Emergency care and emergency care research (Text Version)

On September 27, 2010, Jesse Pines made this presentation at the 2010 Annual Conference. Select to access the PowerPoint® presentation (2.52 MB). 

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Slide 1

Emergency care and emergency care research

Jesse M. Pines, MD, MBA, MSCE
Associate Professor of Emergency Medicine and Health Policy
George Washington University
September 27, 2010

Slide 2

Overview

• Demographics
• Quality of emergency care
• Future directions

Slide 3

Demographics of emergency care

• 124 million ED visits in 2008 (CDC)

A line graph showing the number of emergency departments vs. the number of emergency department visits is shown. In 1995, there were 3,000 emergency departments and in 2005, there were 115 million emergency department visits.

Sources: CDC/NCHS National Hospital Ambulatory Medical Care Survey, American Hospital Association

Slide 4

Demographics of emergency care

• Who are all these people?
• Myth: ED patients are just poor and uninsured, there for minor ailments that could have been treated by a primary doctor

Image: a person with a question mark above his head is shown.

Slide 5

Demographics of emergency care

• Realities
  • Most ED patients have insurance (CDC)
  • Recent increases in visits by Medicaid & uninsured patients (JAMA 2010)

Bar graph showing the number of visits per 100 persons:

• Medicaid or SCHIP: 89.4
• Medicare: 51.0
• No insurance: 45.9
• Private insurance: 23.6

¹ SCHIP is State Children's Health Insurance Program.
² Includes self-pay, no charge, and charity.
Notes: The denominator for each rate is the populations total for each type of insurance obtained from the 2005 National Health Interview Survey. More than one source of payment may be recorded per visit.
Sources: CDC/NCHS National Hospital Ambulatory Medical Care Survey, American Hospital Association

Slide 6

Demographics of emergency care

• Realities
  • According to most recent estimates, on 8% of ED visits were non-urgent

Number of visits per 100 persons

• Medicaid or SCHIP: 89.4
• Medicare: 51.0
• No insurance: 45.9
• Private insurance: 23.6

¹ SCHIP is State Children's Health Insurance Program.
² Includes self-pay, no charge, and charity.
Notes: The denominator for each rate is the populations total for each type of insurance obtained from the 2005 National Health Interview Survey. More than one source of payment may be recorded per visit.
Sources: CDC/NCHS National Hospital Ambulatory Medical Care Survey, American Hospital Association

Slide 7

Demographics of emergency care

• Why increased visits?
  • Primary care access
    • Higher visit rates for Medicaid, Uninsured
  • Appeal of the ED
    • One-stop shop
    • Comprehensive service
  • EMTALA

A chart showing the number of emergency departments vs. the number of emergency department visits is shown. In 1995, there were 3,000 emergency departments and in 2005, there were 115 million emergency department visits.

Sources: CDC/NCHS National Hospital Ambulatory Medical Care Survey, American Hospital Association

Slide 8

Demographics of emergency care

• At what cost?
  • Cost of an off-hours visit is no higher than a PCP (NEJM 1996)
  • There may be few economies of scale (Ann Emerg Med 2005)
  • But certainly, the "price" is higher

A chart showing the number of emergency departments vs. the number of emergency department visits is shown. In 1995, there were 3,000 emergency departments and in 2005, there were 115 million emergency department visits.

Sources: CDC/NCHS National Hospital Ambulatory Medical Care Survey, American Hospital Association

Slide 9

Demographics of emergency care

• At what cost?
  • More gets "done" in the ED
  • There is a balance
    • Sometimes diagnoses that are "missed" in doctors' offices are diagnosed in the ED

Image: A chart showing the number of emergency departments vs. the number of emergency department visits is shown. In 1995, there were 3,000 emergency departments and in 2005, there were 115 million emergency department visits.

