Interest in high users of acute care continues to grow as health care organizations look to deliver cost-effective and high-quality care to patients. Since “super-utilizers” of acute care are ...responsible for disproportionately high health care spending, many programs and interventions have been implemented to reduce medical care use and costs in this population. This article presents a systematic review of the peer-reviewed and grey literature on evaluations of interventions to decrease prehospital and emergency care use among U.S. super-utilizers. Forty-six distinct evaluations were included in the review. The most commonly evaluated intervention was case management. Although a number of interventions reported reductions in prehospital and emergency care utilization and costs, methodological and study design weaknesses—especially regression to the mean—were widespread and call into question reported positive findings. More high-quality research is needed to accurately assess the impact of interventions to reduce prehospital and emergency care use in the super-utilizer population.
We characterize hospital admissions among older adults for any cause in the 30 days after a significant natural disaster in the United States. The main outcome was all-cause hospital admissions in ...the 30 days after natural disaster. Separate analyses were conducted to examine all-cause hospital admissions excluding the 72 hours after the disaster, ICU admissions, all-cause inhospital mortality, and admissions by state.
A self-controlled case series analysis using the 2011 Medicare Provider and Analysis Review was conducted to examine exposure to natural disaster by elderly adults located in zip codes affected by tornadoes during the 2011 southeastern superstorm. Spatial data of tornado events were obtained from the National Oceanic and Atmospheric Administration’s Severe Report database, and zip code data were obtained from the US Census Bureau.
All-cause hospital admissions increased by 4% for older adults in the 30 days after the April 27, 2011, tornadoes (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). When the first 3 days after the disaster that may have been attributed to immediate injuries were excluded, hospitalizations for any cause also remained higher than when compared with the other 11 months of the year (incidence rate ratio 1.04; 95% confidence interval 1.01 to 1.07). There was no increase in ICU admissions or inhospital mortality associated with the natural disaster. When data were examined by individual states, Alabama, which had the highest number of persons affected, had a 9% increase in both hospitalizations and ICU admissions.
When all time-invariant characteristics were controlled for, this natural disaster was associated with a significant increase in all-cause hospitalizations. This analysis quantifies acute care use after disasters through examining all-cause hospitalizations and represents an important contribution to building models of resilience—the ability to recover from a disaster—and hospital surge capacity.
Out-of-hospital cardiac arrest (OHCA) affects over 300,000 individuals per year in the United States with poor survival rates overall. A remarkable 5-fold difference in survival-to-hospital discharge ...rates exist across United States communities.
We conducted a study using qualitative research methods comparing the system of care across sites in Michigan communities with varying OHCA survival outcomes, as measured by return to spontaneous circulation with pulse upon emergency department arrival.
Major themes distinguishing higher performing sites were (1) working as a team, (2) devoting resources to coordination across agencies, and (3) developing a continuous quality improvement culture. These themes spanned the chain of survival framework for OHCA. By examining the unique processes, procedures, and characteristics of higher- relative to lower-performing sites, we gleaned lessons learned that appear to distinguish higher performers. The higher performing sites reported being the most collaborative, due in part to facilitation of system integration by progressive leadership that is willing to build bridges among stakeholders.
Based on the distinguishing features of higher performing sites, we provide recommendations for toolkit development to improve survival in prehospital systems of care for OHCA.
Abstract
Background
Patients presenting to academic medical centers (AMC) typically receive primary care, specialty care, or both. Resources needed for each type of care vary, requiring different ...levels of care coordination. We propose a novel method to determine whether a patient primarily receives primary or specialty care to allow for optimization of care coordination.
Objectives
We aimed to define the concepts of a Lifer Patient and Destination Patient and analyze the current state of care utilization in those groups to inform opportunities for improving care coordination.
Methods
Using AMC data for a 36-month study period (FY17-19), we evaluated the number of unique patients by residence zip code. Patients with at least one primary care visit and patients without a primary care visit were classified as Lifer and Destination patients, respectively. Cohen’s effect sizes were used to evaluate differences in mean utilization of different care delivery settings.
Results
The AMC saw 35,909 Lifer patients and 744,037 Destination patients during the study period. Most patients were white, non-Hispanic females; however, the average age of a Lifer was seventy-two years whereas that of a Destination patient was thirty-eight. On average, a Lifer had three times more ambulatory care visits than a Destination patient. The proportion of Inpatient encounters is similar between the groups. Mean Inpatient length of stay (LOS) is similar between the groups, but Destination patients have more variance in LOS. The rate of admission from the emergency department (ED) for Destination patients is nearly double Lifers’.
