0.6%; 95% CI 0.2% to 1.5%) patients receiving warfarin and 0 of 243 (0%; 95% CI 0% to 1.5%) patients receiving clopidogrel. CONCLUSION Although there may be unmeasured confounders that limit intergroup comparison, patients receiving clopidogrel have a significantly higher prevalence of immediate traumatic intracranial hemorrhage compared with patients receiving warfarin. Delayed traumatic intracranial hemorrhage is rare and occurred only in patients receiving warfarin. Discharging patients receiving anticoagulant or antiplatelet medications from the ED after a normal cranial CT scan result is reasonable, but appropriate instructions are required because delayed traumatic intracranial hemorrhage may occur.

Validation of an Algorithm for Categorizing the Severity of Hospital Emergency Department Visits

Background:Differentiating between appropriate and inappropriate resource use represents a critical challenge in health services research. The New York University Emergency Department (NYU ED) visit severity algorithm attempts to classify visits to the ED based on diagnosis, but it has not been formally validated. Objective:To assess the validity of the NYU algorithm. Research Design:A longitudinal study in a single integrated delivery system from January 1999 to December 2001. Subjects:A total of 2,257,445 commercial and 261,091 Medicare members of an integrated delivery system. Measures:ED visits were classified as emergent, nonemergent, or intermediate severity, using the NYU ED algorithm. We examined the relationship between visit-severity and the probability of future hospitalizations and death using a logistic model with a general estimating equation approach. Results:Among commercially insured subjects, ED visits categorized as emergent were significantly more likely to result in a hospitalization within 1-day (odds ratio = 3.37, 95% CI: 3.31–3.44) or death within 30-days (odds ratio = 2.81, 95% CI: 2.62–3.00) than visits categorized as nonemergent. We found similar results in Medicare patients and in sensitivity analyses using different probability thresholds. ED overuse for nonemergent conditions was not related to socio-economic status or insurance type. Conclusions:The evidence presented supports the validity of the NYU ED visit severity algorithm for differentiating ED visits based on need for hospitalization and/or mortality risk; therefore, it can contribute to evidence-based policies aimed at reducing the use of the ED for nonemergencies.

Outpatient Electronic Health Records and the Clinical Care and Outcomes of Patients With Diabetes Mellitus

BACKGROUND Physicians can receive federal payments for meaningful use of complete certified electronic health records (EHRs). Evidence is limited on how EHR use affects clinical care and outcomes. OBJECTIVE To examine the association between use of a commercially available certified EHR and clinical care processes and disease control in patients with diabetes. DESIGN Quasi-experimental design with outpatient EHR implementation sequentially across 17 medical centers. Multivariate analyses adjusted for patient characteristics, medical center, time trends, and facility-level clustering. SETTING Kaiser Permanente Northern California, an integrated delivery system. PATIENTS 169 711 patients with diabetes mellitus. INTERVENTION Use of a commercially available certified EHR. MEASUREMENTS Drug treatment intensification and hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein cholesterol (LDL-C) testing and values. RESULTS Use of an EHR was associated with statistically significant improvements in treatment intensification after HbA(1c) values of 9% or greater (odds ratio, 1.10 [95% CI, 1.05 to 1.15]) or LDL-C values of 2.6 to 3.3 mmol/L (100 to 129 mg/dL) (odds ratio, 1.06 [CI, 1.00 to 1.12]); increases in 1-year retesting for HbA(1c) and LDL-C levels among all patients, with the most dramatic change among patients with the worst disease control (HbA(1c) levels ≥9% or LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]); and decreased 90-day retesting among patients with HbA(1c) levels less than 7% or LDL-C levels less than 2.6 mmol/L (<100 mg/dL). The EHR was also associated with statistically significant reductions in HbA(1c) and LDL-C levels, with the largest reductions among patients with the worst control (0.06-mmol/L [2.19-mg/dL] reduction among patients with baseline LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]; P < 0.001). LIMITATION The EHR was implemented in a setting with strong baseline performance on cardiovascular care quality measures. CONCLUSION Use of a commercially available certified EHR was associated with improved drug treatment intensification, monitoring, and physiologic control among patients with diabetes, with greater improvements among patients with worse control and less testing in patients already meeting guideline-recommended glycemic and lipid targets. PRIMARY FUNDING SOURCE National Institute of Diabetes and Digestive and Kidney Diseases.

Coping with prescription drug cost sharing: knowledge, adherence, and financial burden.

