Dataset Information

Impact of an Emergency Department-to-Home Transitional Care Intervention on Health Service Use in Medicare Beneficiaries: A Mixed Methods Study.

ABSTRACT:

Background

Hospital-based acute care [emergency department (ED) visits and hospitalizations] that is preventable with high-quality outpatient care contributes to health care system waste and patient harm.

Objective

To test the hypothesis that an ED-to-home transitional care intervention reduces hospital-based acute care in chronically ill, older ED visitors.

Research design

Convergent, parallel, mixed-methods design including a randomized controlled trial.

Setting

Two diverse Florida EDs.

Subjects

Medicare fee-for-service beneficiaries with chronic illness presenting to the ED.

Intervention

The Coleman Care Transition Intervention adapted for ED visitors.

Measures

The main outcome was hospital-based acute care within 60 days of index ED visit. We also assessed office-based outpatient visits during the same period.

Results

The Intervention did not significantly reduce return ED visits or hospitalizations or increase outpatient visits. In those with return ED visits, the Intervention Group was less likely to be hospitalized than the Usual Care Group. Interview themes describe a cycle of hospital-based acute care largely outside patients' control that may be difficult to interrupt with a coaching intervention.

Conclusions and relevance

Structural features of the health care system, including lack of access to timely outpatient care, funnel patients into the ED and hospital admission. Reducing hospital-based acute care requires increased focus on the health care system rather than patients' care-seeking decisions.

SUBMITTER: Schumacher JR

PROVIDER: S-EPMC8689563 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description:ImportanceAmbulatory follow-up care is frequently recommended after an emergency department (ED) visit. However, the frequency with which follow-up actually occurs and the degree to which follow-up is associated with postdischarge outcomes is unknown.ObjectivesTo examine the frequency and variation in ambulatory follow-up among Medicare beneficiaries discharged from US EDs and the association between ambulatory follow-up and postdischarge outcomes.Design, setting, and participantsThis cohort study of 9 470 626 ED visits to 4728 US EDs among Medicare beneficiaries aged 65 and older from 2011 to 2016 who survived the ED visit and were discharged to home used Kaplan-Meier curves and proportional hazards regression. Data analysis was conducted from December 2019 to July 2020.ExposuresAmbulatory follow-up after discharge from the ED.Main outcomes and measuresPostdischarge mortality, subsequent ED visit, or inpatient hospitalization within 30 days of an index ED visit.ResultsThe study sample consisted of 9 470 626 index outpatient ED visits to 4684 EDs; most visits (5 776 501 [61.0%]) were among women, and the mean (SD) age of patients was 77.3 (8.4) years. In this sample, the cumulative incidence of ambulatory follow-up was 40.5% (3 822 133 patients) at 7 days and 70.8% (6 662 525 patients) at 30 days, after accounting for censoring and for mortality as a competing risk. Characteristics associated with lower rates of ambulatory follow-up included beneficiary Medicaid eligibility (hazard ratio [HR], 0.77; 95% CI, 0.77-0.78; P < .001), Black race (HR, 0.82; 95% CI, 0.81-0.83; P < .001), and treatment at a rural ED (HR, 0.75; 95% CI, 0.73-0.77; P < .001) in the multivariable regression model. Ambulatory follow-up was associated with lower risk of postdischarge mortality (HR, 0.49; 95% CI, 0.49-0.50; P < .001) but higher risk of subsequent inpatient hospitalization (HR, 1.22; 95% CI, 1.21-1.23; P < .001) and ED visits (HR, 1.01; 95% CI, 1.00-1.01; P < .001), adjusting for visit diagnosis, patient demographic characteristics, and chronic conditions.Conclusions and relevanceIn this cohort study of Medicare beneficiaries discharged from the ED, nearly 30% lacked ambulatory follow-up at 30 days, with variation in follow-up rates by patient and hospital characteristics. Having an ambulatory follow-up visit was associated with higher risk of subsequent hospitalization but lower risk of mortality. Ambulatory care access may be an important driver of clinical outcomes after an ED visit.