Conclusion
There were differences in ED, ambulatory care, and inpatient utilization between the Lifer and Destination patients. Furthermore, there were incongruities between rate of hospital admissions and LOS between two groups. The Lifer and Destination patient definitions allow for identification of opportunities to tailor care coordination to these unique groups and to allocate resources more efficiently.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
We describe the self-reported socioeconomic and health impacts, as well as the coping mechanisms employed by a drug-using cohort of adults during the Flint water crisis (FWC) in Flint, Michigan. ...Participants from an ongoing longitudinal Emergency Department study were contacted between April 2016 and July 2016 and completed a survey focusing on exposure, consequences, and coping strategies. One hundred thirty-three participants (mean age = 26, 65% African-American, 61% public assistance) completed the survey (37.9% response rate). Of these, 75% reported exposure to water with elevated lead levels. Of these, 75% reported additional monthly expenses resulting from exposure. Almost 40% of parents reported changes in their children’s health and 65% reported changes to their health since the FWC. Participants indicated the use of both positive (e.g., advice from trusted neighbors, 99.0%) and negative coping mechanisms (e.g., increased substance use, 20.0%) in response to this public health emergency. High-risk Flint residents reported multiple social, economic, and health-related consequences stemming from the FWC. Policymakers should consider additional resources for those affected, including increased access to mental health to aid recovery within the community.
Large- and small-scale transformation of healthcare delivery toward improved patient experience through promotion of patient-centered and coordinated care continues to be at the forefront of health ...system efforts in the United States. As part of a Quality Improvement (QI) project at a large, midwestern health system, a case series of high-performing organizations was explored with the goal of identifying best practices in patient-centered care and/or care coordination (PCC/CC). Identification of best practices was done through rapid realist review of peer-reviewed literature supporting three PCC/CC interventions per case. Mechanisms responsible for successful intervention outcomes and associated institutional-level facilitators were evaluated, and cross-case analysis produced high-level focus items for health system leadership, including (1) institutional values surrounding PCC/CC, (2) optimization of IT infrastructure to enhance performance and communication, (3) pay structures and employment models that enhance accountability, and (4) organizing bodies to support implementation efforts. Health systems may use this review to gain insight into how institutional-level factors may facilitate small-scale PCC/CC behaviors, or to conduct similar assessments in their own QI projects. Based on our analysis, we recommend health systems seeking to improve PCC/CC at any level or scale to evaluate how IT infrastructure affects provider-provider and provider-patient communication, and the extent to which institutional prioritization of PCC/CC is manifest and held accountable in performance feedback, incentivization, and values shared among departments and settings. Ideally, this evaluation work should be performed and/or supported by cross-department organizing bodies specifically devoted to PCC/CC implementation work.
Celotno besedilo
Dostopno za:
CEKLJ, DOBA, IZUM, KILJ, NUK, PILJ, PNG, SAZU, SIK, UILJ, UKNU, UL, UM, UPUK
Objective
The study was done to evaluate levels of missing and invalid values in the Michigan (MI) National Emergency Medical Services Information System (NEMSIS) (MI-EMSIS) and explore possible ...causes to inform improvement in data reporting and prehospital care quality.
Methods
We used a mixed-methods approach to study trends in data reporting. The proportion of missing or invalid values for 18 key reported variables in the MI-EMSIS (2010–2015) dataset was assessed overall, then stratified by EMS agency, software platform, and Medical Control Authorities (MCA)—regional EMS oversight entities in MI. We also conducted 4 focus groups and 10 key-informant interviews with EMS participants to understand the root causes of data missingness in MI-EMSIS.
Results
Only five variables of the 18 studied exhibited less than 10% missingness, and there was apparent variation in the rate of missingness across all stratifying variables under study. No consistent trends over time regarding the levels of missing or invalid values from 2010 to 2015 were identified. Qualitative findings indicated possible causes for this missingness including data-mapping issues, unclear variable definitions, and lack of infrastructure or training for data collection.
Conclusions
The adoption of electronic data collection in the prehospital setting can only support quality improvement if its entry is complete. The data suggest that there are many EMS agencies and MCAs with very high levels of missingness, and they do not appear to be improving over time, demonstrating a need for investment in efforts in improving data collection and reporting.
