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Overview of Emergency Department Visits in the United States, 2011

July 4, 2014 Comments off

Overview of Emergency Department Visits in the United States, 2011
Source: Agency for Healthcare Research and Quality

Emergency departments (EDs) provide a significant source of medical care in the United States, with over 131 million total ED visits occurring in 2011. Over the past decade, the increase in ED utilization has outpaced growth of the general population, despite a national decline in the total number of ED facilities. In 2009, approximately half of all hospital inpatient admissions originated in the ED. In particular, EDs were the primary portal of entry for hospital admission for uninsured and publicly insured patients (privately insured patients were more likely to be directly admitted to the hospital from a doctor’s office or clinic).

ED utilization reflects the greater health needs of the surrounding community and may provide the only readily available care for individuals who cannot obtain care elsewhere. Many ED visits are “resource sensitive” and potentially preventable, meaning that access to high-quality, community-based health care can prevent the need for a portion of ED visits.

This HCUP Statistical Brief presents data on ED visits in the United States in 2011. Patient and hospital characteristics for two types of ED visits are provided: ED visits with admission to the same hospital and ED visits resulting in discharge, which includes patients who were stabilized in the ED and then discharged home, transferred to another hospital, or any other disposition. The most frequent conditions treated by patient age group also are presented for both types of ED visits. All differences between estimates noted in the text are statistically significant at the .0005 level or better.

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Dating Violence Among Male and Female Youth Seeking Emergency Department Care

July 3, 2014 Comments off

Dating Violence Among Male and Female Youth Seeking Emergency Department Care
Source: Annals of Emergency Medicine

Study objective
We determine prevalence and correlates of dating violence, dating victimization, and dating aggression among male and female patients aged 14 to 20 years seeking emergency department (ED) care.

Methods
This was a systematic sampling of subjects aged 14 to 20 years seeking care at a single large academic ED between September 2010 and March 2013. Participants completed a computerized, self-administered, cross-sectional survey of demographics, dating violence from physical abuse measures of the Conflict in Adolescent Dating Relationships Inventory, associated behaviors, and ED health service use. Separate analyses were conducted for male and female patients.

Results
Four thousand three hundred eighty-nine youths (86.1% participation rate) were screened, and 4,089 (mean age 17.5 years; 58% female patients) were eligible for analysis. Almost 1 in 5 female patients (n=215; 18.4%) and 1 in 8 male patients (n=212; 12.5%) reported past-year dating violence. Of female patients, 10.6% reported dating victimization and 14.6% dating aggression, whereas of male patients, 11.7% reported dating victimization and 4.9% reported dating aggression. Multivariate analyses showed that variables associated with any male dating violence were black race (adjusted odds ratio [AOR] 2.26; 95% CI 1.54 to 3.32), alcohol misuse (AOR 1.03; 95% CI 1.00 to 1.06), illicit drug use (AOR 2.38; 95% CI 1.68 to 3.38), and depression (AOR 2.13; 95% CI 1.46 to 3.10); any female dating violence was associated with black race (AOR 1.68; 95% CI 1.25 to 2.25), public assistance (AOR 1.64; 95% CI 1.28 to 2.09), grades D and below (AOR 1.62; 95% CI 1.07 to 2.43), alcohol misuse (AOR 1.04; 95% CI 1.02 to 1.07), illicit drug use (AOR 2.85; 95% CI 2.22 to 3.66), depression (AOR 1.86; 95% CI 1.42 to 2.44), and any past year ED visit for intentional injury (AOR 2.64; 95% CI 1.30 to 5.40).

Conclusion
Nearly 1 of 6 male and female patients aged 14 to 20 years and seeking ED care report recent dating violence, and health disparities remain among this population. Dating violence was strongly associated with alcohol, illicit drug use, and depression and correlated with previous ED service use among female youths. ED interventions should consider addressing these associated health conditions, as well as improving screening protocols to address dating violence among male and female youths.

