Michelle P. Lin

Emergency Physician Knowledge, Attitudes, and Behavior Regarding ACEP's Choosing Wisely Recommendations: A Survey Study

OBJECTIVEnIn 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.nnnMETHODSnWe performed a cross-sectional survey of emergency physicians at a national meeting. We approached 819 physicians; 765 (93.4%) completed the survey.nnnRESULTSnAs 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 nontraumaticxa0low 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.nnnCONCLUSIONSnDespite 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.

Estimating the cost of care for emergency department syncope patients: Comparison of three models

Introduction 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. Methods 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. Results 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). Conclusion 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.

Engagement of Accountable Care Organizations in Acute Care Redesign: Results of a National Survey

Accountable Care Organizations (ACOs) are integrated provider groups aiming to improve health care value for a population. Hospitalizations account for ~u200932% of US health care expenditures, and ED visits account for up to 6%; therefore, one strategy to improve value is to manage the acute care needs of the population in lower cost settings.1 To date, most cost-reduction efforts have focused on improving chronic disease management, for example, through medication management and decreasing readmissions.2 n nWe aim to describe how ACOs are prioritizing cost-reduction strategies related to acute unscheduled care using responses from a national survey of ACOs.

Trends in Emergency Department Visits and Admission Rates Among US Acute Care Hospitals

This observational study describes trends in emergency department visits and admission rates among US acute care hospitals using data from the National Emergency Department Survey.

Improving perceptions of empathy in patients undergoing low-yield computerized tomographic imaging in the emergency department

OBJECTIVEnWe 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.nnnMETHODSnMulti-center survey study of low-risk ED patients undergoing computerized tomography (CT) scanning.nnnRESULTSnWe 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%).nnnCONCLUSIONnThe majority of phrases were identified as important. Participants preferred statements conveying cognitive reassurance, medical knowledge and risks of testing.nnnPRACTICE IMPLICATIONSnOur 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.

Health Policy and Shared Decision Making in Emergency Care: A Research Agenda

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.