Project description:ImportanceThere has been a significant increase in the implementation and dissemination of geriatric emergency department (GED) programs. Understanding the costs associated with patient care would yield insight into the direct financial value for patients, hospitals, health systems, and payers.ObjectiveTo evaluate the association of GED programs with Medicare costs per beneficiary.Design, setting, and participantsThis cross-sectional study included data on Medicare fee-for-service beneficiaries at 2 hospitals implementing Geriatric Emergency Department Innovations in Care Through Workforce, Informatics, and Structural Enhancement (GEDI WISE) (Mount Sinai Medical Center [MSMC] and Northwestern Memorial Hospital [NMH]) from January 1, 2013, to November 30, 2016. Analyses were conducted and refined from August 28, 2018, to November 20, 2020, using entropy balance to account for observed differences between the treatment and comparison groups.InterventionsTreatment included consultation with a transitional care nurse (TCN) or a social worker (SW) trained for the GEDI WISE program at a beneficiary's first ED visit (index ED visit). The comparison group included beneficiaries who were never seen by either a TCN or an SW during the study period.Main outcomes and measuresThe main outcome evaluated was prorated total Medicare payer expenditures per beneficiary over 30 and 60 days after the index ED visit encounter.ResultsOf the total 24 839 unique Medicare beneficiaries, 4041 were seen across the 2 EDs; 1947 (17.4%) at MSMC and 2094 (15.4%) at the NMH received treatment from either a GED TCN and/or a GED SW. The mean (SD) age of beneficiaries at MSMC was 78.8 (8.5) years and at NMH was 76.4 (7.7) years. Most patients at both hospitals were female (6821 [60.8%] at MSMC and 8023 [58.9%] at NMH) and White (7729 [68.9%] at MSMC and 9984 [73.3%] at NMH). Treatment was associated with statistically significant mean savings per beneficiary of $2436 (95% CI, $1760-$3111; P < .001) at one ED and $2905 (95% CI, $2378-$3431; P < .001) at the other ED in the 30 days after the index ED visit. The association between treatment and mean cumulative savings at 60 days after the index ED visit per beneficiary was also significant: $1200 (95% CI, $231-$2169; P = .02) at one ED and $3202 (95% CI, $2452-$3951; P < .001) at the other ED.Conclusions and relevanceAmong Medicare fee-for-service beneficiaries, receipt of ED-based geriatric treatment by a TCN and/or an SW was associated with lower Medicare expenditures. These estimated cost savings may be used when calculating or considering the bundled value and potential reimbursement per patient for GED care programs.

Project description:Importance:Emergency department (ED) visits are common and increasing. Whether outcomes associated with care in the ED are improving over time is largely unknown to date. Objective:To examine trends in 30-day mortality rates associated with ED care among Medicare beneficiaries aged 65 years or older. Design, Setting, and Participants:This cross-sectional study used a random 5% sample in 2009 and 2010 and a 20% sample from 2011 to 2016, for a total of 15?416?385 ED visits from 2009 to 2016 among Medicare beneficiaries aged 65 years or older. Exposures:Time (year) as a continuous variable. Main Outcomes and Measures:The primary outcome was 30-day mortality, overall and stratified by illness severity and hospital characteristics. Secondary outcomes included mortality rates on the day of the ED visit (day 0) as well as at 7 and 14 days. Changes in disposition from the ED (admission, observation, transfer, died in the ED, and discharged) over time were also examined. Results:The sample included 15?416?385 ED visits (60.8% women and 39.2% men; mean [SD] age, 78.6 [8.5] years) at 4828 acute care hospitals. The percentage of patients discharged from the ED increased from 53.6% in 2009 to 56.7% in 2016. Unadjusted 30-day mortality declined from 5.1% in 2009 to 4.6% in 2016 (-0.068% per year; 95% CI, -0.074% to -0.063% per year; P?<?.001). After adjusting for hospital random effects, patient demographics, and chronic conditions, the adjusted 30-day mortality trend was -0.198% per year (95% CI, -0.204% to -0.193% per year; P?<?.001). The magnitude of this trend was greatest for patients with a high severity of illness (-0.662%; 95% CI, -0.681% to -0.644%; P?<?.001), followed by those with a medium severity of illness (-0.103% per year; 95% CI, -0.108% to -0.097% per year; P?<?.001) and those with a low severity of illness (-0.009% per year; 95% CI, -0.006% to -0.011% per year; P?<?.001). Declines in mortality were seen in each category of ED disposition, including visits resulting in admission (-0.356% per year; 95% CI, -0.368% to -0.343% per year; P?<?.001) as well as those resulting in discharge (-0.059% per year; 95% CI, -0.064% to -0.055% per year; P?<?.001). The decline was greater for major teaching hospitals (compared with nonteaching hospitals), nonprofit hospitals (compared with for-profit hospitals), and urban hospitals (compared with rural hospitals). Conclusions and Relevance:Among Medicare beneficiaries receiving ED care in the United States, mortality within 30 days of an ED visit appears to have declined in recent years, particularly for patients with the highest severity of illness, even as fewer patients are being admitted from an ED visit. This study's findings suggest that further study is needed to understand the reasons for this decline and why certain types of hospitals are seeing greater improvements in outcomes.