State-Based Medicaid Costs for Pediatric Asthma Emergency Department Visits

June 28, 2014 Comments off

State-Based Medicaid Costs for Pediatric Asthma Emergency Department Visits
Source: Preventing Chronic Disease (CDC)

Introduction
The prevalence of childhood asthma in the United States increased from 8.7% in 2001 to 9.5% in 2011. This increased prevalence adds to the costs incurred by state Medicaid programs. We provide state-based cost estimates of pediatric asthma emergency department (ED) visits and highlight an opportunity for states to reduce these costs through a recently changed Centers for Medicare and Medicaid Services (CMS) regulation.

Methods
We used a cross-sectional design across multiple data sets to produce state-based cost estimates for asthma-related ED visits among children younger than 18, where Medicaid/CHIP (Children’s Health Insurance Program) was the primary payer.

Results
There were approximately 629,000 ED visits for pediatric asthma for Medicaid/CHIP enrollees, which cost $272 million in 2010. The average cost per visit was $433. Costs ranged from $282,000 in Alaska to more than $25 million in California.

Conclusions
Costs to states for pediatric asthma ED visits vary widely. Effective January 1, 2014, the CMS rule expanded which type of providers can be reimbursed for providing preventive services to Medicaid/CHIP beneficiaries. This rule change, in combination with existing flexibility for states to define practice setting, allows state Medicaid programs to reimburse for asthma interventions that use nontraditional providers (such as community health workers or certified asthma educators) in a nonclinical setting, as long as the service was initially recommended by a physician or other licensed practitioner. The rule change may help states reduce Medicaid costs of asthma treatment and the severity of pediatric asthma.

Statewide Ban on Ambulance Diversions Reduces Ambulance Turnaround Time and Emergency Department Length of Stay for Patients Admitted to the Hospital

June 23, 2014 Comments off

Statewide Ban on Ambulance Diversions Reduces Ambulance Turnaround Time and Emergency Department Length of Stay for Patients Admitted to the Hospital
Source: Agency for Healthcare Research and Quality

Summary
In 2009, the Massachusetts Department of Public Health became the first State to ban ambulance diversions—a practice in which a crowded emergency department temporarily stops accepting patients who are transported by ambulance, instead sending them to other nearby emergency departments. To make implementation of the ban as smooth as possible, the Department of Public Health gave hospitals 6 months advance notice, provided general guidance on how hospitals could improve overall patient flow (thereby reducing crowding), and offered administrators frequent opportunities to ask questions and seek guidance on implementation. Despite fears that the ban would lead to increased emergency department crowding and ambulance delays, the steps hospitals took to improve patient flow in the wake of the ban prevented such problems. At nine Boston-area hospitals, emergency department length of stay for patients subsequently admitted to the hospital fell, as did ambulance turnaround time (i.e., how long the ambulance spends at the hospital before returning to service). Emergency department leaders strongly support the ban, believing it has improved patient care, strengthened relationships among health care staff, and increased patient satisfaction.

Evidence Rating
Moderate: The evidence consists of pre- and post-implementation comparisons of length of stay for patients in the emergency department and ambulance turnaround times, along with post-implementation feedback from emergency department leaders about their impressions of the impact of the ban.

Developing Organizations
Massachusetts Department of Public Health

Use By Other Organizations
In King County, WA, 18 emergency departments voluntarily agreed to halt diversions in 2011.

Date First Implemented
2009

Cohort Turnover and Productivity: The July Phenomenon in Teaching Hospitals

June 11, 2014 Comments off

Cohort Turnover and Productivity: The July Phenomenon in Teaching Hospitals
Source: Harvard Business School Working Papers

We consider the impact of cohort turnover-the planned simultaneous exit of a large number of experienced employees and a similarly sized entry of new workers-on productivity in the context of teaching hospitals. Specifically, we examine the impact of the annual July turnover of residents in American teaching hospitals on levels of resource utilization and quality relative to a control group of non-teaching hospitals. We find that, despite the anticipated nature of the cohort turnover and the supervisory structures that exist in teaching hospitals, this annual cohort turnover results in increased resource utilization (i.e., longer length of hospital stay) for both minor and major teaching hospitals and decreased quality (i.e., higher mortality rates) for major teaching hospitals. Particularly in major teaching hospitals, we find evidence of a gradual trend of decreasing performance that begins several months before the actual cohort turnover and may result from a transition of responsibilities at major teaching hospitals in anticipation of the cohort turnover.