Sources: CDC/NCHS National Hospital Ambulatory Medical Care Survey, American Hospital Association

Slide 10

Demographics of emergency care

• But EDs are a victim of their own success
• Higher demand + Less Space = ED crowding

Image: A chart showing the number of emergency departments vs. the number of emergency department visits is shown. In 1995, there were 3,000 emergency departments and in 2005, there were 115 million emergency department visits.

Sources: CDC/NCHS National Hospital Ambulatory Medical Care Survey, American Hospital Association

Slide 11

Demographics of emergency care

• Crowding matters
  • Longer waits
  • Poorer quality
  • Higher complications
  • Boarding
    • Higher medical errors
    • Higher mortality rates

Image: Exhibit 2, Median Wait Time To See An Emergency Department (ED) Physician, Selected Years 1997-2004 is shown.

Source: National Hospital Ambulatory Medical Care Survey (NHAMCS) database, National Center for Health Statistics, 1997-2000 and 2003-2004.
Notes: "All patients" are those age eighteen and older. "Patients with AMI" are those with an ultimate ED diagnosis of acute myocardial infarction. "Emergent Triage group" are those age eighteen and older assigned to this group, which should be seen within fifteen minutes. In 2001 and 2001, the NHAMCS did not record wait times.

Slide 12

Institute of Medicine Reports...

"The state of emergency care affects every American. When illness or injury strikes, Americans count on the emergency care system to respond with timely and high-quality care. Yet today, the emergency care and trauma care than Americans receive can fall short of what they expect any deserve."

— Harvey Fineberg, MD, PhD, President, IOM 2006

Image: a book cover labeled "Future of Emergency Care, Hospital-Based Emergency Care at the Breaking Point" is shown.

Slide 13

Institute of Medicine Reports.

"The state of emergency care affects every American. When illness or injury strikes, Americans count on the emergency care system to respond with timely and high-quality care. Yet today, the emergency care and trauma care than Americans receive can fall short of what they expect any deserve."

— Harvey Fineberg, MD, PhD, President, IOM 2006

Image: a book cover labeled "Future of Emergency Care, Hospital-Based Emergency Care at the Breaking Point" is shown.

Slide 14

The breaking point

• Building a 21st century system
  • Coordination, Regionalization, Accountability
• ED & hospital flow
  • Boarding of admitted patients
• Health information technology
  • EMRs, Interoperability
• Workforce issues
• Disaster preparedness
• Emergency care research

Slide 15

AHRQ's emergency care portfolio

• The importance of quality (Romano)
• The importance of timing (Carr)
• Clinical focus: CO poisoning (Iqbal)

Slide 16

Focus on quality

• Large variety of case-mix
  • Quality of care means something different to different people
  • Depends on why you're there

Table titled "Ten Most Frequent Complaints in Acute Care Visits, By Setting, 2001-4

Setting of care/complaint	Percent (standard error)
Emergency department total	33.6 (0.6)
Stomach and abdominal pain	6.6
Chest pain and related symptoms	5.3
Fever	4.6
Cough	2.9
Headache, pain in head	2.7
Shortness of breath	2.5
Back symptoms	2.4
Vomiting	2.2
Symptoms referable to throat	2.2
Pain, nonspecific	2.1
General/family practice total	37.0 (0.9)
Cough	8.0
Symptoms referable to throat	6.6
Skin rash	3.1
Earache or ear infection	3.1
Head cold, upper respiratory infection	2.9
Stomach and abdominal pain	2.9
Sinus problems	2.7
Nasal congestion	2.6
Back symptoms	2.5
Fever	2.5
Non-primary care specialty total	23.5 (0.7)
Vision dysfunctions	4.0
Knee symptoms	3.4
Stomach and abdominal pain	2.6
Hand and finger symptoms	2.4
Skin rash	2.3
Shoulder symptoms	1.9
Counseling NOS	1.8
Discoloration or pigmentation	1.7
Abnormal sensations of the eye	1.7
Cough	1.6