Project description:ImportanceThere is little evidence regarding how total costs of care associated with an emergency department (ED) visit have changed, despite increasing policy focus on the value of acute care.ObjectiveTo examine trends in total standardized 30-day costs of care associated with an ED visit.Design, setting, and participantsThis cross-sectional study of 14 113 088 ED visits at 4730 EDs from 2011 to 2016 included a 20% national sample of traditional Medicare beneficiaries aged 65 years and older. Data analysis was conducted from August 2018 to April 2020.ExposuresTime (year) as a continuous variable.Main outcomes and measuresTrends in disposition from the ED and 30-day total standardized costs for all ED visits as well as the following spending components: index visit cost, physician costs, subsequent ED visit costs, subsequent inpatient costs, subsequent observation costs, non-ED outpatient care, postacute care, and aggregated total spending after the index ED visit.ResultsThe analytic sample consisted of 14 113 088 ED visits at 4730 EDs. The mean (SD) beneficiary age was 78.6 (8.6) years, 8 573 652 visits (60.7%) were among women, and 11 908 691 visits (84.7%) were among white patients. The proportion of patients discharged from the ED rose from 1 233 701 of 2 309 563 visits (53.4%) in 2011 to 1 279 701 of 2 268 363 visits (56.4%) in 2016. Total adjusted 30-day standardized costs of care declined from a mean (SE) of $8851 ($35.3) in 2011 to a mean (SE) of $8143 ($35.4) in 2016 (-$126/y; 95% CI, -$130 to -$121; P < .001) for all ED visits. This decrease was primarily associated with a decline in total spending on the index ED visit (-$48/y; 95% CI, -$50 to -$47; P < .001) as well as lower spending on postacute care (-$42/y; 95% CI, -$44 to -$41; P < .001) and subsequent inpatient care (-$34/y; 95% CI, -$36 to -$32; P < .001). There was an increase in spending after the index visit on downstream observation care ($3.6/y; 95% CI, $3.5 to $3.7; P < .001), outpatient ED care ($4.6/y; 95% CI, $4.4 to $4.8; P < .001), and other outpatient care ($15/y; 95% CI, $12 to $18; P < .001).Conclusions and relevanceIn this study, total 30-day standardized costs of ED care for Medicare beneficiaries decreased in recent years. It may be that more intensive ED spending up front is associated with reductions in total costs of an acute episode.

