Robin M. Weinick

Emergency department crowding: Consensus development of potential measures

STUDY OBJECTIVE We identify measures of emergency department (ED) and hospital workflow that would be of value in understanding, monitoring, and managing crowding. METHODS A national group of 74 experts developed 113 potential measures using a conceptual model of ED crowding that segmented the measures into input, throughput, and output categories. Ten investigators then used group consensus methods to revise and consolidate them into a refined set of 30 measures that were rated by all 74 experts, who used a magnitude estimation technique on a Web site. Each measure was compared with a standard to obtain numeric ratings for feasibility, affordability, early warning potential, long-term planning potential, a summary rating of operational usefulness, and research potential. After review of the comprehensiveness of the resulting measures, 8 additional measures were developed and also rated by all reviewers. RESULTS The original set of 113 measures (46 input, 35 throughput, and 32 output) was reduced to 38 through the iterative revision and rating process (15 input, 9 throughput, and 14 output). Summary scores in each rating category showed significant variation in ratings among the various potential measures. For measures that address similar concepts, the priority ranking depended on the rating category chosen. CONCLUSION The final 38 measures of ED and hospital workflow provide a useful pool from which EDs and policymakers can draw to improve their ability to understand and address the issue of ED crowding. These measures require rigorous testing for feasibility, reliability, and value.

Hispanic healthcare disparities: challenging the myth of a monolithic Hispanic population.

Background:Hispanic Americans are often treated as a monolithic ethnic group with a single pattern of healthcare utilization. However, there could be considerable differences within this population. We examine the association between use of healthcare services and Hispanic Americans’ country of ancestry or origin, language of interview, and length of time lived in the United States. Methods:Our data come from the Medical Expenditure Panel Survey, a nationally representative survey of healthcare use and expenditures. Descriptive statistics and logistic regression results are presented. Results:Multivariate models show that Mexicans and Cubans are less likely, and Puerto Ricans more likely, to have any emergency department visits than non-Hispanic whites. Mexicans, Central American/Caribbeans, and South Americans are less likely to have any prescription medications. All Hispanics are less likely to have any ambulatory visits and prescription medications, whereas only those with a Spanish-language interview are less likely to have emergency department visits and inpatient admissions. More recent immigrants are less likely to have any ambulatory care or emergency department visits, whereas all Hispanics born outside the United States are less likely to have any prescription medications. Conclusions:The Hispanic population is composed of many different groups with diverse health needs and different barriers to accessing care. Misconceptions of Hispanics as a monolithic population lacking within-group diversity could function as a barrier to efforts aimed at providing appropriate care to Hispanic persons and could be 1 factor contributing to inequalities in the availability, use, and quality of healthcare services in this population.

Many Emergency Department Visits Could Be Managed At Urgent Care Centers And Retail Clinics

Americans seek a large amount of nonemergency care in emergency departments, where they often encounter long waits to be seen. Urgent care centers and retail clinics have emerged as alternatives to the emergency department for nonemergency care. We estimate that 13.7-27.1 percent of all emergency department visits could take place at one of these alternative sites, with a potential cost savings of approximately

Emergency Department Care in the United States: A Profile of National Data Sources

4.4 billion annually. The primary conditions that could be treated at these sites include minor acute illnesses, strains, and fractures. There is some evidence that patients can safely direct themselves to these alternative sites. However, more research is needed to ensure that care of equivalent quality is provided at urgent care centers and retail clinics compared to emergency departments.

Women's Use of Preventive Screening Services: A Comparison of HMO versus Fee-for-Service Enrollees

STUDY OBJECTIVE Emergency departments (EDs) are an integral part of the US health care system, and yet national data sources on the care received in the ED are poorly understood, thereby limiting their usefulness for analyses. We provide a comparison of data sources that can be used to examine utilization and quality of care in the ED nationally. DATA SOURCES AND COMPARISONS: This article compares 7 data sources available in 2005 for conducting analyses of ED encounters: the American Hospital Association Annual Survey Database(), Hospital Market Profiling Solution(c), National Emergency Department Inventory, Nationwide Emergency Department Sample, National Hospital Ambulatory Medical Care Survey, National Electronic Injury Surveillance System-All-Injury Program, and the National Health Interview Survey. In addition to describing the type and scope of data collection, available characteristics, and sponsor of the ED data sources, we compare (where possible) estimates of the total number of EDs, national and regional volume of ED visits, national and regional admission rates (percentage of ED visits resulting in hospital admission), patient characteristics, hospital characteristics, and reasons for visit generated by the various data sources. MAJOR FINDINGS The different data sources yielded estimates of the number of EDs that ranged from 4,609 to 4,884 and the number of ED encounters from more than 109 million to more than 116 million. Admission rates across data sources varied from 12.0% to 15.3%. Although comparisons of the 7 data sources were somewhat limited by differences in available information and operational definitions, variation in estimates of utilization and patterns of care existed by region, expected payer, and patient and hospital characteristics. The rankings and estimates of the top 5 first-listed conditions seen in the ED are relatively consistent between the 2 data sources with diagnoses, although the Nationwide Emergency Department Sample estimates 1.3 to 5.8 times more ED visits for each chronic and acute all-listed condition examined relative to the National Hospital Ambulatory Medical Care Survey. CONCLUSION Each of the data sources described in this article has unique advantages and disadvantages when used to examine patterns of ED care, making the different data sources appropriate for different applications. Analysts should select a data source according to its construction and should bear in mind its strengths and weaknesses in drawing conclusions based on the estimates it yields.

Who can't pay for health care?