To identify modifiers of emergency medical services (EMS) oversight quality, including facilitators and barriers, and inform best practices and policy related to EMS oversight and system performance.
...We used a qualitative design, including 4 focus groups and 10 in-depth, 1-on-1 interviews. Primary data were collected from EMS stakeholders in Michigan from June to July 2016. Qualitative data were analyzed using the rapid assessment technique.
Emergent themes included organizational structure, oversight and stakeholder leadership, interorganizational communication and relationships, competition or collaboration among MCA stakeholders, quality improvement practices, resources, and needs specific to rural communities.
EMS is a critical component of disaster response. This study revealed salient themes and modifiers, including facilitators and barriers, of EMS oversight quality. These findings were evaluated in the context of current evidence and informed state policy to improve the quality of EMS oversight and prehospital care for both routine and disaster settings. Some were particular to geographic regions and communities, whereas others were generalizable.
Introduction In a 2015 report, the Institute of Medicine (IOM; Washington, DC USA), now the National Academy of Medicine (NAM; Washington, DC USA), stated that the field of Emergency Medical Services ...(EMS) exhibits signs of fragmentation; an absence of system-wide coordination and planning; and a lack of federal, state, and local accountability. The NAM recommended clarifying what roles the federal government, state governments, and local communities play in the oversight and evaluation of EMS system performance, and how they may better work together to improve care.
This systematic literature review and environmental scan addresses NAM's recommendations by answering two research questions: (1) what aspects of EMS systems are most measured in the peer-reviewed and grey literatures, and (2) what do these measures and studies suggest for high-quality EMS oversight?
To answer these questions, a systematic literature review was conducted in the PubMed (National Center for Biotechnology Information, National Institutes of Health; Bethesda, Maryland USA), Web of Science (Thomson Reuters; New York, New York USA), SCOPUS (Elsevier; Amsterdam, Netherlands), and EMBASE (Elsevier; Amsterdam, Netherlands) databases for peer-reviewed literature and for grey literature; targeted web searches of 10 EMS-related government agencies and professional organizations were performed. Inclusion criteria required peer-reviewed literature to be published between 1966-2016 and grey literature to be published between 1996-2016. A total of 1,476 peer-reviewed titles were reviewed, 76 were retrieved for full-text review, and 58 were retained and coded in the qualitative software Dedoose (Manhattan Beach, California USA) using a codebook of themes. Categorizations of measure type and level of application were assigned to the extracted data. Targeted websites were systematically reviewed and 115 relevant grey literature documents were retrieved.
A total of 58 peer-reviewed articles met inclusion criteria; 46 included process, 36 outcomes, and 18 structural measures. Most studies applied quality measures at the personnel level (40), followed by the agency (28) and system of care (28), and few at the oversight level (5). Numerous grey literature articles provided principles for high-quality EMS oversight.
Limited quality measurement at the oversight level is an important gap in the peer-reviewed literature. The grey literature is ahead in this realm and can guide the policy and research agenda for EMS oversight quality measurement. Taymour RK , Abir M , Chamberlin M , Dunne RB , Lowell M , Wahl K , Scott J . Policy, practice, and research agenda for Emergency Medical Services oversight: a systematic review and environmental scan. Prehosp Disaster Med. 2018;33(1):89-97.
There are few reported efforts to define universal disaster response performance measures. Careful examination of responses to past disasters can inform the development of such measures. As a first ...step toward this goal, we conducted a literature review to identify key factors in responses to 3 recent events with significant loss of human life and economic impact: the 2003 Bam, Iran, earthquake; the 2004 Indian Ocean tsunami; and the 2010 Haiti earthquake. Using the PubMed (National Library of Medicine, Bethesda, MD) database, we identified 710 articles and retained 124 after applying inclusion and exclusion criteria. Seventy-two articles pertained to the Haiti earthquake, 38 to the Indian Ocean tsunami, and 14 to the Bam earthquake. On the basis of this review, we developed an organizational framework for disaster response performance measurement with 5 key disaster response categories: (1) personnel, (2) supplies and equipment, (3) transportation, (4) timeliness and efficiency, and (5) interagency cooperation. Under each of these, and again informed by the literature, we identified subcategories and specific items that could be developed into standardized performance measures. The validity and comprehensiveness of these measures can be tested by applying them to other recent and future disaster responses, after which standardized performance measures can be developed through a consensus process. (Disaster Med Public Health Preparedness. 2017;11:505-509).
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