OBJECTIVE Assess patient knowledge of and response to drug cost sharing. STUDY SETTING Adult members of a large prepaid, integrated delivery system. STUDY DESIGN/DATA COLLECTION Telephone interviews with 932 participants (72 percent response rate) who reported knowledge of the structures and amounts of their prescription drug cost sharing. Participants reported cost-related changes in their drug adherence, any financial burden, and other cost-coping behaviors. Actual cost sharing amounts came from administrative databases. PRINCIPAL FINDINGS Overall, 27 percent of patients knew all of their drug cost sharing structures and amounts. After adjustment for individual characteristics, additional patient cost sharing structures (tiers and caps), and higher copayment amounts were associated with reporting decreased adherence, financial burden, or other cost-coping behaviors. CONCLUSIONS Patient knowledge of their drug benefits is limited, especially for more complex cost sharing structures. Patients also report a range of responses to greater cost sharing, including decreasing adherence.

The Digital Divide and Patient Portals: Internet Access Explained Differences in Patient Portal Use for Secure Messaging by Age, Race, and Income.

Background:Online access to health records and the ability to exchange secure messages with physicians can improve patient engagement and outcomes; however, the digital divide could limit access to web-based portals among disadvantaged groups. Objectives:To understand whether sociodemographic differences in patient portal use for secure messaging can be explained by differences in internet access and care preferences. Research Design:Cross-sectional survey to examine the association between patient sociodemographic characteristics and internet access and care preferences; then, the association between sociodemographic characteristics and secure message use with and without adjusting for internet access and care preference. Subjects:One thousand forty-one patients with chronic conditions in a large integrated health care delivery system (76% response rate). Measures:Internet access, portal use for secure messaging, preference for in-person or online care, and sociodemographic and health characteristics. Results:Internet access and preference mediated some of the differences in secure message use by age, race, and income. For example, using own computer to access the internet explained 52% of the association between race and secure message use and 60% of the association between income and use (Sobel-Goodman mediation test, P<0.001 for both). Education and sex-related differences in portal use remained statistically significant when controlling for internet access and preference. Conclusions:As the availability and use of patient portals increase, it is important to understand which patients have limited access and the barriers they may face. Improving internet access and making portals available across multiple platforms, including mobile, may reduce some disparities in secure message use.

High-Deductible Health Insurance Plans: Efforts To Sharpen A Blunt Instrument

High deductible-based health insurance plans require consumers to pay for care until reaching the deductible amount. However, information is limited on how well consumers understand their benefits and how they respond to these costs. In telephone interviews, we found that consumers had limited knowledge about their deductibles yet frequently reported changing their care-seeking behavior because of the cost. Poor knowledge limited the effects of the deductible design, with some consumers avoiding care for services that were exempt from the deductible. Consumers need more information and decision support to understand their benefits and to differentiate when care is necessary, discretionary, or unnecessary.

Cost-sharing: Patient knowledge and effects on seeking emergency department care

BackgroundThe use of cost-sharing to control healthcare expenditures is increasing, but there is scant information about patients’ knowledge of cost-sharing or its influence on behavior. ObjectiveThe objective of this study was to evaluate what patients know about their individual levels of cost-sharing and how it influences decisions to seek care. Study DesignWe conducted a cross-sectional telephone survey with a 69% response rate. SubjectsWe studied a stratified random sample of 695 adult patients in an integrated delivery system: 266 subjects ≥65 years, 218 low-income subjects, and 211 subjects from the overall membership. MeasuresWe used perceived and actual levels of copayments for emergency department (ED) visits, office visits, and prescription drugs; and self-reports of copayment-related behavior changes. ResultsOne third of subjects correctly reported their ED copayment, whereas three fourths correctly reported their prescription drug and office visit copayments. Over half of the subjects (57%) underestimated their ED copayment by

Care-seeking behavior in response to emergency department copayments.

20 or more. Among patients who reported having any copayment, 11% described changing their behavior because of the copayment, ie, delayed or avoided emergency care. The perceived copayment level was strongly associated with behavior change (odds ratio, 3.9). Other significant factors included having more ED visits in the past 12 months and having a low health status. ConclusionsPatients have less knowledge of their ED cost-sharing levels than for other services. The perceived copayment amount was strongly associated with avoidance of or delays in emergency care. Further research is needed to determine whether these responses reflect greater efficiency or harmful decisions.

Risk of Traumatic Intracranial Hemorrhage in Patients with Head Injury and Preinjury Warfarin or Clopidogrel Use

Background:Patients are increasingly paying for more of their medical care through cost-sharing, yet little is known about how patients change the ways that they seek care in response. Objective:We sought to assess how patients change their care-seeking behavior in response to emergency department (ED) copayments. Research Design:Telephone interviews with a stratified random sample of adult members of a large integrated delivery system. Subjects:There were 932 respondents (72% response rate). Measures:We examined participants’ knowledge of their copayment level for ED services, and measures of how the cost-sharing affected their decisions about where or when to seek care. Results:Overall, 82% of participants faced a copayment for ED services (ranging between

In Consumer-Directed Health Plans, A Majority Of Patients Were Unaware Of Free Or Low-Cost Preventive Care

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