Project description:ImportanceRural US residents disproportionately rely on emergency departments (ED), yet little is known about patient outcomes after ED visits to rural hospitals or critical access hospitals (CAHs).ObjectiveTo compare 30-day outcomes after rural vs urban ED visits and in CAHs, a subset of rural hospitals.Design, setting, and participantsThis propensity-matched, retrospective cohort study used a 20% sample of national Medicare fee-for-service beneficiaries from January 1, 2011, to October 31, 2015. Rural and urban ED visits were matched on demographics, patient prior use of EDs, comorbidities, and diagnoses. Thirty-day outcomes overall and stratified by 25 common ED diagnoses were evaluated, with similar analysis of CAHs vs non-CAHs. Data were analyzed from February 15, 2020, to May 17, 2021.Main outcomes and measuresThe primary outcome was 30-day all-cause mortality. Secondary outcomes were ED revisits with and without hospitalization.ResultsThe matched cohort included 473 152 rural and urban Medicare beneficiaries with a mean (SD) age of 75.1 (7.9) years (59.1% and 59.3% women, respectively; 86.9% and 87.1% White, respectively). Medicare beneficiaries at rural vs urban EDs experienced similar all-cause 30-day mortality (3.9% vs 4.1%; effect size, 0.01), ED revisits (18.1% vs 17.8%; effect size, 0.00), and ED revisits with hospitalization (6.0% vs 8.1%; effect size, 0.00). Rural ED visits were associated with more transfer (6.2% vs 2.0%; effect size, 0.22) and fewer hospitalizations (24.7% vs 39.2; effect size, 0.31). Stratified by diagnosis, patients in rural EDs with life-threatening illnesses experienced more transfer with 30-day mortality similar to that of patients in urban EDs. In contrast, mortality differed for patients in rural EDs with symptom-based diagnoses, including chest pain (odds ratio [OR], 1.54 [95% CI, 1.25-1.89]), nausea and vomiting (OR, 1.68 [95% CI, 1.26-2.24), and abdominal pain (OR, 1.73 [95% CI, 1.42-2.10]). All findings were similar for CAHs.Conclusions and relevanceThe findings of this cohort study of rural ED care suggest that patient mortality for potentially life-threatening conditions is comparable to that in urban settings. Further research is needed to understand the sources of greater rural ED mortality for symptom-based conditions. These findings underscore the importance of ensuring access to treatment of life-threatening conditions at local EDs in rural communities, which are increasingly endangered by hospital closures.

Project description:OBJECTIVE:To use patient-level clinical variables to develop and validate a parsimonious model to predict hospital readmissions from home healthcare (HHC) in Medicare fee-for-service beneficiaries. DESIGN:Retrospective analysis using multivariable logistic regression and gradient boosting machine (GBM) learning to develop and validate a predictive model. SETTING/PARTICIPANTS/MEAUREMENTS:A 5% national sample of patients, aged 65?years or older, with Medicare fee-for-service who received skilled HHC services within 5 days of hospital discharge in 2012 (n = 43 407). Multiple data sets were merged, including Medicare Outcome and Assessment Information Set, Home Health Claims, Medicare Provider Analysis and Review, and Master Beneficiary Summary Files, to extract patient-level variables from the first HHC visit after discharge and measure 30-day readmission outcomes. RESULTS:Among 43 407 patients with inpatient hospitalizations followed by HHC, 14.7% were readmitted within 30?days. Of the 53 candidate variables, seven remained in the final model as individually predictive of outcome: Elixhauser comorbidity index, index hospital length of stay, urinary catheter presence, patient status (ie, fragile health with high risk of complications or serious progressive condition), two or more hospitalizations in prior year, pressure injury risk or presence, and surgical wound presence. Of interest, surgical wounds, either from a total hip or total knee arthroplasty procedure or another surgical procedure, were associated with fewer readmissions. The optimism-corrected c-statistics for the full model and parsimonious model were 0.67 and 0.66, respectively, indicating fair discrimination. The Brier score for both models was 0.120, indicating good calibration. The GBM model identified similar predictive variables. CONCLUSION:Variables available to HHC clinicians at the first postdischarge HHC visit can predict readmission risk and inform care plans in HHC. Future analyses incorporating measures of social determinants of health, such as housing instability or social support, have the potential to enhance prediction of this outcome. J Am Geriatr Soc 67:2505-2510, 2019.

