Health affairs
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Historical Article
Quality measurement in the emergency department: past and future.
As the United States seeks to improve the value of health care, there is an urgent need to develop quality measurement for emergency departments (EDs). EDs provide 130 million patient visits per year and are involved in half of all hospital admissions. Efforts to measure ED quality are in their infancy, focusing on a small set of conditions and timeliness measures, such as waiting times and length-of-stay. ⋯ Initial priorities include measures of effective care for serious conditions that are commonly seen in EDs, such as trauma; measures of efficient use of resources, such as high-cost imaging and hospital admission; and measures of diagnostic accuracy. More research is needed to support the development of measures of care coordination and regionalization and the episode cost of ED care. Policy makers can advance quality improvement in ED care by asking ED researchers and organizations to accelerate the development of quality measures of ED care and incorporating the measures into programs that publicly report on quality of care and incentive-based payment systems.
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Some Medicare beneficiaries who place 911 calls to request an ambulance might safely be cared for in settings other than the emergency department (ED) at lower cost. Using 2005-09 Medicare claims data and a validated algorithm, we estimated that 12.9-16.2 percent of Medicare-covered 911 emergency medical services (EMS) transports involved conditions that were probably nonemergent or primary care treatable. ⋯ If Medicare had the flexibility to reimburse EMS for managing selected 911 calls in ways other than transport to an ED, we estimate that the federal government could save $283-$560 million or more per year, while improving the continuity of patient care. If private insurance companies followed suit, overall societal savings could be twice as large.
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Comparative Study Observational Study
Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions.
Many patients who seek emergency department (ED) treatment are not well enough for immediate discharge but are not clearly sick enough to warrant full inpatient admission. These patients are increasingly treated as outpatients using observation services. Hospitals employ four basic approaches to observation services, which can be categorized by the presence or absence of a dedicated observation unit and of defined protocols. ⋯ Compared to patients receiving observation services elsewhere in the hospital, patients cared for in "type 1" observation units-dedicated units with defined protocols-have a 23-38 percent shorter length-of-stay, a 17-44 percent lower probability of subsequent inpatient admission, and $950 million in potential national cost savings each year. Furthermore, we estimate that 11.7 percent of short-stay inpatients nationwide could be treated in a type 1 unit, with possible savings of $5.5-$8.5 billion annually. Policy makers should have hospitals report the setting in which observation services are provided and consider payment incentives for care in a type 1 unit.
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In its short modern history, Israel has had to contend with numerous mass-casualty incidents caused by terrorism. As a result, it has developed practical national preparedness policies for responding to such events. ⋯ Israel's emergency management system includes contingency planning, command and control, centrally coordinated response, cooperation, and capacity building. Although every nation is unique, many of the lessons that Israel has learned may be broadly applicable to preparation for mass-casualty incidents in the United States and other countries.
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Urban legend has often characterized frequent emergency department (ED) patients as mentally ill substance users who are a costly drain on the health care system and who contribute to ED overcrowding because of unnecessary visits for conditions that could be treated more efficiently elsewhere. This study of Medicaid ED users in New York City shows that behavioral health conditions are responsible for a small share of ED visits by frequent users, and that ED use accounts for a small portion of these patients' total Medicaid costs. ⋯ It is possible to use predictive modeling to identify who will become a repeat ED user and thus to help target interventions. However, policy makers should view reducing frequent ED use as only one element of more-comprehensive intervention strategies for frequent health system users.