Peter B. Smulowitz

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.

Increased use of the emergency department after health care reform in Massachusetts.

STUDY OBJECTIVE With implementation of the Patient Protection and Affordable Care Act, 30 million individuals are predicted to gain access to health insurance. The experience in Massachusetts, which implemented a similar reform beginning in 2006, should provide important lessons about the effect of health care reform on emergency department (ED) utilization. Our objective is to understand the extent to which Massachusetts health care reform was associated with changes in ED utilization. METHODS We compared changes in ED utilization at the population level for individuals from areas of the state that were affected minimally by health care reform with those from areas that were affected the most, as well as for those younger than 65 years and aged 65 years or older. We used a difference-in-differences identification strategy to compare rates of ED visits in the prereform period, during the reform, and in the postreform period. Because we did not have population-level data on insurance status, we estimated area-level insurance rates by using the percentage of actual visits made during each period by individuals with insurance. RESULTS We studied 13.3 million ED visits during 2004 to 2009. Increasing insurance coverage in Massachusetts was associated with increasing use of the ED; these results were consistent across all specifications, including the younger than 65 years versus aged 65 years or older comparison. Depending on the model used, the implementation of health care reform was estimated to result in an increase in ED visits per year of between 0.2% and 1.2% within reform and 0.2% and 2.2% postreform compared with the prereform period. CONCLUSION The implementation of health care reform in Massachusetts was associated with a small but consistent increase in the use of the ED across the state. Whether this was due to the elimination of financial barriers to seeking care in the ED, a persistent shortage in access to primary care for those with insurance, or some other cause is not entirely clear and will need to be addressed in future research.

Ex vivo cardiac allograft preservation by continuous perfusion techniques.

The current technique of cardiac preservation for clinical transplantation by infusion of cold cardioplegia and immersion of the heart in an isotonic saline bath at 4°C limits safe tissue preservation time to 4 to 6 hours. The myriad of benefits to be gained by extending cardiac preservation time has prompted the search for alternatives to hypothermic immersion of the heart, the most promising of which involves techniques of coronary artery perfusion. Countless studies have shown the benefits of long-term storage of donor hearts by perfusion rather than the immersion technique. Continuous perfusion preservation has three basic advantages over simple immersion. Perfusion preservation with oxygen carrying solutions has the advantage of preventing ischemia, anaerobic metabolism, and reperfusion injury. Second, nutritional supplementation and provision of substrate can be more effectively delivered to myocardial cells. Third, continuous perfusion preservation effects the clearance of metabolic waste products from the coronary circulation. The composition of the ideal perfusion solution and optimal preservation conditions remain incompletely defined.

Frequent ED users: are most visits for mental health, alcohol, and drug-related complaints?☆ , ☆☆ ,★,★★

STUDY OBJECTIVE To determine whether frequent emergency department (ED) users are more likely to make at least one and a majority of visits for mental health, alcohol, or drug-related complaints compared to non-frequent users. METHODS We performed a retrospective cohort study exploring frequent ED use and ED diagnosis at a single, academic hospital and included all ED patients between January 1 and December 31, 2010. We compared differences in ED visits with a primary International Classification of Diseases, 9th Revision visit diagnosis of mental health, alcohol or drug-related diagnoses between non-frequent users (<4 visits during previous 12-months) and frequent (repeat [4-7 visits], highly frequent [8-18 visits] and super frequent [≥19 visits]) users in univariate and multivariable analyses. RESULTS Frequent users (2496/65201 [3.8%] patients) were more likely to make at least one visit associated with mental health, alcohol, or drug-related diagnoses. The proportion of patients with a majority of visits related to any of the three diagnoses increased from 5.8% among non-frequent users (3616/62705) to 9.4% among repeat users (181/1926), 13.1% among highly frequent users (62/473), and 25.8% (25/97 patients) in super frequent users. An increasing proportion of visits with alcohol-related diagnoses was observed among repeat, highly frequent, and super frequent users but was not found for mental health or drug-related complaints. CONCLUSION Frequent ED users were more likely to make a mental health, alcohol or drug-related visit, but a majority of visits were only noted for those with alcohol-related diagnoses. To address frequent ED use, interventions focusing on managing patients with frequent alcohol-related visits may be necessary.

Disclosure, Apology, and Offer Programs: Stakeholders’ Views of Barriers to and Strategies for Broad Implementation

CONTEXT The Disclosure, Apology, and Offer (DA&O) model, a response to patient injuries caused by medical care, is an innovative approach receiving national attention for its early success as an alternative to the existing inherently adversarial, inefficient, and inequitable medical liability system. Examples of DA&O programs, however, are few. METHODS Through key informant interviews, we investigated the potential for more widespread implementation of this model by provider organizations and liability insurers, defining barriers to implementation and strategies for overcoming them. Our study focused on Massachusetts, but we also explored themes that are broadly generalizable to other states. FINDINGS We found strong support for the DA&O model among key stakeholders, who cited its benefits for both the liability system and patient safety. The respondents did not perceive any insurmountable barriers to broad implementation, and they identified strategies that could be pursued relatively quickly. Such solutions would permit a range of organizations to implement the model without legislative hurdles. CONCLUSIONS Although more data are needed about the outcomes of DA&O programs, the model holds considerable promise for transforming the current approach to medical liability and patient safety.

