jesse m. pines, md, mba, msce associate professor of emergency medicine and health policy george...
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Emergency care and emergency care research
Jesse M. Pines, MD, MBA, MSCEAssociate Professor of Emergency Medicine and Health Policy
George Washington UniversitySeptember 27, 2010
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Demographics
Quality of emergency care
Future directions
Overview
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124 million ED visits in 2008 (CDC)
Demographics of emergency care
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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
Demographics of emergency care
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Realities
◦ Most ED patients have insurance (CDC)
◦ Recent increases in visits by Medicaid & uninsured patients (JAMA 2010)
Demographics of emergency care
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Realities
◦ According to most recent estimates, on 8% of ED visits were non-urgent
Demographics of emergency care
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Why increased visits?
◦ Primary care access Higher visit rates for
Medicaid, Uninsured
◦ Appeal of the ED One-stop shop Comprehensive service
◦ EMTALA
Demographics of emergency care
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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
Demographics of emergency care
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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
Demographics of emergency care
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But EDs are a victim of their own success
Higher demand + Less Space = ED crowding
Demographics of emergency care
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Demographics of emergency care
•
Crowding matters
◦ Longer waits◦ Poorer quality◦ Higher
complications◦ Boarding
Higher medical errors
Higher mortality rates
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“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
Institute of Medicine Reports…
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“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
Institute of Medicine Reports…
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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
The breaking point
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The importance of quality (Romano)
The importance of timing (Carr)
Clinical focus: CO poisoning (Iqbal)
AHRQ’s emergency care portfolio
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Large variety of case-mix
◦ Quality of care means something different to different people
◦ Depends on why you’re there
Focus on quality
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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
Quality of emergency care
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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
Emergency care research: Future
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Trauma outcomes are similar at night and during the day, ?better on weekends◦ (Dr. Carr)
Delays in diagnosis is associated with poor outcomes◦ SAH, AMI, Stroke, Trauma
The future◦ Understanding the relationship between
timeliness and outcomes for more “urgent” conditions
Timeliness and outcomes
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Proliferation of testing◦ Increased rate of abdominal CT in EDs◦ 2001: 10%, 2005: 22% (Pines Med Care 2009)
The future
Testing rates v. Missed diagnosis
Resource Consumption
Minimizing misses
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Fixing the emergency care system
◦ Within the ED
Ensuring evidence based best-practices Streamlining operations Optimizing clinical service delivery
Moving beyond associations…
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Fixing the emergency care system
◦ Between the ED and hospital
Reducing boarding Improving care transitions
Moving beyond associations…
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Fixing the emergency care system
◦ Among EDs and hospitals
Regionalization of emergency services Coordination of care at the community-level
Moving beyond associations…
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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
Moving beyond associations…
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Interventions to Assure Quality in the Crowded ED
◦ Co-Chairs: Jesse Pines & Melissa McCarthy◦ Marriott Boston Copley Place◦ June 1, 2011
2011 SAEM Consensus Conference
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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
2011 SAEM Consensus Conference
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Questions?