New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings

May 9, 2014 Comments off

New HHS Data Shows Major Strides Made in Patient Safety, Leading to Improved Care and Savings (PDF)
Source: U.S. Department of Health and Human Services

The data in this report shows a substantial nine percent decrease in harms experienced by patients in hospitals in 2012 compared to the 2010 baseline, and an eight percent decrease in Medicare Fee-for-Service (FFS) 30-day readmissions. National reductions in adverse drug events, falls, infections and other forms of harm are estimated to have prevented nearly 15,000 deaths in hospitals, and saved $4.1 billion in costs, and prevented 560,000 patient harms in 2011 and 2012. These historic improvements are a result of strong, diverse public-private partnerships, active engagement by patients and families, and a wide range of aligned federal programs and initiatives – including new tools provided by the Affordable Care Act – working in concert towards shared aims.

Discharged from a mental health admission ward: is it safe to go home? A review on the negative outcomes of psychiatric hospitalization

May 6, 2014 Comments off

Discharged from a mental health admission ward: is it safe to go home? A review on the negative outcomes of psychiatric hospitalization
Source: Psychology Research and Behavior Management

Before psychiatry emerged as a medical discipline, hospitalizing individuals with mental disorders was more of a social stigmatizing act than a therapeutic act. After the birth of the mental health disciplines, psychiatric hospitalization was legitimized and has proven to be indispensable, preventing suicides and helping individuals in need. However, despite more than a century passing since this legitimization occurred, psychiatric hospitalization remains a controversial issue. There is the question of possible negative outcomes after a psychiatric admission ceases to take its protective effect, and even of whether the psychiatric admission itself is related to a negative setback after discharge. This review aims to summarize some of the most important negative outcomes after discharge from a psychiatric institution. These experiences were organized into two groups: those after a brief psychiatric hospitalization, and those after a long-stay admission. The author further suggests possible ways to minimize these adversities, emphasizing the need of awareness related to this important issue.

European Hospitals: An Industry Operating in the Red

April 30, 2014 Comments off

European Hospitals: An Industry Operating in the Red
Source: Accenture

A new Accenture study shows that many of Europe’s hospitals are operating in the red. An analysis of 1,500 hospitals, accounting for about 30 percent of the entire hospital market across nine major European economies, highlights the significant financial risks that hospitals are facing.

Transitioning Newborns from NICU to Home: A Resource Toolkit

April 29, 2014 Comments off

Transitioning Newborns from NICU to Home: A Resource Toolkit
Source: Agency for Healthcare Research and Quality

This toolkit includes resources for hospitals that wish to improve safety when newborns transition home from their neonatal intensive care unit (NICU) by creating a Health Coach Program, tools for coaches, and information for parents and families of newborns who have spent time in the NICU.

Infants born preterm or with complex congenital conditions are surviving to discharge in growing numbers and often require significant monitoring and coordination of care in the ambulatory setting.

This manual is designed to be adapted for any institution that cares for fragile newborn infants.

The Innovator Hospital: Poised to Deliver Future Care

March 19, 2014 Comments off

The Innovator Hospital: Poised to Deliver Future Care
Source: Deloitte

The Innovator Hospital: Poised to Deliver Future Care is an eBook that features valuable insights on the changing landscape of the Healthcare IT industry. Learn about leading practices from our thought leaders and their strategic thinking through a series of interviews by Deloitte’s key industry leaders, client interviews, research and thought leadership articles on government reform, new risk-based models such as value-based care, M&A activities, growing patient populations with complex needs and increased competition amid shrinking resources that are driving transformation.