Cardiac function after eight hour storage by using polyethylene glycol hemoglobin versus crystalloid perfusion.

Efforts to extend myocardial preservation for transplantation by crystalloid perfusion have been limited by edema and compromised function. We hypothesized that hypothermic perfusion preservation with a polyethylene glycol (PEG) conjugated hemoglobin solution may extend preservation times. The purpose of this study was to compare cardiac function after continuous perfusion by using a hypocalcemic, normokalemic crystalloid perfusate with and without the addition of PEG-hemoglobin (Hb). The hearts of 20 anesthetized and ventilated New Zealand White rabbits were harvested after cold cardioplegic arrest. Group I (n = 10) hearts were continuously perfused with a hypocalcemic, normokalemic 3% bovine PEG-Hb solution at 20°C and 30 mm Hg for 8 hours. Group II (n = 10) hearts were continuously perfused with an identical crystalloid solution without PEG-Hb for 8 hours under the same conditions as group I hearts. Cardiac function was measured with a left ventricular force transducer after transfer to a standard crystalloid Langendorff circuit at 37°C and an aortic root pressure of 59 mm Hg. After 8 hours of perfusion preservation, heart rate was similar for groups I and II (p = not significant [NS]). Coronary blood flow after and during preservation was similar between PEG-Hb and crystalloid preserved hearts (p = NS). Left ventricular developed pressure, peak dP/d t, and peak −dP/d t were superior in hearts preserved with PEG-Hb. Percent water of total ventricular weight was 82.0% for group I and 81.6% for group II (p = NS). Continuous perfusion preservation of rabbit hearts for 8 hours with a hypocalcemic normokalemic PEG-Hb based solution at 30 mm Hg and 20°C yields left ventricular function that is superior to perfusion with a similar crystalloid solution without PEG-Hb, despite similar myocardial edema and coronary flow. Extended cardiac perfusion preservation with this PEG-Hb based solution deserves further study, including comparison with traditional cardioplegic preservation solutions.

The effect of a CT and MR preauthorization program on ED utilization

OBJECTIVES To determine if a new outpatient preauthorization process for radiologic studies was associated with a change in emergency department (ED) CT and MRI utilization rates. METHODS This was a retrospective study set in an urban tertiary teaching hospital. Subjects included all nonadmitted ED patients who had either a CT or MRI during a control or preauthorization period. The study group consisted of those patients whose insurance required preauthorization. The control group consisted of those patients for whom preauthorization was not required. We used a multiple regression with autoregressive error adjusting for seasonal and monthly variation to obtain the rates of change of CT and MRI usage over time for the control and preauthorization periods. RESULTS The control period consisted of 29,303 ED visits over 54 weeks not resulting in hospital admission. The preauthorization period contained 33,858 patients over 64 weeks. The baseline ordering of CT and MRI was not significantly different between the groups. After controlling for seasonal and monthly variation, our results demonstrated that while both insurance groups demonstrated an increase in use of CT and MRI from the control to preauthorization periods, there is a statistically significant increase only in the rate of MRI utilization in the study group during the preauthorization period. CONCLUSION A telephone preauthorization process for radiological studies produced a statistically significant change in the rate of ordering MRI studies, but not CT, in the study group. We conclude that this preauthorization process may have resulted in additional ED visits for outpatient MR scans.

Comparison of 1-Day Emergency Department Observation and Inpatient Ward for 1-Day Admissions in Syncope Patients