Project description:BackgroundPre-hospital emergency medical services (EMS) transport can be associated with benefits following pediatric injury. However, many pediatric trauma patients do not use EMS. The objective of this study was to elucidate guardians' decision factors for pre-hospital transport for children after injury.MethodsThis is a multi-methods study of pediatric trauma patients (≤14 years) and their guardians presenting to the ED of a Level I Pediatric Trauma Center via both EMS and non-EMS modalities. Demographic information and injury characteristics were collected. Semi-structured interviews were conducted, and qualitative codes were identified and assigned into themes.Results(Quantitative): Of the 29 child-guardian pairs, five participants initially presented by EMS, 18 were admitted, and the majority (66%) sustained mild injuries. Guardians' assessment of their child's injury severity did not correlate with Injury Severity Score (ISS). Neither EMS status (did or did not use EMS to transport to first hospital) nor rurality status of participants' place of residence were associated with disparate management in any of the three scenarios.(qualitative)Five themes emerged, which informed guardians' transport decisions: Factors Related to the Nature of the Patient's Injury, Guardian Attributes and Prior Experiences, Access and Availability of EMS, Perceived Risks and Benefits of EMS and Hospital, and Collaborative Decision-Making. Injury characteristics and contextual factors, like perceived EMS response times and advice from family or medical providers, were considered in choices about EMS utilization and hospital selection. Despite the view that EMS response times were important in determining what to do following injury, both EMS and non-EMS users were largely unfamiliar with the capabilities of EMS in their area. Finally, guardians described cost to be a theoretical risk of EMS use, and a few cited this as a factor contributing to their decision-making.ConclusionsGuardians used a variety of considerations to make transport decisions, including the five themes identified above. Future studies could explore modalities to disseminate information about pre-hospital decision-making for guardians and determine the relationship between EMS utilization and patient outcomes.

Project description:ImportancePrior authorization requirements may be a barrier to accessing medications for opioid use disorder treatment and may, therefore, be associated with poor health care outcomes.ObjectiveTo determine the association of prior authorization with use of buprenorphine-naloxone and health care outcomes.Design, setting, and participantsThis comparative interrupted time series analysis examined enrollment and insurance claims data from Medicare beneficiaries with an opioid use disorder diagnosis or who filled a prescription for an opioid use disorder medication between 2012 and 2017. Over this period, 775?874 members were in 1479 Part D plans that always required prior authorization, 113?286 members were in 206 plans that removed prior authorization, 189?461 members were in 489 plans that never required prior authorization, and 619?919 members were in 485 plans that added prior authorization. Data analysis was performed from April 2019 to February 2020.ExposuresRemoval or addition of prior authorization and new prescriptions filled for buprenorphine-naloxone.Main outcomes and measuresBuprenorphine-naloxone use, inpatient admissions, emergency department visits, and prescription drug and medical expenditures.ResultsThe study population in 2012 included 949?206 Medicare beneficiaries (mean [SD] age, 57 [15] years; 550?445 women [58%]). Removal of prior authorization was associated with an increase of 17.9 prescriptions (95% CI, 1.1 to 34.7 prescriptions) filled for buprenorphine-naloxone per plan per year, which is a doubling of the number of prescriptions, on average. Each prescription filled was associated with statistically significant decreases in adverse health care outcomes: substance use disorder-related inpatient admissions decreased by 0.1 admission per plan per year (95% CI, -0.2 to -0.1 admission per plan per year), and substance use disorder-related emergency department visits decreased by 0.1 visit per plan per year (95% CI, -0.13 to -0.03 visit per plan per year) (all P?<?.001). Combining these results, removal of prior authorization was associated with a reduction in substance use disorder-related inpatient admissions by 2.0 admissions per plan per year (95% CI, -4.3 to -0.1 admissions per plan per year) and substance use disorder-related emergency department visits by 1.4 visits per plan per year (95% CI, -3.2 to -0.1 visits per plan per year).Conclusions and relevanceRemoving prior authorization for buprenorphine-naloxone was associated with an increase in the medication use and decreases in health care utilization and expenditures.