Topics explored in this eBook include:

  • Mergers & Acquisition
  • mHealth
  • Analytics
  • HIT
  • Virtual Health
  • ACO’s
  • Security Risks

CDC Grand Rounds: Preventing Hospital-Associated Venous Thromboembolism

March 11, 2014 Comments off

CDC Grand Rounds: Preventing Hospital-Associated Venous Thromboembolism
Source: Morbidity and Mortality Weekly Report (CDC)

Deep venous thrombosis (DVT) is a blood clot in a large vein, usually in the leg or pelvis. Sometimes a DVT detaches from the site of formation and becomes mobile in the blood stream. If the circulating clot moves through the heart to the lungs it can block an artery supplying blood to the lungs. This condition is called pulmonary embolism. The disease process that includes DVT and/or pulmonary embolism is called venous thromboembolism (VTE). Each year in the United States, an estimated 350,000–900,000 persons develop incident VTE, of whom approximately 100,000 die, mostly as sudden deaths, the cause of which often goes unrecognized. In addition, 30%–50% of persons with lower-extremity DVT develop postthrombotic syndrome (a long-term complication that causes swelling, pain, discoloration, and, in severe cases, ulcers in the affected limb). Finally, 10%–30% of persons who survive the first occurrence of VTE develop another VTE within 5 years.

VTE can result from three pathogenic mechanisms: hypercoagulability (increased tendency of blood to clot), stasis or slow blood flow, and vascular injury to blood vessel walls. Individual characteristics include congenital and acquired factors, such as advanced age or cancer, and interact with external factors, such as hospitalization or surgery (Table). Hospitalization is an important risk factor in the latter two mechanisms; injury and surgery are causes of vascular injury, and prolonged bed rest can cause stasis. Approximately half of new VTE cases occur during a hospital stay or within 90 days of an inpatient admission or surgical procedure, and many are not diagnosed until after discharge.

As a health-care–associated condition, VTE is receiving increased attention from patient safety experts, the Agency for Healthcare Research and Quality (AHRQ), and the Centers for Medicare & Medicaid Services (CMS). Despite that recognition, the number of secondary diagnoses of VTE in hospital patients has increased, and during 2007–2009, an average of nearly 550,000 adult hospital stays each year had a discharge diagnosis of VTE (8). Nonetheless, VTE often is not recognized as an issue of public health importance. No ongoing surveillance system monitors the occurrence of VTE at the population level, and public education and awareness is limited.

Vital Signs: Improving Antibiotic Use Among Hospitalized Patients

March 6, 2014 Comments off

Vital Signs: Improving Antibiotic Use Among Hospitalized Patients
Source: Morbidity and Mortality Weekly Report (CDC)

Background:
Antibiotics are essential to effectively treat many hospitalized patients. However, when antibiotics are prescribed incorrectly, they offer little benefit to patients and potentially expose them to risks for complications, including Clostridium difficile infection (CDI) and antibiotic-resistant infections. Information is needed on the frequency of incorrect prescribing in hospitals and how improved prescribing will benefit patients.

Methods:
A national administrative database (MarketScan Hospital Drug Database) and CDC’s Emerging Infections Program (EIP) data were analyzed to assess the potential for improvement of inpatient antibiotic prescribing. Variability in days of therapy for selected antibiotics reported to the National Healthcare Safety Network (NHSN) antimicrobial use option was computed. The impact of reducing inpatient antibiotic exposure on incidence of CDI was modeled using data from two U.S. hospitals.

Results:
In 2010, 55.7% of patients discharged from 323 hospitals received antibiotics during their hospitalization. EIP reviewed patients’ records from 183 hospitals to describe inpatient antibiotic use; antibiotic prescribing potentially could be improved in 37.2% of the most common prescription scenarios reviewed. There were threefold differences in usage rates among 26 medical/surgical wards reporting to NHSN. Models estimate that the total direct and indirect effects from a 30% reduction in use of broad-spectrum antibiotics will result in a 26% reduction in CDI.

Conclusions:
Antibiotic prescribing for inpatients is common, and there is ample opportunity to improve use and patient safety by reducing incorrect antibiotic prescribing.

Implications for Public Health:
Hospital administrators and health-care providers can reduce potential harm and risk for antibiotic resistance by implementing formal programs to improve antibiotic prescribing in hospitals.