BACKGROUND In an era of increasing health care costs, the need for hospitalization is being scrutinized. In particular, 1-day hospitalizations are thought to be especially costly and unnecessary, and, increasingly, emergency department observation units (EDOUs) are being used as alternatives. OBJECTIVE Our aim was to determine the differences in outcomes and diagnoses between 1-day inpatient and EDOU stays for syncope. METHODS We retrospectively reviewed a cohort of patients with syncope who were seen in an urban ED with 1-day admission to an inpatient ward, EDOU, or full hospitalization. Etiology of syncope was classified as benign (vasovagal, dehydration), serious (dysrhythmia, sepsis, stroke/intracranial bleed, hemorrhage, valvular, ischemia, pulmonary embolism), or unknown. Data were analyzed using Fishers exact test and t-test. RESULTS One hundred and seventy-two of 351 patients were >1-day admissions, 152 (85%) were admitted for 1 day, and 27 (15%) were admitted to EDOU. The mean (standard deviation [SD]) age when admitted to the hospital was significantly higher at 72 (18.4) years for > 1-day admissions and 68.8 (19.6) years for 1-day admissions vs. 53.0 (18.9) years for EDOU patients (p < 0.01). For fully admitted patients, 36% had benign etiologies of syncope and 38% had serious causes of syncope; in 1-day admitted patients, 48% had benign etiologies and 14% had serious causes. Among EDOU patients, 44% had benign etiologies and none were serious. One-day patients were more likely to have unknown causes of syncope at discharge (36%; 95% confidence interval 0.28 to 0.43) when compared with admitted patients (26%; 95% CI 0.2 to 0.33); similarly, observation patients were more likely to be discharged without a diagnosis (56%; 95% CI 0.37 to 0.74; p ≤ 0.05). CONCLUSIONS EDOU patients were less likely than patients admitted to the hospital to be discharged with an etiology of their syncope. Future EDOU protocols can benefit from set admission criteria and standardized evaluation protocols to facilitate maximal use of EDOU for syncope.

Recovery of cardiac function after standard hypothermic storage versus preservation with Peg-hemoglobin.

Preservation of the heart for transplantation after infusion of cardioplegia and extirpation of a cardiac allograft results in an ischemic insult to the myocardium. This ischemic insult may lead to a loss of function in the transplanted heart. Hypothermic perfusion preservation with an oxygen hemoglobin carrying solution may avert ischemic injury and lead to improved recovery of cardiac function. The purpose of this study was to compare cardiac function after 8 hours of continuous hypothermic perfusion with a unique polyethylene-glycol-hemoglobin (PEG-Hb) solution to hearts preserved by 4 hours of hypothermic ischemic storage. Freshly extirpated hearts served as functional controls. The hearts of 26 anesthetized and intubated New Zealand white rabbits were harvested after cold cardioplegic arrest. Group I (n = 12) hearts were perfused with a PEG-Hb solution at 20°C and 30 mm Hg for 8 hours. PO2 was maintained ≥ 500 mm Hg. Group II (n = 7) hearts were preserved by cold ischemic storage for 4 hours at 4°C. Group III (n = 7) were tested immediately after harvest. Left ventricular (LV) function was measured in the nonworking state at 15 minutes, 1 hour, and 2 hours after transfer to a standard crystalloid Langendorff circuit. Measurement of LV developed pressure, peak + dP/dt and −dP/dt revealed a superior trend between Group I and Group II hearts in comparison with freshly extirpated hearts. Heart rate was similar among all groups throughout testing (p = ns). Coronary blood flow was not significantly different between groups. Continuous perfusion preservation of rabbit hearts for 8 hours with PEG-Hb solution at 30 mm Hg and 20°C yielded LV function that was similar to 4 hours of ischemic hypothermic storage. Furthermore, return of cardiac function after 8 hours of perfusion preservation using this PEG-Hb solution may be superior to that obtained in freshly extirpated hearts. These data suggest that some recovery of myocardial function may occur during perfusion preservation with this PEG-Hb solution after the ischemic insult of cardioplegic arrest. Continuous perfusion preservation using this PEG-Hb solution deserves further investigation in large animal transplant models.

Physician Variability in Management of Emergency Department Patients with Chest Pain

Introduction Chest pain is a common emergency department (ED) presentation accounting for 8–10 million visits per year in the United States. Physician-level factors such as risk tolerance are predictive of admission rates. The recent advent of accelerated diagnostic pathways and ED observation units may have an impact in reducing variation in admission rates on the individual physician level. Methods We conducted a single-institution retrospective observational study of ED patients with a diagnosis of chest pain as determined by diagnostic code from our hospital administrative database. We included ED visits from 2012 and 2013. Patients with an elevated troponin or an electrocardiogram (ECG) demonstrating an ST elevation myocardial infarction were excluded. Patients were divided into two groups: “admission” (this included observation and inpatients) and “discharged.” We stratified physicians by age, gender, residency location, and years since medical school. We controlled for patient- and hospital-related factors including age, gender, race, insurance status, daily ED volume, and lab values. Results Of 4,577 patients with documented dispositions, 3,252 (70.9%) were either admitted to the hospital or into observation (in an ED observation unit or in the hospital), while 1,333 (29.1%) were discharged. Median number of patients per physician was 132 (interquartile range 89–172). Average admission rate was 73.7±9.5% ranging from 54% to 96%. Of the 3,252 admissions, 2,638 (81.1%) were to observation. There was significant variation in the admission rate at the individual physician level with adjusted odds ratio ranging from 0.42 to 5.8 as compared to the average admission. Among physicians’ characteristics, years elapsed since finishing medical school demonstrated a trend towards association with a higher admission probability. Conclusion There is substantial variation among physicians in the management of patients presenting with chest pain, with physician experience playing a role.