Slide 17

Quality of emergency care

• Simple approach
  • Deliver the right care, in a timely, patient-centered manner, and don't send home anyone who you it apparently "ok" but turns out later to be really sick

Table titled "Ten Most Frequent Complaints in Acute Care Visits, By Setting, 2001-4

Setting of care/complaint	Percent (standard error)
Emergency department total	33.6 (0.6)
Stomach and abdominal pain	6.6
Chest pain and related symptoms	5.3
Fever	4.6
Cough	2.9
Headache, pain in head	2.7
Shortness of breath	2.5
Back symptoms	2.4
Vomiting	2.2
Symptoms referable to throat	2.2
Pain, nonspecific	2.1
General/family practice total	37.0 (0.9)
Cough	8.0
Symptoms referable to throat	6.6
Skin rash	3.1
Earache or ear infection	3.1
Head cold, upper respiratory infection	2.9
Stomach and abdominal pain	2.9
Sinus problems	2.7
Nasal congestion	2.6
Back symptoms	2.5
Fever	2.5
Non-primary care specialty total	23.5 (0.7)
Vision dysfunctions	4.0
Knee symptoms	3.4
Stomach and abdominal pain	2.6
Hand and finger symptoms	2.4
Skin rash	2.3
Shoulder symptoms	1.9
Counseling NOS	1.8
Discoloration or pigmentation	1.7
Abnormal sensations of the eye	1.7
Cough	1.6

Slide 18

Emergency care research: Future

• Value propositions of emergency care:
  • America's 24-7 One-stop healthcare shop
  • Convenience is patient-centered, but may not make anyone healthier or extend life.
• Real value:
  • Timely diagnosis and treatment of acutely ill Americans reduces morbidity and mortality.
  • This resource is available to Americans 24-7, regardless of the ability to pay.

Slide 19

Timeliness and outcomes

• Trauma outcomes are similar at night and during the day, ?better on weekends:
  • (Dr. Carr)
• Delays in diagnosis is associated with poor outcomes
  • Subarachnoid hemorrhage (SAH), acute myocardial infarction (AMI), Stroke, Trauma
• The future
  • Understanding the relationship between timeliness and outcomes for more "urgent" conditions

Slide 20

Testing rates v. Missed diagnosis

• Proliferation of testing:
  • Increased rate of abdominal CT in EDs
  • 2001: 10%, 2005: 22% (Pines Med Care 2009)
• The future [Image: a key]:
  • Resource Consumption vs. Minimizing misses

Slide 21

Moving beyond associations...

• Fixing the emergency care system
  • Within the ED
    • Ensuring evidence based best-practices
    • Streamlining operations
    • Optimizing clinical service delivery

Slide 22

Moving beyond associations...

• Fixing the emergency care system
  • Between the ED and hospital
    • Reducing boarding
    • Improving care transitions

Slide 23

Moving beyond associations...

• Fixing the emergency care system
  • Among EDs and hospitals
    • Regionalization of emergency services
    • Coordination of care at the community-level

Slide 24

Moving beyond associations...

• Fixing the emergency care system
  • Between the ED and outpatient system
    • Sharing data, reducing duplicate testing
    • Improving care transitions, coordination
    • Reducing avoidable admissions by creating alternative pathways
    • Reducing resource consumption... safely

Slide 25

2011 SAEM Consensus Conference

• Interventions to Assure Quality in the Crowded ED
  • Co-Chairs: Jesse Pines & Melissa McCarthy
  • Marriott Boston Copley Place
  • June 1, 2011

Slide 26

2011 SAEM Consensus Conference

• Interventions to Assure Quality in the Crowded ED (Boston, June 1 2011)
  • Review interventions that have been implemented to reduce crowding
  • Identify strategies within or outside of the healthcare setting that may help reduce crowding or improve the quality of care during episodes of ED crowding
  • Identify the most appropriate design and analytic techniques for rigorously evaluating ED interventions

Slide 27

Questions?