The Diseconomies of Queue Pooling: An Empirical Investigation of Emergency Department Length of Stay

February 28, 2014 Comments off

The Diseconomies of Queue Pooling: An Empirical Investigation of Emergency Department Length of Stay
Source: Harvard Business School Working Paper

We conduct an empirical investigation of the impact of two different queue management systems on throughput times. Using an Emergency Department’s (ED) patient-level data (N = 231,081) from 2007 to 2010, we find that patients’ lengths of stay (LOS) were longer when physicians were assigned patients under a pooled queuing system, compared to when each physician operated under a dedicated queuing system. The dedicated queuing system resulted in a 10 percent decrease in LOS-a 32-minute reduction in LOS for an average patient of medium severity in this ED. We propose that the dedicated queuing system yielded shorter throughput times because it provided physicians with greater ability and incentive to manage their patients’ flow through the ED from arrival to discharge. Consistent with social loafing theory, our analysis shows that patients were treated and discharged at a faster rate in the dedicated queuing system than in the pooled queuing system. We conduct additional analyses to rule out alternate explanations, such as stinting on care and decreased quality of care. Our paper has implications for health care organizations and others seeking to reduce throughput time, resource utilization, and costs.

CRS — Medicaid Disproportionate Share Hospital Payments

February 13, 2014 Comments off

Medicaid Disproportionate Share Hospital Payments (PDF)
Source: Congressional Research Service (via Health Reform GPS)

The Medicaid statute requires states to make disproportionate share hospital (DSH) payments to hospitals treating large numbers of low-income patients. This provision is intended to recognize the disadvantaged financial situation of those hospitals because low-income patients are more likely to be uninsured or Medicaid enrollees. Hospitals often do not receive payment for services rendered to uninsured patients, and Medicaid provider payment rates are generally lower than the rates paid by Medicare and private insurance.

As with most Medicaid expenditures, the federal government reimburses states for a portion of their Medicaid DSH expenditures based on each state’s federal medical assistance percentage (FMAP). While most federal Medicaid funding is provided on an open-ended basis, federal Medicaid DSH funding is capped. Each state receives an annual DSH allotment, which is the maximum amount of federal matching funds that each state is permitted to claim for Medicaid DSH payments. In FY2012, federal DSH allotments totaled $11.4 billion.

Understanding Differences Between High- And Low-Price Hospitals: Implications For Efforts To Rein In Costs

February 4, 2014 Comments off

Understanding Differences Between High- And Low-Price Hospitals: Implications For Efforts To Rein In Costs
Source: Health Affairs

Private insurers pay widely varying prices for inpatient care across hospitals. Previous research indicates that certain hospitals use market clout to obtain higher payment rates, but there have been few in-depth examinations of the relationship between hospital characteristics and pricing power. This study used private insurance claims data to identify hospitals receiving inpatient prices significantly higher or lower than the median in their market. High-price hospitals, compared to other hospitals, tend to be larger; be major teaching hospitals; belong to systems with large market shares; and provide specialized services, such as heart transplants and Level I trauma care. High-price hospitals also receive significant revenues from nonpatient sources, such as state Medicaid disproportionate-share hospital funds, and they enjoy healthy total financial margins. Quality indicators for high-price hospitals were mixed: High-price hospitals fared much better than low-price hospitals did in U.S. News & World Report rankings, which are largely based on reputation, while generally scoring worse on objective measures of quality, such as postsurgical mortality rates. Thus, insurers may face resistance if they attempt to steer patients away from high-price hospitals because these facilities have good reputations and offer specialized services that may be unique in their markets.

Nation’s Grade Drops to a Dismal D+ for Failure to Support Emergency Patients

January 30, 2014 Comments off

Nation’s Grade Drops to a Dismal D+ for Failure to Support Emergency Patients
Source: American College of Emergency Physicians

Emergency physicians today sounded a warning that the continuing failure of state and national policies is endangering emergency patients, citing as proof a worse grade of D+ in the latest edition of a state-by-state report card on support for emergency care (Report Card). The Report Card forecasts an expanding role for emergency departments under Obamacare and describes the harmful effects of the competing pressures of shrinking resources and increasing demands. The Report Card measures conditions and policies under which emergency care is being delivered, not the quality of care provided by hospitals and emergency providers.