Health maintenance organizations (HMOs) may relax some of the institutional barriers to using preventive screening services by requiring only a nominal copayment for such services and by promoting their use via educational programs. However, the gatekeeper system employed by HMOs may discourage the use of these services if referrals are required to access them. Using the 1987 National Medical Expenditure Survey and the 1992 National Health Interview Survey, the authors investigate whether HMO enrollment is associated with the use of preventive screening services for nonelderly, privately insured women. Employing models that control for self-selection into HMOs, the authors find that women who were enrolled in HMOs in 1987 were more likely to have received Pap smears and breast exams within the last year and to have ever received a mammogram when compared with women with fee-for-service coverage. By 1992, however, HMOs had lost this comparative advantage.

Children's health insurance coverage and family structure, 1977-1996.

AbstractBACKGROUND: In an era of rising health care costs, many Americans experience difficulty paying for needed health care services. With costs expected to continue rising, changes to private insurance plans and public programs aimed at containing costs may have a negative impact on Americans’ ability to afford care. OBJECTIVES: To provide estimates of the number of adults who avoid health care due to cost, and to assess the association of income, functional status, and type of insurance with the extent to which people with health insurance report financial barriers. RESEARCH DESIGN: Cross-sectional observational study using data from the Commonwealth Fund 2001 Health Care Quality Survey, a nationally representative telephone survey. PARTICIPANTS: U.S. adults age 18 and older (N=6,722). MEASURES: Six measures of avoiding health care due to cost, including delaying or not seeking care; not filling prescription medicines; and not following recommended treatment plan. RESULTS: The proportion of Americans with difficulty affording health care varies by income and health insurance coverage. Overall, 16.9% of Americans report at least 1 financial barrier. Among those with private insurance, the poor (28.4%), near poor (24.3%), and those with functional impairments (22.9%) were more likely to report avoiding care due to cost. In multivariate models, the uninsured are more likely (OR, 2.3; 95% CI, 1.7 to 3.0) to have trouble paying for care. Independent of insurance coverage and other demographic characteristics, the poor (OR, 3.6; 95% CI, 2.1 to 4.6), near poor (OR, 2.1; 95% CI, 1.9 to 3.7), and middle-income (OR, 1.8; 95% CI, 1.3 to 2.5) respondents as well as those with functional impairments (OR, 1.6; 95% CI, 1.3 to 2.0) are significantly more likely to avoid care due to cost. CONCLUSIONS: Privately and publicly insured individuals who have low incomes or functional impairments encounter significant financial barriers to care despite having health insurance. Proposals to expand health insurance will need to address these barriers in order to be effective.

Health information management and perceptions of the quality of care for children with tracheotomy: A qualitative study

Using data from a series of nationally representative medical expenditure surveys, the authors document changes in children’s health insurance coverage in a period of two decades. Overall, it is found that the proportion of children with private coverage declined, while the proportions publicly insured and uninsured increased. However, when the authors account for differences in family structure, they find striking disparities in children’s insurance experiences. Contrary to overall trends, children in single-parent households made significant gains in private health insurance coverage after 1977 and experienced reductions in public insurance. Coincident with Medicaid expansions in the late 1980s, children in two-parent households experienced significant increases in public health insurance. It is found that the rise in the proportion of children who were uninsured in this period was largely a single-parent family phenomenon, and that parents’ marital status, employment status, and family income are crucial factors associated with children’s insurance status.

Hospital Executives' Perspectives on Pay-for-Performance and Racial/Ethnic Disparities in Care

BackgroundChildren with tracheotomy receive health care from an array of providers within various hospital and community health system sectors. Previous studies have highlighted substandard health information exchange between families and these sectors. The aim of this study was to investigate the perceptions and experiences of parents and providers with regard to health information management, care plan development and coordination for children with tracheotomy, and strategies to improve health information management for these children.MethodsIndividual and group interviews were performed with eight parents and fifteen healthcare (primary and specialty care, nursing, therapist, equipment) providers of children with tracheotomy. The primary tracheotomy-associated diagnoses for the children were neuromuscular impairment (n = 3), airway anomaly (n = 2) and chronic lung disease (n = 3). Two independent reviewers conducted deep reading and line-by-line coding of all transcribed interviews to discover themes associated with the objectives.ResultsChildren with tracheotomy in this study had healthcare providers with poorly defined roles and responsibilities who did not actively communicate with one another. Providers were often unsure where to find documentation relating to a childs tracheotomy equipment settings and home nursing orders, and perceived that these situations contributed to medical errors and delayed equipment needs. Parents created a home record that was shared with multiple providers to track the care that their children received but many considered this a burden better suited to providers. Providers benefited from the parent records, but questioned their accuracy regarding critical tracheotomy care plan information such as ventilator settings. Parents and providers endorsed potential improvement in this environment such as a comprehensive internet-based health record that could be shared among parents and providers, and between various clinical sites.ConclusionsParticipants described disorganized tracheotomy care and health information mismanagement that could help guide future investigations into the impact of improved health information systems for children with tracheotomy. Strategies with the potential to improve tracheotomy care delivery could include defined roles and responsibilities for tracheotomy providers, and improved organization and parent support for maintenance of home-based tracheotomy records with web-based software applications, personal health record platforms and health record data authentication techniques.

Reducing racial and ethnic disparities in health care

With increasing attention paid to reducing racial/ethnic disparities in care and the growth of pay-for-performance programs, policy makers and payers are considering the use of such incentive mechanisms to target disparities reduction. This article describes the results of qualitative interviews with hospital executives to assess the potential impact that such programs would have on hospitals and their minority patients. The authors find that executives have significant concerns regarding funding mechanisms and implementation costs, financial risks for safety net hospitals, and resource constraints, as well as how such programs can be used to create incentives to care for minority patients. The findings suggest that payers should be hesitant to use pay-for-performance as a mechanism for reducing disparities until a wide variety of concerns about the design of such programs can be addressed.