Caring for Health Care’s Costliest Patients; Communities Find Ways to Identify and Treat ER ‘Super-Utilizers’

January 17, 2014 Comments off

Caring for Health Care’s Costliest Patients; Communities Find Ways to Identify and Treat ER ‘Super-Utilizers’
Source: Robert Wood Johnson Foundation

Super-utilizer patients fall into several different categories—from patients with chronic conditions to those who struggle with behavioral health needs that impede their ability to engage in self-care, to frail elderly patients.

In some instances, addressing health care needs isn’t enough on its own—some patients may lack access to phones for providers to check in on them, while others may have trouble keeping their lights on. Some are isolated because they live in remote areas or lack a network of family and friends nearby.

Self Help Packet for Medicare “Observation Status”

January 15, 2014 Comments off

Self Help Packet for Medicare “Observation Status”
Source: Center for Medicare Advocacy

Typical Scenario
You are a Medicare beneficiary who is currently or has recently been hospitalized for three or more days. At the hospital you signed admission paperwork, slept in a hospital bed, underwent many tests, and saw various physician specialists. At some point during the hospitalization or while you were being discharged you were told that the discharging physician ordered follow up care in a skilled nursing facility (nursing home). You were also told that Medicare will not pay for this care because you were admitted to the hospital on observation status rather than as an inpatient.

Introduction
Observation status is not new. However, its use by hospitals to avoid lost revenue, scrutiny and accusations of Medicare fraud is growing. This seriously affects Medicare beneficiaries’ access to care and finances. Attempts have been made to remedy the problem legislatively. For instance, bills have been introduced in Congress to eliminate the problem. In addition, the Center for Medicare Advocacy (Center) filed a national class action lawsuit, Bagnall v. Sebelius, challenging the practice in 2011. While we wait for action on the legislation and the lawsuit, individual beneficiaries continue to be negatively affected by observation status.

This packet includes information about observation status and steps you might take to resolve the problems created by an observation status hospital designation.

Antibiotic Utilization for Acute Respiratory Tract Infections in United States Emergency Departments

January 13, 2014 Comments off

Antibiotic Utilization for Acute Respiratory Tract Infections in United States Emergency Departments (PDF)
Source: Antimicrobial Agents and Chemotherapy
From press release (American Society of Microbiology):

An analysis of emergency room (ER)visits over a 10-year period finds that while inappropriate antibiotic use is decreasing in pediatric settings, it continues to remain a problem in adults, according to an article published ahead of print in Antimicrobial Agents and Chemotherapy.

In the study, the investigators mined data from the National Hospital Ambulatory Medical Care Survey for the years 2001-2010. During this time, acute respiratory tract infections accounted for 126 million visits to emergency departments in the US. In patients under the age of 19 they saw a decrease in the utilization of antibiotics for respiratory infections where they are not indicated. They saw no such reduction in adult patients.

“While emergency department antibiotic use for acute respiratory tract infections decreased in the past decade among children, we saw no decrease in antibiotic use for adults with acute respiratory tract infections,” says coauthor John Baddley, of the University of Alabama at Birmingham, an author on the study. “Given organized efforts to emphasize antibiotic stewardship, we expected to see a decrease in emergency department antibiotic use for such infections.”

That’s very unfortunate, Baddley says, because the ER’s see so many patients, since they are used not just for emergencies, but for primary care visits generally—especially among those who are uninsured or insured by Medicare. A major reduction in use of inappropriate antibiotics in the ER could have a big benefit just due to the large number of patients seen.

Guide to Patient and Family Engagement in Hospital Quality and Safety

January 13, 2014 Comments off

Guide to Patient and Family Engagement in Hospital Quality and Safety
Source: Agency for Healthcare Research and Quality

Research shows that when patients are engaged in their health care, it can lead to measurable improvements in safety and quality. To promote stronger engagement, Agency for Healthcare Research and Quality developed the Guide to Patient and Family Engagement in Hospital Quality and Safety, a tested, evidence-based resource to help hospitals work as partners with patients and families to improve quality and safety.

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